A healthier world for all: is it possible?

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Today the world is facing a crisis that threatens the fundamental pillars of public health, scientific integrity and social stability. These challenges can exacerbate global inequalities, jeopardise health security and undermine the progress achieved through years of international collaboration. It is crucial that health scientists are aware of these interconnected challenges and respond united and determined.

For these reasons, in a paper recently published in the World Journal of Emergency Surgery, a viewpoint declaration was signed by the Global Consortium for Solidarity to Overcome Challenges, Restore Trust and Advance Science for a Sustainable Future. This group included 366 healthcare workers and scientists from 119 countries from across all continents and belonging to numerous disciplines.

The paper aims to highlight the urgent need for global solidarity and collective action to address several global health challenges.

The authors begin their dissertation by focusing on the importance of investing in resilient healthcare systems, considering the vulnerability and fragility of global public health systems revealed by the COVID-19 pandemic. Moreover, the rapid process of globalisation has challenged traditional border-based control mechanisms, calling for new approaches to governing the globalization of public health.

Then, considering climate change as a public health emergency is essential, as well as evaluating the challenges of infectious diseases and antimicrobial resistance (AMR). In particular, AMR is considered by the authors as a global scientific, human, and economic challenge. They wish for a new research model on AMR that promotes collaboration and integrates knowledge across disciplines, ensuring a holistic approach and universal impact. Therefore, these objectives can be achieved adopting a One Health approach to combat infectious diseases and AMR.

Moreover, wars must be considered as public health emergencies. They have devastating effects on health, requiring immediate and coordinated global response. The healthcare community must play a leading role in preventing wars and promoting peace.

Among the challenges to be faced today, the authors included also combating false and misleading information. False narratives regarding health can damage public trust in science. Scientists must actively involve the public and communicate their findings in transparent and accessible ways. Furthermore, rethinking the quality and integrity of scientific research is essential as well.

Regulating artificial intelligence use in healthcare should be a priority, wisely considering its opportunities and challenges in a balance between innovation and ethical oversight. Finally, the importance of strengthening the global health governance is clearly underlined.

The authors conclude that scientists, clinicians, and healers can be stronger and better in restoring global trust and confidence only if they are united by a single but shared goal: a healthier world for all.

Reference

Sartelli M, Mossialos E, Coccolini F, et al. Global health at crossroads: uniting together to overcome challenges, restore trust and advance priorities for a sustainable future. World J Emerg Surg. 2025;20:84.

Antibiotics for Intra-Abdominal Infections: When, Which, How and How Long?

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) are among the most challenging problems in surgical practice, ranging from uncomplicated appendicitis to life-threatening peritonitis. IAIs require prompt diagnosis, timely surgical intervention, and appropriate antimicrobial therapy.

Antibiotics are essential in IAIs management. For years, an empirical broad-spectrum approach, often with prolonged courses of multiple agents, has been the default response to IAIs. This approach certainly saved lives. However, it has promoted the selection of multidrug-resistant organisms.

Prescribing antibiotics in IAIs is challenging: it requires a balance between urgency and precision, between lifesaving therapy and the long-term threat of antimicrobial resistance (AMR). Antibiotic therapy should be individualised and tailored on the patient’s clinical conditions and the local epidemiology.

In community-acquired IAIs, narrow-spectrum coverage is often sufficient, avoiding unnecessary exposure to carbapenems or anti-pseudomonal agents. In contrast, healthcare-associated infections, especially in patients with previous antibiotic exposure or serious illness, may need a broader empiric approach, followed by de-escalation once cultures clarify the microbiologic picture.

For these reasons, in a narrative review recently published in Antibiotics, Massimo Sartelli and his collaborators tried to answer four questions.

When should antibiotics be used in patients with IAIs? Which antibiotics should be selected? How should they be managed? How long should they be administered in patients with IAIs?

The authors concluded that advances in antibiotic agents, optimised pharmacokinetics and pharmacodynamics strategies, and stewardship-driven de-escalation provide opportunities to improve efficacy while preserving future antibiotic utility in an era of increasing AMR.

Reference

Sartelli M, Palmieri M, Labricciosa FM. Antibiotics for Intra-Abdominal Infections: When, Which, How and How Long? Antibiotics. 2025;14(11):1127.

Optimizing surgical antibiotic prophylaxis in the era of antimicrobial resistance: a position paper

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Antimicrobial resistance (AMR) represents a serious threat to global health because antibiotics are losing effectiveness in both prevention and treatment of infections. The rising incidence of multidrug-resistant organisms (MDROs) challenges the efficacy of conventional surgical antibiotic prophylaxis (SAP) regimens.

