Salmonella spp. in livestock, and subsequent increases in human foodborne disease. We use a mathematical model fitted to four case studies, ampicillin and tetracycline usage in fattening pig and broiler poultry populations, to explore the impact of curtailing antibiotic usage in livestock on salmonellosis in humans.Antibiotic usage in livestock has been suggested as a driver of antimicrobial resistance in human and livestock populations. This has contributed to the implementation of stewardship programs to curtail usage of antibiotics in livestock. However, the consequences of antibiotic curtailment in livestock on human health are poorly understood. There is the potential for increases in the carriage of pathogens such as Increases in the daily incidence of salmonellosis and a decrease in the proportion of resistant salmonellosis were identified following curtailment of antibiotic usage in livestock. The extent of these increases in human foodborne disease ranged from negligible, to controllable through interventions to target the farm-to-fork pathway. This study provides a motivating example of one plausible scenario following curtailment of antibiotic usage in livestock and suggests that a focus on ensuring good farm-to-fork hygiene and livestock biosecurity is sufficient to mitigate the negative human health consequences of antibiotic stewardship in livestock populations. •Curtailment of antibiotic usage in livestock can potentially increase the incidence of salmonellosis in humans.•The extent of these increases in salmonellosis are negligible to controllable with interventions.•Interventions targeting the farm-to-fork pathway are effective at controlling increases in incidence. Antibiotic usage in livestock has been identified as an important driver of AMR in human populations, with transmission of resistant bacteria and resistance determinants potentially occurring at the livestock/human interface . This haEnterococci resistance rates following EU growth promotion bans . In. In30]. A Fourier amplitude sensitivity test (FAST) was next performed to identify the parameters which had the greatest influence on the relative increase in the daily incidence of human salmonellosis when antibiotic usage in livestock was curtailed from mean baseline usage (0.00934 → 0 g/PCU) A. The FAFig. S16).Transmission related fitness costs associated with antibiotic-resistance (α), the per capita rate of background transmission to livestock populations (ζ) and efficacy of antibiotic-mediated livestock recovery (κ) were found to be the most influential parameters in determining the relative increase in the daily incidence of human salmonellosis from baseline antibiotic usage in livestock when antibiotics where curtailed A. Specifmitigate increases in the daily incidence of human salmonellosis under antibiotic curtailment to a value below 0.593 per 100,000 population, the incidence currently observed for the modelled case studies (HA) was identified as the key parameter to mitigate increases in daily incidence , above what is currently observed for human salmonellosis . Alterations to βAA and ζ parameters were also chosen as potential intervention targets, due to their relevance in agricultural biosecurity strategies to mitigate livestock disease/AMR [Due to the importance of targeting the animal-to-human transmission route, we quantified the minimum alterations in βease/AMR ,34.HA were capable of mitigating increases to the daily incidence of human salmonellosis below baseline levels across all case studies in the explored parameter space, with a reduction of 1%, 4%, 12% and 18% required for each case study  were found to result in large increases in the daily incidence of human salmonellosis upon antibiotic curtailment. However, interventions to decrease animal-to-human transmission (βHA) were found to effectively mitigate increases in the daily incidence of human salmonellosis following curtailment of antibiotic usage in livestock.A mathematical modelling approach was used to identify increases in the daily incidence of non-typhoidal human salmonellosis following curtailment of antibiotic usage in livestock. This was explored across four antibiotic/livestock specific case studies. Scenarios with high transmission-related fitness costs of resistance (α), high efficacies of antibiotic-mediated livestock recovery (κ) and low background transmission rates of HA could take the form of interventions to increase hygiene throughout the farm-to-fork pathway, reducing microbial contamination on carcasses, as well as public information campaigns to promote safe handling of food products [Salmonella spp. incidence has also plateaued in regions [HA [Reductions to βproducts ,35. Manyproducts . However regions . There wions [HA . This maSalmonella spp. serotypes colonising poultry and pig hosts [E.coli identifying differences in fitness cost across these resistance-encoding plasmids [Curtailment of antibiotic usage in livestock was found to have varying impacts across the modelled livestock host species. This can be attributed to the differences in transmission-related fitness costs associated with antibiotic resistance between species (α = 0.084 and 0.416 for broiler poultry and fattening pigs respectively). Difference in fitness cost between species may reflect heterogeneity in the distribution of plasmids .Fig. S17). Secondly, greater transmission-related fitness costs (high α) and import of sensitive bacteria from the environment (high ζ) will promote a greater relative proportion of sensitive to resistant strains . Therefore, when sensitive strains are more common, we will observe a greater increase in incidence of human salmonellosis when treatment is withdrawn, as sensitive strains are the only strain affected by antibiotic pressure.In addition to α, differences in the relative increase in daily incidence of human salmonellosis between modelled case studies can be attributed to ζ and κ parameters A. The efSalmonella spp. carriage in livestock is highly variable and antibiotic dependent [Antibiotic usage in livestock was also modelled to be a proxy for all modes of application  and therefore by extension, our model implicitly assumes that all types of antibiotic usage have a therapeutic effect in livestock. This assumption can be considered an edge-case, highly positive interpretation of antibiotic usage in livestock, considering that the impact of antibiotic exposure to ependent ,44. HoweListeria spp. and E.coli (i.e. VTEC). This contrasts with Salmonella spp. modelled in this study, which has clear food animal origins and predominantly results in self-limited colonisation and infection in humans [Listeria spp. and E.coli infection in humans [It is also likely that there will be a less clear link between improvements in farm-to-fork hygiene and the incidence of opportunistic infections of commensal pathogens, such as n humans . Factorsn humans ,46.Fig. S5, Table S2) [S17). Therefore, if there is a weak/no association between antibiotic usage and resistance due to negligible fitness costs, then increases in incidence will also be unimportant and of limited public health concern.Due to the historical lack of high-quality AMR surveillance and presence of confounding factors, it is difficult to disentangle whether observed significant relationships between usage and resistance are due to a genuine relationship between usage and resistance or due to noise associated with surveillance data (able S2) . HoweverSalmonella spp. from animals-to-humans was simplified using a single parameter in this study. Future models could use non-linear microbial load dose-response models to more accurately quantify infection risk upon human exposure to Salmonella spp. on food products [The compartmental model structure chosen in this study was simplified for model tractability and certain phenomena were implicitly assumed or modelled. For example, transmission of products . Future products . The impproducts ,50. ExplSalmonella spp. to humans. However, potential increases in the daily incidence of salmonellosis range from negligible to preventable through interventions that target animal-to-human transmission routes. The efficacy of these interventions suggests that a one-health approach with a focus on improving farm-to-fork hygiene to minimise human disease is essential when considering potential strategies to tackle the AMR crisis.The results from this study suggest that curtailment of antibiotic usage in livestock may have unforeseen effects, with a reduction in both livestock and human antibiotic resistance, but with increases in the livestock carriage and onwards transmission of foodborne pathogens such as A.L.K.M. participated in the study design, carried out model analysis and drafted the manuscript. B.A.D.v.B. participated in the study design and provided feedback on manuscript drafts. M.E.J.W. participated in the study design and provided feedback on manuscript drafts. J.A.W. provided feedback on manuscript drafts.10.13039/100010269Wellcome Trust PhD grant (215094/Z/18/Z), 10.13039/501100004191Novo Nordisk (684/21856), 10.13039/501100000780European Union VEO grant (874735-VEO), the 10.13039/501100000848University of Edinburgh and 10.13039/501100003006ETH Zürich.This study was supported by a All authors declare that they have no conflicts of interest.


