Decolonizing drug-resistant E. coli with phage and probiotics: breaking the frequency-dependent dominance of residents.

Widespread antibiotic resistance in commensal bacteria creates a persistent challenge for human health. Resident drug-resistant microbes can prevent clinical interventions, colonize wounds post-surgery, pass resistance traits to pathogens or move to more harmful niches following routine interventions such as catheterization. Accelerating the removal of resistant bacteria or actively decolonizing particular lineages from hosts could therefore have a number of long-term benefits. However, removing resident bacteria via competition with probiotics, for example, poses a number of ecological challenges. Resident microbes are likely to have physiological and numerical advantages and competition based on bacteriocins or other secreted antagonists is expected to give advantages to the dominant partner, via positive frequency dependence. Since a narrow range of Escherichia coli genotypes (primarily those belonging to the clonal group ST131) cause a significant proportion of multidrug-resistant infections, this group presents a promising target for decolonization with bacteriophage, as narrow-host-range viral predation could lead to selective removal of particular genotypes. In this study we tested how a combination of an ST131-specific phage and competition from the well-known probiotic E. coli Nissle strain could displace E. coli ST131 under aerobic and anaerobic growth conditions in vitro. We showed that the addition of phage was able to break the frequency-dependent advantage of a numerically dominant ST131 isolate. Moreover, the addition of competing E. coli Nissle could improve the ability of phage to suppress ST131 by two orders of magnitude. Low-cost phage resistance evolved readily in these experiments and was not inhibited by the presence of a probiotic competitor. Nevertheless, combinations of phage and probiotic produced stable long-term suppression of ST131 over multiple transfers and under both aerobic and anaerobic growth conditions. Combinations of phage and probiotic therefore have real potential for accelerating the removal of drug-resistant commensal targets.

Telemedicine and Vascular Surgery: Expanding Access and Providing Care Through the COVID-19 Pandemic.

INTRODUCTION: Access to surgical service is limited by provider availability and geographic barriers. Telemedicine ensures that patients can access medical care. OBJECTIVE: The objective is to describe our use of telemedicine in delivering vascular surgery services to remote locations before and during the COVID-19 pandemic. METHODS: We conducted a retrospective chart review analyzing care delivered at six vascular surgery telemedicine clinics over a 22-month period. We examined vascular diagnoses, recommended interventions, referrals placed, and emergency department visits within 30 days of evaluation. We calculated travel distance saved for patients between their local clinic and our main hospital. RESULTS: We identified 94 patients and 144 telemedicine visits, with an average of 1.5 visits per patient (SD = 0.73). The most common referrals were for peripheral artery disease (20.2%) and abdominal aortic aneurysm (14.9%). Three patients were immediately referred to the emergency department due to concern for acute limb ischemia (2) or questionable symptomatic AAA (1). Telemedicine visit recommendations were distributed between no intervention (n = 30, 31.9%), medical management (n = 41, 43.6%), and surgical intervention (n = 23, 24.5%).The surgical intervention cohort was most commonly referred to arterial revascularization (n = 4), venous ablation (n = 4), and arteriovenous fistula procedures (n = 4). Fourteen patients came to our main hospital for surgery and four to local providers. Average travel distance saved per telemedicine visit was 104 miles (SD = 43.7). CONCLUSIONS: Telemedicine provided safe, efficient care during the COVID-19 pandemic and saved patients an average of 104 travel miles per visit.

Seasonal operation of dual-mode biofilters: The influence of plant species on stormwater and greywater treatment.

The use of stormwater biofilters (also known as bioretention systems and raingardens), in tropical and semi-arid areas is hindered by seasonal rainfall patterns which cause extended dry periods. These periods can result in plant die-off, long-term damage to system health and leaching of pollutants when stormwater inflows resume. Using an additional polluted water source during dry periods could minimise system stress and eliminate the need to irrigate biofilters with potable water during dry spells. As such, the presented laboratory study tested the seasonal operation of biofilters, by switching from stormwater treatment in wet months to greywater treatment in dry months. Forty-five single planted biofilter columns, incorporating sedges, grasses, understory ornamentals and vines, were subjected to four months of stormwater inflows, followed by three months of greywater inflows. We also investigated the impact of including a carbon source in the saturated zone on treatment performance. The results showed plant species selection to be critical for nitrogen and phosphorus removal, with consistently effective species such as Carex appressa and Canna x generalis able to maintain low outflow concentrations (e.g. total nitrogen of 0.2-0.3 mg/L and 0.3-0.6 mg/L, respectively) across both water sources. Low outflow phosphorus concentrations were associated with plant species that had high filterable reactive phosphorus removal across both water sources. Similarly, higher removal of ammonia and oxidised nitrogen was associated with lower overall nitrogen concentrations. In contrast, high removal of total suspended sediment (>94%), biochemical oxygen demand (>98%) and some heavy metals (e.g. lead >98% and copper >93%) was reported across all designs. The results suggest that with the careful selection of plant species, biofilters can be operated seasonally as a feasible and practical solution to maintaining system health during extended dry periods.

Dual-mode stormwater-greywater biofilters: The impact of alternating water sources on treatment performance.

The intermittent nature of stormwater runoff impacts the treatment performance of biofilters, also known as stormwater biofiltration or bioretention systems and raingardens. During extended dry periods, which are common even in temperate climates, plants can perish, creating unattractive and non-functional systems that might leach pollutants during the next rainfall event. The current solution is to irrigate during long dry spells, which is costly and unsustainable as biofilters become more widespread. This paper presents the development of dual-mode biofilters, where stormwater and greywater are treated within the same system. Fifty columns, utilising eight plant species, including understory and climbing ornamentals, and designs with and without a carbon source in the submerged zone, were subjected to alternating greywater and stormwater inflows over five months. Six sampling events investigated treatment performance across these switching inflows and an extended dry period (atypical event). Good removal of total suspended solids (>83%), biochemical oxygen demand (>86%) and some heavy metals (e.g. lead >96%) were reported irrespective of design. Plant species selection was critical for the removal of nitrogen (2 to 79%) and phosphorus (12 to 75%) under dual-mode operation. However, following the extended dry period, plants with the lowest nutrient outflow concentrations also experienced some of the highest sediment and carbon concentrations, suggesting that a mixture of plant species may be beneficial for withstanding abnormal conditions. Differences between the treatment performance of designs with and without a carbon source were negligible, with potential benefits possibly negated due to the increased root mass that comes with age (systems were approximately two years old) and the release of carbon from root exudates. The results demonstrate the potential for dual-mode stormwater-greywater biofilters as an alternative to single-mode systems as they can provide effective treatment, along with greater volumes of treated water, while maintaining system performance throughout the year.