Addressing this issue requires a re-examination of perioperative protocols, with attention to individual patient risk factors for MDRO colonization. Therefore, a targeted SAP approach should be considered when MDROs represent a significant surgical site infection risk. Thus far, limited evidence provides guidance on SAP selection in high-risk patients.

For these reasons, a position paper has been recently publishedin Pathogens by the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Following the best scientific evidence from PubMed and EMBASE Library a multidisciplinary working group produced 15 recommendation statements to optimize SAP in a context of AMR. They were graded according to the GRADE hierarchy of evidence. Using a Delphi approach, statements reaching ≥80% agreement were approved as strong recommendations.

This position paper is structured in three sections.

The first one widely reviewed the core principles for appropriate SAP. Then, the second section examined screening, decolonization, and targeted SAP in patients colonized with MDROs focusing separately on Gram-positive bacteria (methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]), and Gram-negative bacteria (extended-spectrum beta-lactamase [ESBL]-producing and carbapenem-resistant Enterobacterales [CRE]).

The third section discussed the barriers to changing surgeons’ prescribing behaviours, focusing on surgeons’ awareness and dynamics within surgical teams that influence antibiotic prescribing practices. To track adherence and improvement in SAP, the authors listed the key performance indicators, and suggested a checklist, too.

Finally, they summarized all the 15 recommendation statements expressed by the multidisciplinary working group in order to provide practical guidance for optimising SAP in the context of an AMR era.

The authors concluded that in the AMR era the goal is to ensure that SAP remains effective in preventing infections while minimizing unnecessary antibiotic exposure. This can be achieved balancing patient safety with stewardship principles, tailoring SAP to epidemiological risk, and promoting a culture of shared responsibility across the surgical pathway.

Reference

Sartelli M, Labricciosa FM, Casini B, et al. Optimizing Surgical Antibiotic Prophylaxis in the Era of Antimicrobial Resistance: A Position Paper from the Italian Multidisciplinary Society for the Prevention of Healthcare-Associated Infections (SIMPIOS). Pathogens. 2025;14(10):1031.

Epidemiological analysis of intra-abdominal infections in Italy: the IRIS study

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Intra-abdominal infections (IAIs) are common and serious surgical emergencies. Over the past few years, an increase in antimicrobial resistance (AMR) associated with IAIs has been observed worldwide, responsible for a significant increase in morbidity and mortality rates, and overall healthcare costs. In order to improve the quality of treatment, it is essential to recognize the underlying local epidemiology, clinical implications, and appropriate management of AMR.

In a paper recently published in the World Journal of Emergency Surgery, a prospective, observational, nationwide, multicentre study was conducted to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) included 4,530 consecutively hospitalized patients – older than 16 years of age – from 23 different Italian hospitals, between May 1, 2021 and April 31, 2023, with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment.

Overall, 70.9% of the cases were community acquired infections, the predominant type of infection for all the diagnosis. The majority of healthcare-associated infections were represented by colonic perforation and diverticulitis (28.3%), small bowel occlusion (19%) and intestinal ischemia (18%). At presentation, 27.8% of patients had a septic shock. The overall mortality rate was 5.13%, and 16.5% of patients required admission to Intensive Care Unit.

Microbiological samples were collected from 3,208 (70.8%) patients; 48.8% of intrabdominal samples resulted positive. Not surprisingly, the major pathogen involved in IAIs was E. coli (45.6%). Remarkably, in 29% of the cases microbiological samples were not collected.

During hospital stay, an empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (e.g., in 30.1% appendicitis, 30.5% of cholecystitis, and 55% small bowel perforation), followed by piperacillin/tazobactam (e.g., in 13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles were the most used antifungals in patients that received empiric antifungal therapy.

The authors concluded that antibiotic stewardship programs and correct antimicrobial and antifungal prescription campaigns are needed to further improve the appropriateness of drug usage and reduce the burden of AMR. This will contribute to better care and treatment for the next generations.

Reference

Coccolini F, Brogi E, Ceresoli M, et al. Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections—the IRIS study: a prospective observational nationwide study. World J Emerg Surg. 2025;20:22.

Antimicrobial peptides and their coatings to counter multidrug-resistant clinical pathogens

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Antimicrobial resistance (AMR) is a growing public health issue. Unfortunately, microorganisms use several mechanisms to inactivate antimicrobials, making ineffective traditional therapies currently employed. Therefore, discovering novel antimicrobial agents is essential to successfully address this global challenge.