Antibiotics represent an essential pillar in the treatment of respiratory infections (RI). Overuse of antibiotics in avoidable cases and inappropriate application in bacterial infections facilitate treatment resistance, threatening their effectiveness and causing a significant healthcare challenge. We therefore assessed the savings potential for antibiotics in ambulant care of selected RI  in several European countries based on market research data for the year 2019. Number of antibiotic packages sold in pharmacies varied, with highest values in Serbia and France, and lowest in Sweden and Switzerland. Selected RI contributed nearly half of overall ambulant antibiotic prescriptions, with around one fifth given for bronchitis and cough; the vast majority was estimated to be of viral origin with potentially avoidable antibiotic use. Antibiotic consumption for selected RI in eight European countries  amounted to nearly 100 million, with an overall savings potential between 66.2 and 83.7 million packages. The highest estimated volume of avoidable antibiotics was in France , and lowest in Switzerland . Due to substantial savings potential, prudent use of antibiotics and adequate application of alternatives should be promoted in daily practice. Escherichia coli, known to be associated with various infections including pneumonia [Antibiotics represent an essential pillar in the treatment of respiratory infections, specifically those caused or complicated by bacterial pathogens. Indeed, responsiveness of bacteria to antibiotics is vital for healthcare worldwide but is unfortunately increasingly compromised by antibiotic treatment resistance. Selection pressure and genetic mutations or acquisition of genetic material from already resistant bacteria facilitate the occurrence of resistance ,2,3. By neumonia ,6, was hneumonia . It alsoneumonia . As exponeumonia ,9,10, thneumonia ,12,13,14Clostridium difficile infections or acute allergic reactions [Since antibiotics are only effective against bacteria, they cannot treat infections of viral origin. Antibiotics have accordingly been described as having little to no benefit for common and mostly viral respiratory tract infections in otherwise healthy adults . Analyzieactions ,23,24. Veactions ,26,27, dThe number of packages sold for systemic antibiotic treatment in ambulatory care varied substantially across European pharmacies. Taking into account the population statistics for 2019 , highestEight countries had a total ambulant per capita consumption of antibiotics close to the overall value determined across 28 selected European countries (0.89 vs. 1.04). They were therefore deemed a suitable selection for further analysis . Among tIndications related to respiratory infections  products sold in pharmacies for corresponding treatment. In accordance with the above-reported data, lowest OTC sales in this category were found in France, with Germany and Switzerland at the higher side of the spectrum . ConsistTaken together, our estimates reveal a marked contribution of prevalent respiratory infections to antibiotic consumption across several European countries with substantial savings potential due to viral causes.Our analysis of market research data in Europe offers insights into the extent of antibiotic use for prevalent respiratory indications and corresponding potential for saving antibiotics. Due to its foundation in real-world data, this analysis reflects the magnitude of antibiotic prescriptions and thus provides an impression of their potential impact on a larger scale of several European countries. However, due to limited data availability, certain assumptions were made during the analysis, leading to limitations including the selection of ICD-10 codes in only two of the countries (Germany and France) as well as the classification of avoidable treatment, which might be subject to interpretation. Indeed, antibiotic treatment can also become necessary in viral infections, depending on individual circumstances  and the associated risk of potentially exacerbating existing conditions . Nevertheless, it is important to note that fear of complications, patient age and the setting of long-term aged care facilities have also previously been identified as factors facilitating inappropriate prescriptions ,47,48,49Klebsiella pneumoniae and to carbapenems in Pseudomonas aeruginosa and Acinetobacter species amounted to 34%, 18% and 38%, respectively [Due to the known correlation between exposure to antibiotics and development of antibiotic resistance, high consumption of antibiotics in ambulant care and the substantial contribution of respiratory indications found in our analysis offer important insights for daily practice. Although national action plans on antimicrobial resistance exist and community consumption of antibiotics has reduced in most European countries between 2019 and 2020, levels of resistance to critically important antibiotics in bacteria commonly responsible for healthcare-associated infections remained high (>20% to 50%) or very high (>50% to 70%) ,25. For ectively . Our curectively , althougectively ,54,55. Iectively . It is iectively . The neeectively  and can ectively .Some of the major factors identified as facilitating irrational use of antibiotics in Europe include lack of public knowledge and awareness, access to antibiotics without prescription and leftover antibiotics, inadequate medical training, and lack of rapid and sufficient diagnostic tests . In GermAntibiotics rarely benefit acute bronchitis, exacerbations of asthma and chronic bronchitis, acute pharyngitis and acute sinusitis, although they are commonly prescribed in such cases . Complex® information service for the year 2019  [Data on antibiotic packages sold by pharmacies within ambulant care in Europe were obtained under license from IQVIA’s IQVIA MIDASeserved) . To our eserved)  was focueserved)  were conMarket share of OTC remedies  vs. presNearly half of the overall antibiotic consumption in the ambulant sector across various European countries is attributable to respiratory infections. Due to the predominantly viral origin of respiratory infections, a substantial proportion of corresponding antibiotic prescriptions is avoidable. Since exposure to antibiotics facilitates treatment resistance and can be associated with side effects, appropriate measures should be undertaken to improve healthcare practices by preventing unnecessary use of antibiotics. In this regard, it will be important to consider the impact of the COVID-19 pandemic on antibiotic consumption and antimicrobial resistance and evaluate corresponding trends prior to and following the period of the pandemic in order to optimize antibiotic stewardship efforts. Some of the measures that could facilitate improvements in daily practice might include medical training on antibiotic prescribing, shared decision-making and potential for safe delayed prescriptions, patient education on appropriate use and risks associated with antibiotic consumption and improving diagnostic tools. Corresponding strategies should contain a multifaceted approach to reach prescribers and patients on pertinent issues and also raise awareness on alternative, symptomatic treatments known to be suitable for meeting the needs of patients and thus beneficial for curbing the development of antibiotic resistance.


Controversy remains regarding predictors of surgical outcomes for patients with lumbar spinal stenosis (LSS). Pain sensitization may be an underlying mechanism contributing to LSS surgical outcomes. Further, obesity is associated with dissatisfaction and poorer outcomes after surgery for LSS. Therefore, this study aimed to examine the relationship between central sensitization (CS), visceral fat, and surgical outcomes in LSS.Patients with LSS were categorized based on their central sensitization inventory (CSI) scores into low- (CSI < 40) and high- (CSI ≥ 40) CSI subgroups. The participants completed clinical outcome assessments preoperatively and 12 months postoperatively.p < 0.01). The high-CSI group had a significantly higher mean visceral fat area than the low-CSI group (p < 0.01). Postoperatively, LBP VAS score was significantly worse in the high-CSI group. Relative to preoperatively, postoperative leg pain and leg numbness improved significantly in both groups.Overall, 60 patients were enrolled in the study . The high-CSI group had significantly higher mean low back pain (LBP), leg pain, and leg numbness visual analogue scale (VAS) scores than the low-CSI group (We believe that neuro decompression can be effective for LSS surgical outcomes in patients with CS; nonetheless, it should be approached with caution owing to the potential for worsening LBP. Additionally, visceral fat is an important indicator suggesting the involvement of CS. Lumbar spinal stenosis (LSS) is a degenerative condition involving spinal canal narrowing due to facet joint osteoarthritis, ligamentum flavum hypertrophy, intervertebral disc bulging, and spondylolisthesis . AmundseObesity is associated with a higher degree of dissatisfaction and poorer outcomes after surgery for LSS, and patients with morbid obesity experience more complications than those with lower body mass index (BMI) , 9. AddiCentral sensitization (CS) has recently been recognized as a potential pathophysiological cause of several chronic pain disorders, including chronic LBP (CLBP), chronic neck pain, myofascial pain syndrome, fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, interstitial cystitis, and tension-type headache –16. ThesTherefore, to ascertain the role of visceral fat and CS in LSS, this study aimed to examine the relationship between CS, visceral fat area, and surgical outcomes in patients following surgery for LSS.The Institutional Review Board of Sapporo Medical University approved this study . All participants were provided with written and verbal explanations of the study, and their consent was obtained prior to participation.We enrolled consecutive patients with LSS aged between 41 and 79 years. The surgeons performed physical testing on consecutive patients who reported with symptoms induced or exacerbated with walking or prolonged standing and relieved with lumbar flexion, sitting, and recumbency. These symptoms included pain, numbness, and neurological deficits in the lower extremities and buttocks as well as bladder or bowel dysfunction. Subsequently, radiographic and magnetic resonance imaging (MRI) findings suggestive of degenerative stenosis of the spinal canal or intervertebral foramen were correlated with the reported symptoms and clinical findings, thereby confirming the diagnosis of LSS. The same surgeons made the