In a paper recently published in Antibiotics, a multidisciplinary group of investigators focused on non-antibiotic antimicrobial strategies, particularly on the use of antimicrobial peptides, as potential strategies for managing multidrug resistant (MDR) pathogens.

The authors started their narrative review discussing the alternative non-antibiotic approaches for the prevention and control of MDR pathogens, namely bacteriophage therapy, probiotics, immunotherapies, photodynamic therapy, essential oils, nanoparticles, and antimicrobial peptides (AMPs).

After summarising the benefits and limitations of these different approaches, the authors focused on AMP mimetics and strategies to enhance AMP activity, the mechanisms of action of AMPs, and the reduction in virulence factors by peptidomimetics.

Specific subsections of the paper concerned antifungal, antiviral and antiparasitic peptides and their mimetics. Moreover, the authors provided an overview of antimicrobial coatings using AMPs and their relevance in medical settings. Finally, they presented several additional strategies for attachment and functionalization.

AMPs are promising alternative antimicrobial agents to tackle AMR. Although their clinical potential is limited by different challenges, their stability, safety, and efficacy can be enhanced, making them more appropriate for clinical applications.

AMPs and their synthetic mimetics represent a new frontier in antimicrobial coatings against bacterial and viral pathogens. Indeed, they are a precious tool in the fight against infectious diseases, being able to disrupt microbial membranes and prevent pathogen adhesion.

The authors concluded that further research should be performed in the future, focusing on in vivo studies to evaluate both the antimicrobial and anti-virulence efficacy of these molecules.

Reference

Mishra SK, Akter T, Urmi UL, Enninful G, Sara M, Shen J, Suresh D, Zheng L, Mekonen ES, Rayamajhee B, Labricciosa FM, Sartelli M, Willcox M. Harnessing Non-Antibiotic Strategies to Counter Multidrug-Resistant Clinical Pathogens with Special Reference to Antimicrobial Peptides and Their Coatings. Antibiotics. 2025;14(1):57.

Prevention and control of healthcare-associated infections: the first principle of every antimicrobial stewardship program

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

The misuse and overuse of antimicrobials are among the main drivers in the development of drug-resistant pathogens, and the appropriate use of these precious medications is paramount to preserve them for future generations to come. However, healthcare professionals should always keep in mind that also an inadequate infection prevention and control contributes considerably to the emergence and spread of antimicrobial resistance (AMR).

AMR is closely related to healthcare-associated infections (HAIs): the management of patients with HAIs frequently requires the administration of broader spectrum antibiotic regimens due to the higher risk of acquiring multidrug-resistant organisms. For this reason, even before using antimicrobials correctly, preventing the occurrence and controlling the spread of HAIs in healthcare facilities is essential. It should be considered the first principle of an appropriate antimicrobial stewardship program in every hospital worldwide.

In a paper recently published in Antibiotics, an international working group of physicians defined the most important measures to prevent and control HAIs in hospital settings.

In this narrative review, the authors presented seven measures that all healthcare workers must know and support. They focused their attention not only on the pivotal role of hand hygiene and the prevention of HAIs, but also on the importance of an effective environmental hospital hygiene, the implementation of surveillance systems, and patients’ screening, decolonization, isolation and cohorting. Finally, they did not forget to discuss about adapting evidence-based practices to the local context, and promoting safety culture.

The authors hope that this document can contribute to raise awareness among healthcare professionals about all issues associated with HAIs, and the need to embrace a personal involvement in the strategies that can help reduce their occurrence.

Fewer microorganisms there will be in our hospitals, fewer antimicrobials we will use. Fewer HAIs will develop in our hospitals, fewer broad-spectrum antibiotics we will have to use to combat multidrug-resistant organisms.

Reference

Sartelli M, Marini CP, McNelis J, Coccolini F, Rizzo C, Labricciosa FM, Petrone P. Preventing and Controlling Healthcare-Associated Infections: The First Principle of Every Antimicrobial Stewardship Program in Hospital Settings. Antibiotics. 2024;13(9):896.

Antibiotic prophylaxis in trauma patients: indications for an optimal management

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

By definition, antibiotic prophylaxis (AP) is the use of antibiotics to prevent infections at the site of injury and/or surgical site. It must be administered close to the time of procedure initiation or time of injury, and based on its pharmacodynamics and pharmacokinetics.