final diagnosis of symptomatic LSS, which necessitated the presentation both of clinical symptoms and radiographic findings of LSS. Symptoms of leg pain/numbness and intermittent claudication in patients with LSS who did not respond to conservative therapies for more than 3 months were considered to be indications for decompression surgery . The excThe CSI measures the extent to which an individual’s symptoms are likely attributable to CS , 18. Parr = 0.919; 95% CI 0.908–0.930], p < 0.001), and the ICC of CT-measured and manually-measured abdominal circumference was 0.954 (95% CI 0.947–0.960). The patients underwent CT imaging , which was performed simultaneously with myelography. We measured the visceral fat area, subcutaneous fat area, and abdominal circumference at the level of the umbilicus. The respiratory phase was at the end of exhalation, and the parameters were set as follows: tube voltage, 120 kV; tube current, 360 Ma; spin time, 0.5 s/rotation; and slice thickness, 0.6 mm. Typical CT images of a low-CSI patient and a high-CSI patient are presented in Fig. Visceral and subcutaneous fat cross-sectional areas were calculated semiautomatically using tissue-specific attenuation thresholds including adipose tissue (− 190 to − 30 Hounsfield unit [HU]) and skeletal muscle (− 29 to 150 HU) , 29. LeeU test. Analysis of covariance (ANCOVA) was used to compare the CT measurements between the low- and high-CSI groups, adjusted for age and sex. Differences in VAS scores between the pre- and post-12 months periods were analysed using the Mann–Whitney U test. All statistical analyses were performed using SPSS . Statistical significance was set at p < 0.05.All numerical data are expressed as the mean ± standard error of the mean. Differences between men and women were analysed using the chi-square test. Additionally, differences between the groups regarding age, BMI, and VAS scores were compared using the Mann–Whitney p = 0.72). The high-CSI group had significantly higher mean LBP, leg pain, and leg numbness VAS score compared to the low-CSI group (p < 0.01). Table p < 0.01). No statistically significant differences were found in the mean subcutaneous fat area (p = 0.65) or abdominal circumference (p = 0.41) between the two groups. The mean preoperative and postoperative LBP VAS scores, respectively, were 37.1 ± 4.2 and 35.9 ± 3.9 mm in the low-CSI group . A previous study involving patients with chronic spinal pain disorder with musculoskeletal injury reported that 67% of the patients were classified into the high-CSI group upon admission for an interdisciplinary functional restoration programme [In the present study, the prevalence of high-CSI was 35.0% (high-CSI, rogramme . Tanaka rogramme  reportedrogramme  reportedThere were two important findings concerning the preoperative analysis in the current study. First, the high-CSI group had significantly higher VAS scores than those of the low-CSI group, suggesting that patients with high-CSI experienced more severe LBP, leg pain, and leg numbness. In a previous report, pain severity based on CSI score was significantly related to other types of pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance . PatientIn the present study, the high-CSI group presented with more symptoms and reported higher LBP intensity after lumber decompression relative to before surgery. A high preoperative CSI score is associated with worse quality of life and increased duration of hospital stay following spinal fusion . MoreoveThe outcomes of our study indicate that neuro decompression can be effective for LSS with CS; nevertheless, the caveat of the potential for worsened LBP must be considered. In addition, our study highlights the importance of visceral fat in the involvement of CS. To this end, under the condition of giving informed consent before surgery, surgeons should explain the factors influencing postoperative improvement of lower extremity symptoms and worsening of LBP to patients with a high-CSI, ensure patients’ understanding of the expected postoperative recovery outcomes, and avoid patients’ insufficient understanding of heightened LBP postoperatively, thereby improving postoperative satisfaction.This study has some limitations. First, this study had a relatively short follow-up period of 12 months; postoperative outcomes might change over a longer periods. Second, the duration of neurological symptoms from onset to the lumbar surgeries may affect the extent of CS pre- and postoperatively; however, this was not evaluated in this study. In the future, we would like to investigate whether preoperative interventions, such as aerobic exercise and medical diet, can improve CS along with visceral fat reduction. Subsequently, we would endower to compare surgical outcomes concerning LBP between patients receiving a preoperative aerobic exercise and medical diet interventions and those receiving no intervention. We believe this would contribute to understanding the pathogenesis of LBP after LSS surgery and improve surgical outcomes.This study evaluated the relationship between CS, visceral fat area, and surgical outcomes in LSS. We report that patients with a high CSI had significantly higher VAS scores, indicative of more severe LBP, leg pain, and leg numbness, than those with a low-CSI. Additionally, patients with a high CSI had significantly more visceral fat compared to those with low CSI, implying the role of visceral fat in CS. Furthermore, patients with a high CSI presented with more symptoms and reported higher LBP intensity after lumber decompression than before surgery, while leg pain and leg numbness improved in both groups, albeit to a greater extent in patients with a lower preoperative CSI. We conclude that neuro decompression can be effective for LSS with CS; nevertheless, caution must be taken for the possibility of worsened postoperative LBP.


An appropriate and evidence-based strategy for treating patients with recurrent urinary tract infection (rUTI) is to use low-dose antibiotics as prophylaxis. All antibiotics used for rUTI prophylaxis are associated with problems of resistance and adverse effects. Antimicrobial resistance (AMR) refers to a natural phenomenon in which micro-organisms become resistant to antibiotics that were originally effective in killing them. There is an established link between antibiotic use and the emergence of resistant organisms. Current NICE guidelines  state that patients on antibiotic prophylaxis for rUTI should have a clinical review within 6 months to assess success from the prophylactic regimen. At this review, consideration should be given to discontinuing the antibiotic and the promotion of self-care measures in its place. This project aims to assess current practice in relation to rUTI management in primary care and identify opportunities for improved antimicrobial stewardship.An audit was developed to review rUTI management, and it was used in three GP practices (patient population 35 134) within the Bridgend Locality of Cwm Taf Morgannwg University Health Board. If regular antibiotic prophylaxis is required, nitrofurantoin 50 mg/100 mg nocte or trimethoprim 100 mg nocte should be considered first line, unless associated with resistance, allergy or co-morbidities. Cefalexin 125 mg nocte is the second choice. A search for all repeat prescriptions issued for any strength of these drugs, from 1 July 2017 to 30 June 2018, was run in the GP practice systems, and 179 patients were identified as being on antibiotic prophylaxis for rUTI (∼0.5% of the practice populations). The results of the audit were fed back to the practice, and a co-designed action plan agreed to review the identified patients. The outcome of this activity was the proof of concept for national roll-out and lead to the audit being included in a ‘basket’ of Quality Improvement Projects as part of the Welsh General Medical Services (GMS) 2019/20 contract. Due to the COVID pandemic, it remained live until September 2022.n = 123). Of those taking prophylaxis for >6 months (n = 160), 24% had a prophylactic review within the previous 6 months as per NICE guidance. Patients taking prophylaxis for >3 years accounted for 39% of the total (n = 70). Whilst taking antibiotic prophylaxis, 98 patients (54.7%) had at least one documented acute UTI in the previous 12 months. For an acute UTI, 35 patients (19.6%) were prescribed the same antibiotic as they were taking prophylactically. When an MSU showed resistance to the prophylactic antibiotic, prophylaxis was changed 17.5% of the time, n = 57. Therefore, 82.5% were continued on a potentially ineffective antibiotic. Results from the Welsh GMS contract for the Bridgend locality (patient population 152 041) identified 431 patients on antibiotic prophylaxis for rUTI. Of these, 334 (77.5%) were reviewed, and of those reviewed, 171 (51%) were stopped (confirmed on re-audit after 6 months). This equates to a 40% locality reduction in antibiotic prophylaxis for rUTI, which is estimated to be in the region of 2223 fewer antibiotic prescriptions per year.Primary care–initiated prophylaxis accounted for 69% of the total number of patients identified (UTI Friday audit suggest that there can be marked improvement in antibiotic use for rUTI management. Through a multi-disciplinary approach, this project has demonstrated how pharmacists can support GPs in the review and management of patients with rUTI. Using audit feedback, co-designed action plans have been implemented. The impact of this on resistance seen in urinary isolates is not yet known but, with increased guideline awareness/compliance, a positive step has been made towards improving rUTI management and meeting the antimicrobial stewardship targets set by the UK Antimicrobial Resistance National Action Plan 2019–2024. In order to tackle high rates of antibiotic prescribing in primary care, innovative approaches to quality improvement and prescriber feedback will be essential and should be further developed.Initial results from the


Guest EditorLawrence L. SprietHuman Health and Nutritional Sciences,University of Guelph,Guelph, ON,Canadalspriet@uogelph.caDisclosures: This supplement is supported by the Gatorade Sports Science Institute (GSSI), a division of PepsiCo, Inc.Guest Editor Conflicts of Interest: This supplement was guest edited by Dr. Lawrence L. Spriet, who attended a meeting of the GSSI Expert Panel in October 2022 and received honoraria from GSSI for his participation in the meeting and the writing of the preface for the supplement. Dr. Spriet received no honorarium for guest editing the supplement. Dr. Spriet has no potential conflicts of interest that are directly relevant to the content of this supplement.