The World Health Organization provides strong recommendations on the administration of AP. Nevertheless, AP is often used inappropriately worldwide.

In polytrauma patients, the presence of several injuries implicates multiple potential risks of infections. In these situations, antibiotics – for treatment or prophylaxis – are frequently used without a defined rationale following recommended guidelines. The difficulty of standardizing definitions and approaches leads to this heterogeneous practice.

Ideally, AP in trauma should be specifically targeted for each patient. AP should reduce the risk of infections due to injuries, decrease the selection of multi-resistant bacterial strains, and have no adverse effects.

The fear of infections must not drive AP prescription. Infections must be treated only when present, and their prevention must occur based on specific evidence-based indications.

To address this lack of precise indications, an international group of experts – representing five surgical societies around the world – has recently published in the Journal of Trauma and Acute Care Surgery a paper providing recommendations for an optimal management of AP in trauma patients.

The Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and the World Society of Emergency Surgery participated in the realization of this important document.

A computerized search was performed in different databases (MEDLINE, Scopus, EMBASE), including citations published between January 2000 to May 2023. The grade of recommendation, defined as strong, moderate, and weak, was established, considering the Oxford model. Through the Delphi process, different issues were discussed by the experts in several rounds. After three rounds, the process led to 100% agreement on all statements.

The article suggests the recommendations regarding the use of AP in head and brain trauma, maxillofacial trauma, thoracic and abdominal trauma, open fractures, burns, and skin wounds and bites.

The authors conclude that AP must be used only when it is indicated. Its overuse has no beneficial effects on patients. On the contrary, it has several potential drawbacks. A tailored infection risk calculation for each patient should be always performed, keeping in mind that a correct source control plays a central role in infection prevention.

Reference

Coccolini F, Sartelli M, Sawyer R, Rasa K, Ceresoli M, Viaggi B, Catena F, Damaskos D, Cicuttin E, Cremonini C, et al. Antibiotic prophylaxis in trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery guidelines. J Trauma Acute Care Surg. 2024 Apr 1;96(4):674-682.

Antimicrobial management of intra-abdominal infections: an Italian multidisciplinary Consensus Conference

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

In a paper recently published in the World Journal of Emergency Surgery, an Italian multidisciplinary group of healthcare professionals promoted a Consensus Conference on the antimicrobial management of intra-abdominal infections (IAIs).

IAIs are common surgical emergencies, representing an important cause of morbidity and mortality across global hospital settings. The cornerstones of IAIs management include timely diagnosis, adequate source control, early and appropriate antimicrobial therapy, and quick physiological stabilization through intravenous fluid therapy and vasopressor agents, especially in critically ill patients.

Optimizing antimicrobial therapy is of utmost importance to improve treatment effectiveness, increase patient safety, minimize the risk of selecting antimicrobial resistant microorganisms, and reduce the risk of opportunistic infections, such as Clostridioides difficile.

The Consensus Conference was promoted by the Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use which included diverse healthcare professionals: not only surgeons, but also infectious disease specialists, microbiologists, clinical pharmacologists, hospital pharmacists, emergency medicine specialists, intensivists, radiologists, and public health specialists.

After focusing on the general principles of diagnosis and treatment of IAIs, a list of relevant clinical questions was constructed to investigate the topic. Concerning the antimicrobial management of IAIs, basic subjects were faced, such as the optimal timing to start an antibiotic therapy, its reassessment based on the results of microbiological culture and susceptibility testing, its optimal duration, daily doses and modality of administration, without forgetting to discuss antifungal treatment, as well.

Following the best scientific evidence from PubMed, EMBASE Library and experts’ opinions, the panel produced 23 recommendation statements for the antimicrobial therapy of IAIs. They were planned and graded according to the GRADE hierarchy of evidence. Using a Delphi approach, a consensus was reached for each statement.

In the last section of the paper, 8 clinical diagnostic-therapeutic pathways for the most common IAIs were presented. The document was endorsed by the Italian Society of Surgery.

The authors concluded that an effective antimicrobial strategy for managing IAIs requires a correct balance between two elements: optimizing empiric therapy to improve clinical outcomes, and curbing excessive antimicrobial use to mitigate the emergence of multidrug-resistant strains.

Reference

Sartelli M, Tascini C, Coccolini F, Dellai F, Ansaloni L, Antonelli M, et al. Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use. World J Emerg Surg. 2024 Jun 8;19(1):23.