The dataset currently available comprises data on the removal rates of heavy metals  through the incorporation of seashells and palm oil kernel shells into pervious concrete for stormwater treatment. Stormwater runoff was collected from commercial areas in Taman University, Skudai, Johor, Malaysia. The stormwater samples underwent filtration and were preserved in high-density polyethylene (HDPE) bottles at a temperature of 4 °C for use as incoming water. The outgoing water, referred to as effluent, was obtained from tests performed on pervious concrete samples after a curing period of 28 days. The pervious concrete mixes were created with a water-to-binder ratio (w/b ratio) of 32% and a sand ratio of 10%. Three different levels of palm oil kernel shell and seashell content were used as coarse aggregate replacements: 0%, 25%, and 50%. Two single-size group were considered for both palm oil kernel shell and seashell: (6.3-9.5 mm) and (4.75-6.3 mm). Heavy metal analyses were conducted on the influent and effluent using a PerkinElmer ELAN 6100 Series Inductively Coupled Plasma– Mass Spectrometer (ICP-MS). The available datasets consist of both raw and analyzed data. Specifications Table1•The presented experimental data show the extent of heavy metal removal from stormwater when pervious concrete pavement incorporates palm oil kernel shells and seashells as partial replacements for coarse aggregates.•The data on the rate of heavy metal removal in pervious concrete incorporating seashells and palm oil kernel shells will help us comprehend the impact of these waste materials on heavy metal removal.•The obtained data can be utilized for comparative analyses to assess the purification capabilities of pervious concrete pavements, thereby facilitating the production of more sustainable pervious concrete solutions.2The reason for collecting this dataset was the absence of a freely accessible dataset suitable for the development of sustainable pervious concrete and to investigate the impact of various waste materials on heavy metal removal in pervious concrete containing these waste materials. This dataset was created to record the removal of heavy metals (barium (Ba), selenium (Se), chromium (Cr), iron (Fe), cadmium (Cd), arsenic (As), and cobalt (Co)) from stormwater using pervious concrete pavements containing palm oil kernel shells and seashells. The measurement of heavy metals in stormwater is intended to assist engineers in comparing the effects of different waste materials on water purification, with the aim of finding the optimal mix design for pervious concrete containing waste materials to achieve more sustainable pervious concrete pavements with improved water purification capabilities. The provided heavy metal removal data were collected from stormwater samples taken in the field as influent and after passing through five pervious concrete specimens as effluent, for a total of ten events. These measurements were conducted using a PerkinElmer ELAN 6100 Series Inductively Coupled Plasma–Mass Spectrometer (ICP-MS). Furthermore, these datasets can supplement the results described in 3https://data.mendeley.com/datasets/zw6wrx4xm7/2. This file is provided in Excel format and comprises two separate sheets containing relevant information. The first sheet, titled "Raw Data," contains the raw data from the ICP-MS results, displaying the concentrations of heavy metals in both influent and effluent for each sample. The second sheet, titled "Analyzed Data," presents the amount of retained heavy metal in each sample based on the volume of influent and effluent. Additionally, the percentage of heavy metal removal by each sample is provided. For further data, please refer to [refer to ,2.Fig. 14To create interconnected voids in pervious concrete, selecting single-sized aggregates is essential To facilitate the application of water to the concrete cylinders, a glass separating funnel was suspended above each concrete cylinder to allow the stormwater to drip through the cylinder. A glass beaker was positioned beneath the concrete cylinder to collect the effluent discharged from it. Effluent collection occurred approximately 5 minutes after the application of stormwater. Specific volumes (200 ml) of the prepared stormwater were applied to the cylinders, and the volume of effluent collected was recorded for mass balance purposes.Individual effluent samples were collected from each cylinder for each event and were subsequently prepared separately for analysis. These samples were acidified to a pH below 2 using nitric acid and then stored in 30 mL glass culture tubes at 4 °C, as depicted in Not applicable.Elnaz Khankhaje: Methodology, Investigation, Writing – original draft. Taehoon Kim: Conceptualization, Methodology, Writing – review & editing. Hyounseung Jang: Conceptualization, Writing – review & editing, Supervision. Chang-Soo Kim: Writing – review & editing. Jimin Kim: Writing – review & editing. Mahdi Rafieizonooz: Writing – review & editing, Data curation.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


This study aims to explore the impacts of knowledge and attitude on the behavior of antibiotic use during the treatment of the common cold based on the expanding KAP model, and then identify the critical behavioral stage.A cross-sectional study was conducted on 815 public from 21 community health centers (CHCs) in Chongqing, China. Based on the expanding KAP model, a self-administered questionnaire was designed to measure knowledge, attitude, multi-stage behavior, and perceived threat, in which multi-stage behavior was divided into pre-use antibiotic behavior, during-use antibiotic behavior, and post-use antibiotic behavior. A structural equation model was used to examine the model fit and the direct, indirect, mediating effects, and moderating effect of the variables.χ²/df = 0.537, RMSEA = 0.033, CFI = 0.973, GFI = 0.971, NFI = 0.934, TLI = 0.979. Knowledge had a positive effect on attitude , pre-use antibiotic behavior , during-use antibiotic behavior , and post-use antibiotic behavior . Attitude had a positive effect on during-use antibiotic behavior , and post-use antibiotic behavior . The mediating effect of attitude was positive among knowledge, during-use antibiotic behavior , and post-use antibiotic behavior . Perceived threat also had a positive moderating effect between knowledge and post-use antibiotic behavior .The expanding KAP showed good model fit indices with Knowledge, attitude and perceived threat had different effects on different stages of antibiotic behavior. The critical behavioral stage prioritized the post-use antibiotic behavior and during-use antibiotic behavior over pre-use antibiotic behavior. Antimicrobial resistance (AR) threatens public health and is a major cause of death globally –3. It waMultiple factors contribute to the issue of public antibiotic misuse , encompaResearch in the field of behavioral psychology provides direction for expanding the KAP model. Behavioral psychologists believe that human behavior is complex unless the behavior is divided into several stages so that the mechanism of the behavior can be observed accurately and the critical behavioral stage can also be identified . A mixedResearch in the field of risk management provides another direction for expanding the KAP model. Risk management experts believe that human behavior is easily influenced by the perceived threat from currently unknown but adopted things . Some stChina is considered the world’s largest consumer of antibiotics for animal and human use . The annIn order to address the limitations of the current KAP model in validating the behavioral outcomes and better observe the behavior of public antibiotic misuse in China. This study aims to verify the validity of the expanding KAP model, accurately explore the impacts of knowledge and attitude on behavior of antibiotic use during the treatment of the common cold based on the expanding KAP model, and then identify the critical behavioral stage. According to the expanding KAP model, the following hypotheses were examined in this study.Hypothesis 1: Knowledge is related to attitude.Hypothesis 2: Attitude is related to multi-stage behavior.Hypothesis 3: Knowledge is directly related to multi-stage behavior.Hypothesis 4: Knowledge is related to multi-stage behavior through the mediating effect of attitude.Hypothesis 5: Perceived threat can moderate the relationship between knowledge and multi-stage behavior.A cross-sectional study using a self-administered questionnaire was conducted in community health centers (CHCs) in Chongqing, China, over the period from July 25 to August 3 in 2022. Chongqing is located in southwest China and has a population of 32.12 million . Its socThis study covered CHCs in areas with different economic levels, and a stratified cluster random sampling strategy was adopted. Chongqing is economically divided into low-income level areas , middle-income level areas , and high-income level areas  . We randWe estimated that at least 21 clusters with a sample size of 35 responses would be required in each CHC using the sample size calculator developed by Dhand and Khatkar  . TherefoThe public aged over 18 years old was approached and invited to participate in the survey. The inclusion criteria of participants were as follows:Experienced symptoms of a common cold  in the past six months .Antibiotics taken during the treatment of the common cold in the past six months.Were able to comprehend the survey content.Were able to communicate with the investigators.The expanding KAP model required assessing knowledge, attitude, multi-stage behavior, and perceived threat. Besides, respondents’ demographics, such as age and gender, were also collected. The specific measurements are presented as follows.Knowledge referred to the public’s comprehension of the efficacy and resistance to antibiotics and was measured by 8 items , 34, incAttitude referred to the public’s preconception of antibiotic use and was measured by 3 items , 34, incMulti-stage