A global evidence-based bundle for surgical antibiotic prophylaxis

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

Recommending a bundle with evidence-based measures for surgical antibiotic prophylaxis (SAP), easily applicable and helpful to improve antibiotic prescribing practices among surgeons worldwide. This is the aim of a narrative review just published in Antibiotics by Massimo Sartelli and colleagues.

Surgical site infections (SSIs) represent the most common healthcare-associated infections occurring in surgical patients. Therefore, all procedures aiming to prevent SSIs should be integrated before, during, and after surgery.

SAP is one of the most important measures to prevent SSIs. Nevertheless, many surgeons erroneously believe that SAP is peripheral to their clinical practice. But actually, surgeons play a central role in prevention SSIs.

Indeed, approximately 15% of all antibiotics in hospitals are prescribed for SAP. Using antibiotics appropriately, both for therapy and prophylaxis, is essential to improve treatment effectiveness and patient safety, reduce the risk of antibiotic-associated infections (e.g., Clostridioides difficile infection), and the selection and spread of antibiotic-resistant bacteria.

Several guidelines have been published regarding SSIs prevention, but measures stated in these guidelines are not self-implementing. Bundles are among the most used methods to adapt guidelines in local contexts, and improve acceptance and adherence to best practices.

As observed by the authors, bundles implemented as stand-alone interventions or as part of multimodal strategies were associated with decreased SSI rates.

For these reasons, an international working group of 30 physicians has been established by the Global Alliance for Infections in Surgery. The authors aimed to define a global evidence-based bundle for the appropriate SAP administration, and evaluated the evidence supporting it.

This bundle includes five different actions that may affect adequate SAP administration.

***A global evidence-based bundle for surgical antibiotic prophylaxis*** *[Adapted from Figure 1 in Ref. 1]*

In administering antibiotics for any indication, including for SAP, surgeons should always be responsible for handling antibiotics with care. Indeed, inappropriate prescriptions of these precious medications, as well as poor implementation of infection prevention and control measures, are contributing to the development and spread of bacterial antimicrobial-resistance.

The authors hope this bundle can be easily applied everywhere, and help to improve antibiotic prescribing practices among surgeons worldwide.

Reference

Sartelli M, Coccolini F, Labricciosa FM, Al Omari AH, Bains L, Baraket O, et al. Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle. Antibiotics. 2024; 13(1):100.

Infection prevention and management in surgery: a global declaration

Francesco M. Labricciosa, MD, Specialist in Hygiene and Preventive Medicine

In a paper recently published in the World Journal of Emergency Surgery, seven surgical societies around the world shared an important declaration.

The authors – expert physicians representing the societies involved in this alliance – highlighted the threat posed by antimicrobial resistance (AMR), and the importance to prevent and manage infections appropriately across the surgical pathway.

The Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) participated in the realization of this document.

The goal was to raise awareness among surgeons about AMR by focusing on the importance of actively participating in this challenge.

Surgeons really play a pivotal role in prevention and management of infections in their daily practice. Indeed, they are primarily responsible for preventing hospital-acquired infections, particularly surgical site infections. Moreover, they are prescribers of antibiotics, both for prophylaxis and therapy.

Nevertheless, among them adequate infection prevention and control (IPC) measures, and appropriate antibiotic prescribing practices are often disregarded. Why?

In healthcare facilities around the world, cultural, contextual, and behavioural determinants can influence surgeons’ clinical practice. Furthermore, other factors – such as the fear of clinical failure, time pressure, or organizational contexts – can limit their adherence to IPC procedures and antibiotic prescribing practices.

According to the authors, surgeons in hospital settings should be aware of their role and responsibility, and follow the fundamental principles for correct infection prevention and management across the surgical pathway.

***Fundamental principles for correct infect*****ion prevention and management across the surgical pathway**
*[Adapted from Figure 1 in Ref. 1].*

Changing clinical behaviour is extremely challenging.

A collaborative and multidisciplinary approach is paramount to optimize individual patients’ outcomes and overall healthcare delivery. Each healthcare provider of the team has to participate, and be responsible for its own contribution to patient care.

The authors concluded calling all surgeons around the world to take part in this global cause, by pledging support for this declaration, and accepting responsibility for maintaining the effectiveness of current and future antibiotics.

Reference

Sartelli M, Coccolini F, Ansaloni L, Biffl WL, Blake DP, Boermeester MA, Coimbra R, Evans HL, Ferrada P, Gkiokas G, et al. Declaration on infection prevention and management in global surgery. World J Emerg Surg. 2023 Dec 6;18(1):56.