behavior was measured by 9 items , includiPerceived threat referred to the public’s judgment of the likelihood of adverse outcomes before using antibiotics and was measured by 3 items , 35, incRespondents’ demographics were also collected, including age, gender, facility, education level, occupation, annual household income, whether they had a medical background, and whether they had a chronic disease.Each CHC was visited by a pair of trained investigators (one person was added or subtracted according to the size of the CHC). The recruited investigators learned theories and methods of social investigation from their courses and received a one-day intensive training, covering the background of the current survey, detailed interpretation of survey instruments, etc. After a simulation survey test, a total of 10 investigators passed and were recruited in the end.The investigators approached all of the respondents who met the inclusion criteria in each CHC. The investigators explained the purpose and procedure of the study and obtained written informed consent from each respondent before the respondent was asked to self-complete the questionnaire.Each investigator was asked to check the quality standards of the questionnaire, including completeness of filling, time appropriateness, and logical rationality of each questionnaire. Based on previous studies, questionnaires with more than 10% missing items were removed . The timIn this study, IBM SPSS Statistics version 25.0 and Amos 28.0 were jointly used to conduct the statistical analyses.One-way ANOVA or Fisher’s exact test was used to test the difference in the knowledge of the respondents among the three areas of different economic levels. Kruskal-Wallis rank test was used to test the difference in the attitude, multi-stage behavior, and perceived threat of the respondents among the three areas of different economic levels.A structural equation model (SEM) was applied to explore the relationship among knowledge, attitude, and multi-stage behavior of respondents, as well as the role of perceived threat and demographics in the relationship based on the expanding KAP model. Since the responses of each item were 5 or 7-point scale , means and variance-adjusted weighted least squares extraction estimation were applied to examine the relations among the study variables.p-value < 0.05. Goodness of fit indices were applied to evaluate the fit of the SEM: CMIN/DF , Root mean square error of approximation , Comparative fit index , Goodness of fit index , Normed fit index , Tucker-Lewis index  [One-way ANOVA, Fisher’s exact test, and Kruskal-Wallis rank test were considered statistically significant when the cellent) .A total of 908 questionnaires were returned, and 815 were deemed valid after applying quality standards, resulting in an effective response rate of 85.3%.The 815 respondents had a mean age of 46.244 years (SD = 16.758), and nearly two-thirds of the respondents surveyed were female (60.9%). The respondents were equally distributed among CHCs in low-income level areas (35.2%), middle-income level areas (33.1%), and high-income level areas (31.7%). On average, half of them received junior high school and below education level (56.8%), one-third of them were farmers (29.1%) and had less than 20,000 annual household income (27.5%). Most of them or their family members did not have a medical background (82.3%), and half of them or their family members had chronic disease (50.4%). The demographics of the respondents are presented in Table p < 0.05).As shown in Table p < 0.001).As shown in Table p < 0.001). The multi-stage behavior of the respondents’ antibiotic use for the common cold is presented in Table As for multi-stage behavior, the respondents reported the highest pre-use antibiotic behavior score in the item “I can recognize the severity of cold” , the respondents reported the highest during-use antibiotic behavior score in the item “I get antibiotics from specialized sources ” , and the respondents reported the highest post-use antibiotic behavior score in the item “In the future, I will not use antibiotics to treat cold” . On average, respondents who lived in high-income level areas had higher scores for antibiotic multi-stage behavior in the highest item than other sub-area (p < 0.05).As shown in Table χ²/df = 0.537 (excellent), RMSEA = 0.033 (excellent), CFI = 0.973 (excellent), GFI = 0.971 (excellent), NFI = 0.934 (excellent), TLI = 0.979 (excellent), and the detailed information is presented in Fig. The SEM based on the expanding KAP showed good model fit indices with β = 0.503, p < 0.05), pre-use antibiotic behavior , during-use antibiotic behavior , and post-use antibiotic behavior . Attitude had a positive effect on during-use antibiotic behavior , and post-use antibiotic behavior . The mediating effect of attitude was positive among knowledge, during-use antibiotic behavior , and post-use antibiotic behavior .As shown in Table β = 0.021, p < 0.001).As shown in Fig. β = 0.097, p < 0.001), a more correct and higher attitude score , and a higher post-use antibiotic behavior score . Respondents with a medical background had a higher knowledge score  and a more correct and higher attitude score . Respondents with a higher annual household income had a higher knowledge score . Compared with farmers and workers, respondents with a decenter job had a higher knowledge score . In addition, elderly respondents had a higher post-use antibiotic behavior score . Compared with other sub-area, respondents who lived in higher income level areas had a higher post-use antibiotic behavior score .As shown in Fig. Our study revealed that the expanding KAP showed good model fit indices. The public held low scores for knowledge, medium scores for attitude and multi-stage behavior, and high scores for perceived threat. Knowledge was a significant predictor of attitude and multi-stage behavior. Attitude was also demonstrated to be a significant predictor of during-use antibiotic behavior and post-use antibiotic behavior. In addition, there were positive mediating effects of attitude between knowledge, during-use antibiotic behavior, and post-use antibiotic behavior. In addition, perceived threat had a positive moderating effect between knowledge and post-use antibiotic behavior, and the demographics of the public were also related to their knowledge, attitude, and post-use antibiotic behavior.In previous research on antibiotic knowledge, attitudes, and behaviors, the conventional KAP model was predominantly employed without modifications, although some studies expanded their focus to encompass multiple attitude types . Our stuCongruent with previous studies, the public held a low level of antibiotic knowledge in this study –46. Our The public exhibited varying attitudes toward different aspects of antibiotic use , 48. OurThe public also exhibited varying behaviors toward different stages of antibiotic use , 52–54. Consistent with the results of many studies, the public perceived threat to antibiotics was relatively high –60. Our Congruent with previous studies, there was a relationship between knowledge, attitude, and behavior , 63–67. In addition, there was a mediating role of attitude , 69. OurInnovatively, our study explored the moderating effect of perceived threat within the expanding KAP model. Our study showed that a high public perceived threat increased the impact of knowledge on post-use antibiotic behavior. Sheeran et al. found that perceived threat had a moderating effect of 0.19 on the relationship between knowledge and COVID-19 vaccination behavioral intention, but perceived risk did not have a significant moderating effect on the relationship between knowledge and vaccination actual behavior . One posIt has been widely confirmed that individual demographics of the public, such as age, area , 71, eduApart from individual factors influencing antibiotic use among the public, the significance of physician training, internet regulations, and pharmacy regulations should also be discussed. A systematic review indicated that enhancing physicians’ rational antibiotic prescribing practices can reduce unrealistic expectations for antibiotics among the public and consequently promote their appropriate utilization . The pubThere were also some limitations in this study. First, it relied on self-report outcomes of the information which depended on the honesty and recall ability of the respondents and thus may be at risk of social desirability bias . Second,In this study, SEM was used to verify the validity of the expanding KAP model, accurately explore the impacts of knowledge and attitude on behavior of antibiotic use during the treatment of the common cold based on the expanding KAP model, and then identify the critical behavioral stage.The main study results revealed that the expanding KAP showed good model fit indices. The public held low scores for knowledge, medium scores for attitude and multi-stage behavior, and high scores for perceived threat. Knowledge had a positive effect on attitude and multi-stage behavior, and attitude also had a positive effect on during-use antibiotic behavior and post-use antibiotic behavior. The mediating effect of attitude was positive between knowledge, during-use antibiotic behavior, and post-use antibiotic behavior. The moderating effect of perceived threat showed a positive relationship between knowledge and post-use antibiotic behavior, and the demographics of the public were also related to their knowledge, attitude, and post-use antibiotic behavior.This study contributes to the development of the KAP model by expanding it to include knowledge, attitude, multi-stage behavior, and perceived threat. The results help to identify the critical behavioral stage, prioritize the post-use antibiotic behavior and during-use antibiotic behavior over pre-use antibiotic behavior, and suggest the need to focus on public health education and assist the public in establishing a correct perceived threat related to antibiotic use.


Antibiotic administration is a standard therapeutic practice for the treatment of reproductive disorders of equids. This might lead to undesirable microbial imbalance and could favour the acquisition of antibiotic resistance. Therefore, it is imperative for clinicians to understand patterns of antibiotic resistance when considering and developing treatment regimes. Continued engagement of clinicians with novel alternative approaches to treat reproductive infections would be essential in order to address this rising threat within the One Health perspective. The objectives of the present review were to present the bacterial infections in the reproductive system of equids , to upraise the literature related to the issue of antibiotic resistance of bacteria causing these infections and to discuss the topic from a clinical perspective. Initially, the review summarised the various infections of the reproductive system of equids  and the causal bacteria, providing relevant information about horses and donkeys. Subsequently, the clinical therapeutics of these infections were presented, taking into account the significance of antibiotic resistance of bacteria as a limiting factor in treating the infections. Finally, approaches to circumvent antibiotic resistance in clinical settings were summarized. It was concluded that awareness regarding antibiotic resistance in equine reproductive medicine would increase, as we would recognise the multifaceted problem of resistance. Actions and initiatives within the One Health approach, minimizing the potential dissemination of resistant strains to humans and to the environment, with specific applications in medicine of equids should be appropriately instituted internationally. Staphylococcus aureus isolates were recovered, despite the short and limited use of the drug by that time [Antibiotic resistance poses a significant threat to global health and sustainability, and it is now regarded as a critical One Health issue. Antibiotic-resistant pathogens exist across the animal, human and environment niches . In vetehat time . Since that time .Antibiotic resistance of pathogens is a significant and increasing problem in veterinary medicine ,6,7. ComWith regard to equine medicine, a large amount of information on the importance of antibiotic-resistant pathogens in horses has been published ,11,12,13The objectives of the present review were to present the bacterial infections in the reproductive system of equids , to upraise the literature related to the issue of antibiotic resistance of bacteria causing these infections and to discuss the topic from a clinical perspective.This narrative review includes primarily references published in journals cited in the Web of Science database ; papers published in these journals have been refereed. Various search terms have been employed to identify relevant publications . Subsequently, the full papers have been retrieved through the websites of the respective journals. The papers were evaluated for suitability for citation and were included and cited if within the scope of the review. The remaining literature items refer to books and book chapters, which provide an overview of existing knowledge, theses, official documents of international organisations and information websites.The median value of the year of publication of the references cited in the review is 2016, with the oldest reference cited date from January 1971 and the most recent one from March 2023, and an interquartile range for the year of publication of the references cited in the review of 12 years.Lactobacillus spp., which protects the reproductive tract from microbial ascension [Lactobacillus has been found to be less abundant in the vagina of mares, referring only to 0.18–0.37% of total bacterial numbers in that tissue [Lactobacillus equi, L. mucosae, L. pantheris, Enterococcus faecalis and E. faecium predominated among these organisms [Akkermansia spp., Arcanobacterium spp., Campylobacter spp., Corynebacterium spp., Fusobacterium spp., Kiritimatiaellae spp., Porphyromonas spp. and Streptococcus spp. (at the genus level) [Escherichia coli predominated in the vagina, a finding that did not differ between mares in which insemination had been performed and unbred control animals [Knowledge of bacteria dominating vaginal microbiota is perennially important to comprehend their role in ascending equine reproductive diseases ,19,20. Tscension . In contt tissue ,23. In as level) . No assos level) . Other r animals .Leptospira spp. should also be considered, as recent findings have indicated colonization of the vagina by L. interrogans serovars Australis and Bratislava of the organism  [The potential significance of l fluid) ,26; the l fluid) , althougl fluid) .To note that variations in the vaginal microbiota may occur as the result of anatomical malformations , which can lead to various disorders of the vaginal vestibule , use of irritant chemicals  during examination of the genital tract or artificial insemination, placement of intra-vaginal devices (for reproductive control), mating, vaginal injury or effects of antibiotics present in semen extenders. The above may lead to disturbance of the normal barrier and an imbalance of the normal vaginal microbiota ,30.It is noteworthy that, overall, the proportion of antibiotic-resistant bacteria recovered from the vagina of inseminated mares was higher than that among bacteria isolated from non-inseminated animals. Possibly, this might indicate a link with the exposure to antibiotics present in semen extenders .Bacillus spp., Corynebacterium spp., Lactobacillus spp., Staphylococcus spp. and Streptococcus spp.) from vaginal samples collected from healthy animals. Among these, Streptococcus equi subsp. zooepidemicus isolates from individuals with reproductive disorders were found to carry a higher number of virulence factors genes than isolates from clinically healthy jennies [With regard to female donkeys (jennies), previous studies have reported the recovery of various Gram-positive bacteria  or animals delaying uterine clearance, compromised immunity and/or exposed to venereal pathogens may fail to clear the bacterial load, as discussed above, which would potentially result in endometritis ,62.In sharp contrast to relevant results in mares, investigation of uterine infections of donkeys has been limited ,34,63. TE. coli, Kl. pneumoniae, Ps. aeruginosa and S. equi subsp. zooepidemicus may be recovered from those sites, often after mating [The semen of healthy stallions is considered to be bacteria-free, although it may become ‘contaminated’ during its passage through the genital tract at ejaculation . Indeed,r mating ,68; Cernr mating  indicateCorynebacterium pseudotuberculosis causing orchitis and epididymitis [Klebsiella pneumoniae causing orchitis, epididymitis and seminal vesiculitis [Other pathogens responsible for infections in the genital tract of stallions include idymitis  and Klebiculitis .Leptospira sp. (L. interrogans serovars Bratislava and Copenhageni) was reported in the semen of stallions, which may play a role in sexual transmission of the pathogen [Leptospira-free before the mating period, based on results of appropriate tests  [pathogen ,71. The samples) .S. equi subsp. zooepidemicus, Streptococcus equisimilis and S. aureus), a variety of other organisms have been isolated from clinically healthy animals. These include Gram-positive  and Gram-negative bacteria  [There are limited data about the bacterial populations in male donkeys (jacks). Further to bacteria with confirmed pathogenicity for these animals  .T. equigenitalis is an obligate parasite, colonising the surface of the terminal urethra and its fossa in stallions [T. asinigenitalis is occasionally isolated from the genital tract of male stallions [T. equigenitalis [tallions , whence tallions . It is ntallions ,75. T. atallions , as welltallions ,78,79,80enitalis ,81,82. TStreptococcus spp. [S. equi subsp. zooepidemicus [Actinobacillus spp., Corynebacterium spp., E. coli, Klebsiella spp., Pseudomonas spp., Rhodococcus equi and Staphylococcus spp. [Bacteria were isolated from milk samples collected from over 40% of clinically healthy mares during the post-foaling period . In genecus spp. ,87, specidemicus . Other pcus spp. ,85,88,89In equids, antibiotic administration is important for the treatment of genital infections. Antibiotics are commonly used for the treatment of a variety of infections, including endometritis, metritis, mastitis in female and orchitis and epididymitis in male animals.Selection of antibiotics must be based on rational principles and decision-making based on up-to-date scientific evidence after taking into consideration the drug, the bacteria involved and the animal. Equine clinicians have to consider a variety of issues in choosing the appropriate antibiotic regime. In most cases, at initiation of treatment, the pathogens involved  in the infection must be taken into account. In a case of a seriously ill or immunocompromised equid patient, a patient with long-standing infection that has already received a broad range of antibiotics or a patient with a history of unsuccessful treatments, precise details are needed to facilitate selection of the optimal antibiotic. In such patients, an array of factors must be evaluated before prescription of the antibiotic.S. aureus underline the importance of this factor [β-lactam antibiotics, time necessary to reach concentrations over the MIC in the tissues of hosts is generally long [β-lactam antibiotics, such pharmacodynamic relationships must be taken into account. Hence, for some infections, regimes including β-lactams may require the administration of these drugs up to four times daily [Among these are results of bacteriological testing, which should include firm identification of causal agents and details of antibiotic susceptibility testing. A frequent reason for possible treatment failure is drug selection pressure, especially when these are ill-chosen and/or administered in suboptimal dose rates. This can lead, additionally to treatment failure, to survival of antibiotic-resistant bacterial populations and induction of antibiotic-resistance mechanisms to other isolates . The recs factor . For β-llly long ; then, tes daily .Additionally, clinicians in choosing antibiotic for administration should take into account the One Health perspective and the World Health Organization classification of antibiotics into categories according to level of importance for treatment of human infections: critically important, highly important and important. In that case, possible alternatives should be preferred for administration.In any case, potential adverse effects of the antibiotic considered for administration should also be taken into account . These gExamples of commonly applied antibiotic administration regimes against reproductive infections of equids are in E. coli, Pseudomonas spp., Staphylococcus spp., S. equi [S. equi genital infections do not respond well to trimethoprim–sulphonamide administration, even though the bacteria might have been found to be susceptible to these antimicrobials [Systemic administration of antibiotics, performed in combination with uterine lavage and administration of ecbolic agents, is a commonly accepted therapeutic protocol for endometritis, as it results in higher antibiotic concentrations in uterine fluid compared to intrauterine administration of the antibiotics ,108. In  S. equi ,114,115.crobials . Additiocrobials ,118.−1 thrice daily, intravenously), as it can minimise the adverse haemodynamic effects of endotoxaemia [Antibiotic administration is also recommended, along with non-steroidal anti-inflammatory drugs, in cases of retention of foetal membranes, which is deemed to be an emergency in equine clinical practice . Non-stetoxaemia .If intrauterine administration of antibiotics is to be selected, only non-irritating water-soluble antibiotics  should be used for successful outcome . RelevanUterine lavage by using normal saline after mating is often employed in stud farms because of its ability to increase the tone of uterine muscular layer and its effect in clearing microorganisms, spermatozoa, inflammatory cells and debris from the uterine lumen, as these have been found to contribute to early embryonic death in mares . Use of Ps. aeruginosa [Bacteroides fragilis) and has also been reported for clinical application [Accumulation of exudate within the uterine lumen can inactivate or dilute the infused antibiotic , thus reruginosa . Gentamiruginosa . In caseruginosa . The useruginosa ,129. Givruginosa ,131. Thelication . HoweverThe treatment regime of penile and preputial infections caused by opportunistic pathogens usually consists of using disinfectants, as systemic antibiotic administration is often unrewarding . When arTreatment of equine mastitis should be based on systemic administration of antibiotics ,135. BroAntibiotic resistance of bacteria isolated from equine reproductive organs has been reported for animals with fertility problems, as shown in studies performed in various countries in Europe  has been based on the administration of immunoglobulins and complement to support treatment of bacterial endometritis in mares . In an i2α was compared to intrauterine administration of penicillin against S. equi subsp. zooepidemicus uterine infection, did not show differences in efficacy between the two regimes [2α would be initiated early, antibiotic administration may not be necessary [The traditional treatment of many common reproductive disorders in female equids includes the application of uterine lavage and the use of ecbolic agents (or uterotonics), which are pharmacological substances employed for the initiation of contractions or increased tonicity of the uterus, for the induction of parturition and/or for the reduction of post-partum haemorrhage , which a regimes . Hence, ecessary .Other ecbolic agents commonly employed include oxytocin or cloprostenol. Oxytocin increases the risk for development of colic-type clinical signs in horses after administration ,170. TheMoreover, it is noteworthy that, in another study, Li et al.  reportedIn any case, the short half-life of oxytocin requires frequent repeated administration, whilst cloprostenol induces uterine contractions of longer duration . As an aThe immune response of the endometrium of mares has been extensively investigated ,177. A pThe addition of antibiotics in semen extenders  may trigger changes in susceptibility/resistance patterns of vaginal bacteria, subsequent to the exposure to semen extenders . Hence, Ps. aeruginosa or Kl. pneumoniae, can be performed by means of daily application of disinfectant solutions, e.g., iodine-based surgical scrubs, hydrochloric acid diluted solutions or sodium hypochlorite bleach solutions, on the external genitalia of the animals [Treatment for infections of the genital system of male equids, caused by  animals .Studies have discussed the immunomodulatory nature of mesenchymal stem cells and the role of antimicrobial peptides, providing a potential alternative to use of antibiotics, by expressing antibacterial proteins, e.g., lipocalin-2 . Harman Antibiotic resistance is an important global public health threat . ImproviS. aureus from infections of horses have been found to disseminate often to veterinarians in Germany [mecC-carrying methicillin-resistant S. aureus between a horse and the attending veterinarian. Examples of regulatory interventions taken to control antimicrobial resistance may include strict regulations for licencing, prescribing and marketing of antibiotics [Among these, regulatory and voluntary initiatives aim to decrease the dissemination of antibiotic-resistant bacteria to animals, as well as to people, given that recent studies have linked horses as a potential reservoir of a variety of pathogens, which may be transmitted to people . For exa Germany ; moreove Germany  have recibiotics .Awareness regarding antibiotic resistance in equine reproductive medicine would increase, as we would recognise the multifaceted problem of resistance. This practice may lead to undesirable microbial imbalance and can favour the acquisition of antibiotic resistance. It is imperative for equine clinicians to understand local patterns of antibiotic resistance when considering and developing treatment regimes . ContinuWith regard to work in equids, specific initiatives have been set up. Examples include the BEVA Toolkit in the United Kingdom  and the This approach, additionally to control of dissemination between animals and people, also involves the monitoring of antibiotic-resistant bacteria or resistance genes to various environmental matrices; these may refer to waste, surface waters, agricultural runoff and water for use in aquaculture, and should not be ignored, further shaping the directions for controlling the problem as much as possible. In recent relevant studies, the environment–animal sharing of resistance has been found to have hindered the impact of interventions for the reduction of antibiotic consumption in animals and to have affected the epidemiology of infections caused by resistant bacteria .


Streptococcus sobrinus (S. sobrinus). Methods: this in vitro study included premolar teeth and compared APC FF adhesive brackets  with conventional adhesive brackets  from the same company. Specimens were incubated with a positive control group  and a negative control group  in an S. sobrinus suspension for three weeks. To evaluate the grade of enamel demineralization, the samples were analyzed using a polarizing microscope. Results: the test specimens of group B with conventionally bonded bracket adhesive showed significantly greater (+10.8 μm) demineralization with regard to the penetration depth of the demineralization than the PCG (p = 0.012). Thus, there was a difference from group A with the new bracket adhesive of the FF brackets (+7.29 μm). Significantly, demineralization was more pronounced cervically than coronally in both groups, and it occurred cervically more frequently than grade 3 demineralization (p = 0.001). Conclusions: it seems plausible that new orthodontic bracket adhesives and the modern FF adhesive system positively contribute to the reduction in enamel demineralization during orthodontic treatment.Background: enamel demineralization is a common side effect of orthodontic therapy with fixed braces. The aim of the present in vitro study was to compare a conventional adhesive system and a modern adhesive system (APC Flash-Free [FF] technology) with regard to the demineralization of enamel by  Orthodontic treatment often involves the use of fixed treatment appliances. These are applied to the surface of teeth using certain adhesive systems. The adhesion between the tooth tissue and the dental material depends on various factors. The surface and the adhesive are decisive for the bonding between the tooth and the bracket. The correct preparation of the surfaces is ensured by roughening with phosphoric acid and bonding systems . HoweverStreptococcus sobrinus, the main bacteria that colonizes oral surfaces in the occurrence of cariogenesis [In addition to the preventive methods mentioned above, there is another component that influences bacterial adhesion—the spatial nature of the adhesive system . Ideallyogenesis ,11.Extracted teeth were collected from dental and oral surgery practices and subsequently sorted for suitability for the study. The teeth were manually cleaned with water after extraction, disinfected in alcohol for 2 min, and stored in 0.9% sodium chloride solution. As intact enamel is essential for the experimental procedure, any teeth with caries, fluorosis, enamel cracks, white spot lesions, anatomical anomalies, enamel spalling due to extraction, and iatrogenic restorations were excluded. The teeth were examined under a JenaPol polarizing microscope  by a dentist. Only teeth with intact and caries-free enamel surfaces and free of enamel structural defects were selected. The patients gave their consent to release the extracted teeth for the study. The consent of the ethics committee of the medical faculty at the University of Jena was also obtained (no. 2021-2486_1).The teeth were manually cut along the longitudinal fissure from the mesial direction to the distal direction with a diamond-coated disc  with the dental mikromotor AM-25 A RM  under water cooling at 12.000 rpm. In a second cut, the roots of the teeth were separated horizontally in the area just below the enamel–cement interface and embedded in epoxy resin .To avoid contamination with foreign germs, the test specimens were autoclaved for 20 min at 121 °C in the autoclave Vacuklav 40 B+ Evolution . The following steps were performed on a sterile workbench with a suction unit. The teeth were placed on the work surface under the suction unit to dry. After 1 h, the test specimens were sufficiently dry to start bonding the brackets. For both bracket adhesive systems, the enamel was prepared with Transbond TM Plus Self Etching Primer . The mixing process was carried out according to the manufacturer’s instructions. Transbond TM Plus Self Etching Primer was applied to the area of the tooth intended for the bracket and massaged in for 5 s on the tooth surface. The bonding was then lightly blown for approximately 2 s and then lightly polymerized for 20 s. An Acteon Mini LED polymerization lamp  was used for this purpose.n = 15), Clarity Advanced ceramic brackets  were removed from the packaging, and the bracket bases were coated with Transbond XT Ligth Cure Adhesive Paste , and the brackets were positioned on the teeth with moderate pressure using bracket tweezers. The resulting excess was removed using a Heideman spatula , and then the brackets were light-polymerized from the mesial and distal sides for 20 s. For group A (n = 15), the FF brackets  were removed from the opaque packaging, positioned on the pretreated teeth using bracket tweezers, and fixed with moderate pressure. Subsequently, light polymerization was performed for 20 s from each side. In addition, a positive control group (PCG) (n = 5) and a negative control group (NCG) (n = 5) were created. The PCG was included in the bacterial suspension without gluing a bracket. The NCG was only placed in the culture medium. After application of the brackets and before inoculation with S. sobrinus, UV sterilization was performed for 30 min on the sterile workbench  to prevent contamination with foreign germs. Thus, a total of forty teeth were produced as test specimens—fifteen for group A, fifteen for group B, and five each for the PCG and NCG.For group B (S. sobrinus (strain no: DSM 20742 dated 05/19)  was thawed, and a 48 h culture was established on a blood agar plate . One to two colonies were collected and suspended in 10 mL Schaedler bouillon  and then cultured again for 24 h. The culture was then centrifuged at 3500 u/min for 5 min, and the supernatant was discarded. The sediment was mixed with 1 mL Schaedler bouillon  and further diluted with Schaedler bouillon  to prepare an inoculum with an optical density of 0.01 from this bacterial batch. Next, all samples of groups A and B and the PCG were inoculated with 1 mL of the bacterial inoculum and 2 mL tryptic soy broth. The NCG was filled with 3 mL pure Schaedler bouillon  per well. A check of the pH of the solution showed a value of 7 at the beginning.2, 10% CO2, and 10% H2. The medium was changed once a week, removing 2 mL from each well and adding 2.5 mL Schaedler bouillon  to compensate for any evaporated medium. All test specimens were incubated in the anaerobic box for 3 weeks.The well plates were stored in an anaerobic box  at 37 °C, 80% NS. sobrinus, a determination of the colony-forming units was made at each medium change. The determination was made from any well, 1× per group. For this purpose, 10 µL bacterial preparation plus 990 µL Schaedler bouillon  were diluted . Of this, 20 µL were spatted out on Schaedler bouillon  or agar plates . For the negative control, 20 µm were spatted directly onto Skinner agar plates. After 3 d, the colonies were counted and calculated as follows: number of colonies × 50 (factor converted 20 µL to 1 mL) × 100 (dilution 1:100).To control the bacterial growth of After 3 weeks, the test specimens were removed from the solution. The slices were rinsed with NaCl. Bacteria were fixed in 4% paraformaldehyde (PFA)  for 48 h at approximately 4 °C. A repeat pH control of the bacterial suspension revealed a pH value of 5.0 for six randomly selected wells of group A and group B. The pH value of the negative controls remained stable at 7.0. The pH control was performed with buffers from Thermo Fisher . After 48 h, the PFA was rinsed from the specimens with NaCl. The group A and B brackets were carefully detached from the teeth using direct bond and bracket removal forceps . The bonding was left in place. Special attention was paid to keeping the enamel surface intact in order not to damage the surface under observation. After careful removal, all specimens were stored in 20 mL of distilled water at approximately 4 °C. The epoxy resin  in which the teeth were initially embedded was removed. This was performed manually using two flat forceps. For analysis, by means of a polarization microscope haircut, a thickness of 80–100 μm was required. This was achieved with two saw microtomes of the Leica type SP1600 . Due to the surface area, approximately 16 sections on a test specimen can be evaluated in the polarization microscope. With a total of 40 test specimens, this would theoretically be 640 measuring points. Cross-sectional images were obtained showing the teeth tilted 90° in cross-section from the cusp tip to beyond the enamel–cement interface. Microscopy was performed with a JenaPol polarizing microscope  at 30× magnification. The sections were photographed using an AxioCam microscope camera . The sections were evaluated using Axiovision software, version 4.8.2.0 . The choice of magnification allowed exact scaling on the recorded image and, thus, a micrometer-precise measurement of the demineralization depth.For the evaluation, the field to be considered was set at 1000 μm from the beginning of the transition of the bracket adhesive to the enamel in the direction of the periphery. Demineralization was measured from the deepest point of penetration to the enamel surface. Because demineralization was often similar in depth, but varied in severity, each measured case of demineralization was assigned a severity level, and, for this purpose, a classification into demineralization grades was developed for this study:Grade 0 = No demineralizationGrade 1 = Incipient demineralizationGrade 2 = Demineralization with strongly visible lesion bodyGrade 3 = Demineralization with clearly visible lesion body and broken surfacep-value < 0.05 was considered significant. Statistical analyses were conducted in SPSS . Descriptive statistics were performed for both groups, and median, as well as interquartile ranges, were calculated. Data distribution was assessed with the Kolmogorov-Smirnov normality test. The Mann–Whitney U test for pairwise comparisons was used for non-parametric testing, as data did not pass the normality test. A two-sided The procedure is generally feasible and suitable for the detection of demineralization in the bracket environment. Incipient demineralization was particularly evident in the area of the transition from the bracket adhesive to the enamel. All groups  that were placed in a bacterial suspension showed slight demineralization. The NCG showed no demineralization. There is no evidence to suggest that the bacterial medium used in this experiment has a demineralizing effect on the surface of human enamel.Of the theoretical 640 measured values to be collected, 100 measuring points could not be evaluated. This was mainly due to melt fractures that occurred during the production of the fine sections in the saw microtome. A total of 540 measured values for the depth of demineralization were included in the statistical evaluation. Regarding the severity of demineralization, differences were found between the bracket groups and the PCG.p = 0.402) was found for this mean difference. Compared to the PCG, grade 1 demineralization decreased by 16.8%, grade 2 demineralization increased by 13.8%, and grade 3 demineralization increased by 3%. The conventionally bonded brackets in group B had a mean penetration depth of 76.14 μm at 211 measurement sites. This value increased by 10.83 μm compared to the PCG. Significance was found in this mean difference at p = 0.012 . Both bracket groups A and B had a higher chance of grade 2 demineralization than the PCG  increased on average compared to the PCG (not bonded with brackets) . In this the PCG . The oddp = 0.808 for group A and p = 0.850 for group B and is due to the low number of readings in the PCG. Demineralization-free sections could only be microscoped in the NCG  was different. Regarding the penetration depth, the demineralization at the coronal junction of adhesive and enamel was, on average, 2.091 µm deeper than at the cervical junction . There w = 0.001 .The insertion of a multiband appliance increases the occurrence of demineralization in relation to the penetration depth and severity of demineralization. There are different strategies of modern adhesive systems to reduce the demineralization of the enamel. These adhesive systems are often combined with sealers for smooth surfaces. It is, therefore, obvious that smooth surfaces and a homogeneous adhesive layer have a positive effect on the structural surface and reduce the demineralization of the enamel. One possible approach that could reduce the demineralization which occurs on tooth surfaces, is to use brackets with precoated adhesive, as this provides the optimal amount of adhesive on the bracket base, results in less excess adhesive, and therefore less bacterial accumulation. This has already been shown in a study, where less excess adhesive in the area around the bracket reduces the adhesion surface, and, therefore, fewer bacteria accumulate in the bracket periphery . In addiTherefore, practitioners had to be vigilant in removing any excess to prevent plaque retention, gingival irritation, and white spots ,14,15. FOur study relates to the demineralization of enamel, which is caused by bacterial biofilm accumulation on the materials, particularly on the bracket adhesive. The nature of the material, as well as the localization and size of the material, plays a decisive role in biofilm deposition. As early as 1979, electron microscopic investigations of biofilms formed around brackets revealed that biofilms preferentially form on roughened surfaces at the transition from enamel to bracket adhesive. Particularly mature plaque was found gingival to the bracket . RegardiS. sobrinus during the experimental procedure. According to the preliminary tests, the measured values were in the targeted interval between 50 μm and 100 μm; this is in agreement with the research results of previous studies [The present study shows that, with regard to the amount of demineralization that occurred, there was measurable demineralization in groups A and B and the PCG in every evaluable section. The choice of different bracket adhesive systems can, therefore, only influence the formation of demineralization and not prevent it. Therefore, it is essential to maintain sufficient oral hygiene, regardless of the brackets or adhesives used. The demineralization in the PCG was intermediate with a penetration depth of 65.31 μm. Demineralization was found in all 42 sections; 66.7% of the demineralization was grade 1.31% was grade 2, and 2.4% was grade 3. This was a significant increase compared to the NCG, which proves that the measured demineralization was caused by metabolic products of  studies . Therefop = 0.001 was shown in the comparison of severity grades in coronal and cervical lesions. Here, cervical lesions had a 2.65-fold higher probability of grade 2 demineralization compared to coronal lesions. For grade 3, the probability increased by a factor of 10.02. The cause is not evident from the available data, but it could be an increased tendency to erosion and abrasion of the cervical enamel. The thinner enamel running out here could lead to increased enamel cracks. The worse cervical hygienity compared to the coronal cusp discharge and, consequently, the more premineralized areas in the cervical enamel could favor the formation of more severe demineralization.Furthermore, a significance of S. sobrinus, which represents a significantly simplified simulation of the otherwise very complex microbiological flora of the oral cavity. In the caries model used, S. sobrinus was chosen because it is a guide germ for surface adhesion in the oral cavity. Along with S. mutans and Lactobacilli, it is one of the leading germs in cariogenesis, but it has the highest virulence factor [A limitation of the study is the in vitro experiment with the monoculture consisting of e factor . FurtherIn addition, the hygienity of the bracket adhesives used in this trial represents a component with a major influence on demineralization in the bracket environment. Therefore, strictly speaking, the actual effects can only be determined by human clinical studies. Further studies should, therefore, be conducted to test and further develop materials for bacteria adhesion and subsequent demineralization of enamel in the bracket environment.Both groups of brackets showed demineralization, which was more pronounced in comparison to non-adhered teeth. These results emphasize the importance of sufficient oral hygiene during multiband therapy. However, it was found that the nature of the dental material (the bracket adhesive) with which the bracket is applied to the enamel has an influence on bacterial accumulation and the resulting demineralization of the tooth structure. The test specimens of group B with conventionally bonded bracket adhesive showed significantly less (+10.8 μm) demineralization with regard to the penetration depth of the demineralization than the PCG. The difference in this respect to group A with the new bracket adhesive of FF brackets (+7.29 μm) was verifiable.For final clarification of the full caries-protective potential of the modern FF bracket adhesive system, a series of tests under clinical conditions with implementation of a rinsing protocol should be undertaken, as the adhesive excess formed as a chamfer enables significantly improved hygienity. It seems plausible that new orthodontic bracket adhesive and the modern FF adhesive system could produce further positive results in such a study.