The antibiotic vancomycin, recommended as first-line treatment for infection caused by the deadly superbug Clostridioides difficile, may not be living up to its promise, according to new US-based research.
C. diff infection is the leading cause of death due to gastroenteritis in the US. It causes gastrointestinal symptoms ranging from diarrhoea and abdominal pain to toxic megacolon, sepsis and death.
Based on 2018 clinical practice guidelines, the use of oral vancomycin has increased by 54% in the past six years, but the clinical cure rates have decreased from nearly 100% in the early 2000’s to around 70% in contemporary clinical trials.
“Despite the increasing prevalence of data showing reduced effectiveness of vancomycin, there is a significant lack of understanding regarding whether antimicrobial resistance to these strains may affect the clinical response to vancomycin therapy,” reports Anne J. Gonzales-Luna, research assistant professor in the Department of Pharmacy Practice and Translational Research, UH College of Pharmacy, in the journal Clinical Infectious Diseases. “In fact, the prevailing view has been that antibiotic resistance to these strains are unlikely to impact clinical outcomes, given the high concentrations of vancomycin in stools.”
But the University of Houston College of Pharmacy team arrived at a different conclusion after sifting through research included in a multicentre study, which included adults treated with oral vancomycin between 2016-2021 for C. diff infection.
“We found reduced vancomycin susceptibility in C. difficile was associated with lower 30-day sustained clinical response and lower 14-day initial cure rates in the studied patient cohort,” said Gonzales-Luna.
The finding is cause for concern.
“It’s an alarming development in the field of C. diff as there are only two recommended antibiotics,” said Kevin Garey, professor of pharmacy practice and translational research. “If antimicrobial resistance increases in both antibiotics, it will complicate the management of C. diff infection leading us back to a pre-antibiotic era.”
A study in more than 3000 US counties, with 315 million residents, has suggested that air pollution is linked with stress and depression, putting under-65-year-olds at increased risk of dying from cardiovascular disease. The research was presented at ESC Preventive Cardiology 2024, a scientific congress of the European Society of Cardiology (ESC).1
“Our study indicates that the air we breathe affects our mental well-being, which in turn impacts heart health,” said study lead author Dr Shady Abohashemof Harvard Medical School, Boston, US.
According to the World Health Organization, air pollution is estimated to have caused 4.2 million premature deaths worldwide in 2019.2 Mental illness has also been linked with premature death.3 This study examined whether air pollution and poor mental health are interrelated and have a joint impact on death from cardiovascular disease.
The study focused on particles less than 2.5 micrometres in diameter, also referred to as fine particles or PM2.5. They come from vehicle exhaust fumes, power plant combustion, and burning wood, and present the highest health risk. To conduct the study, county-level data on annual PM2.5 levels were obtained from the Centers for Disease Control and Prevention (CDC).4 PM2.5 exposure was categorised as high or low according to World Health Organization (WHO) standards. The researchers gathered data on the average number of days (age-standardised) that county residents experienced mental health issues – including stress, depression, and emotional problems – from the CDC.5 Each county was then categorised into three groups based on these numbers. Counties in the top third reported the most days of poor mental health (PMH).4 Age-adjusted premature cardiovascular mortality rates (under 65 years of age) per county, were obtained from the CDC.6 County characteristics were sourced from the County Health Rankings project.
The study included 3047 US counties, representing 315 720 938 residents (with over 207 million aged 20 to 64 years and 50% females) in 2013. Between 2013 and 2019, some 1 079 656 (0.34%) participants died from cardiovascular disease before the age of 65 years. The researchers analysed the associations between pollution, mental health, and premature cardiovascular mortality after adjusting for factors that could influence the relationships.7
Counties with dirty air (high PM2.5 concentrations) were 10% more likely to report high levels of PMH days compared to counties with clean air (low PM2.5 concentrations). That risk was markedly greater in counties with a high prevalence of minority groups or poverty. The link between PMH and premature cardiovascular mortality was strongest in counties with higher levels (above WHO recommended levels: ≥10 µm2) of air pollution. In these counties, higher levels of PMH were associated with a three-fold increase in premature cardiovascular mortality compared to lower PMH levels. Further, one-third of the pollution-related risk of premature cardiovascular deaths was explained by increased burden of PMH.
Dr Abohashem said: “Our results reveal a dual threat from air pollution: it not only worsens mental health but also significantly amplifies the risk of heart-related deaths associated with poor mental health. Public health strategies are urgently needed to address both air quality and mental wellbeing in order to preserve cardiovascular health.”
1The abstract ‘Air pollution associates with poor mental health and amplifies the premature cardiovascular death in the United States: longitudinal nationwide analysis’ will be presented during the session ‘Young Investigators Award – Population Science and Public Health’ which takes place on 26 April 2024.
2World Health Organization: Ambient (outdoor) air pollution.
3Byrne P. Meeting the challenges of rising premature mortality in people with severe mental illness. Future Healthc J. 2023;10(2):98-102.
4CDC PLACES databases.
5CDC Behavioral Risk Factor Surveillance System.
6CDC WONDER databases.
7The analyses were adjusted for calendar year and county characteristics such as demographics, median household income, unemployment rates, violent crime rates, education level, food environment index, rates of health insurance, level of mental health provision, level of primary care provision.
New research published inNature has shown that a healthy, balanced diet was linked to superior brain health, cognitive function and mental wellbeing. The study, involving researchers at the University of Warwick, sheds light on how food preferences influence more than just physical health, and also significantly impact brain health.
With the help of machine learning, the researchers analysed a large sample of 181 990 participants from the UK Biobank, comparing their dietary choices against a range of physical evaluations, including cognitive function, blood metabolic biomarkers, brain imaging, and genetics.
The food preferences of each participant were collected via an online questionnaire, which the team categorised into 10 groups (eg, alcohol, fruits and meats).
A balanced diet was associated with better mental health, superior cognitive functions and even higher amounts of grey matter in the brain – linked to intelligence – compared with those with a less varied diet.
The study also highlighted the need for gradual dietary modifications, particularly for individuals accustomed to highly palatable but nutritionally deficient foods. By slowly reducing sugar and fat intake over time, individuals may find themselves naturally gravitating towards healthier food choices.
Genetic factors may also contribute to the association between diet and brain health, the scientists believe, showing how a combination of genetic predispositions and lifestyle choices shape wellbeing.
Lead Author Professor Jianfeng Feng, University of Warwick, emphasised the importance of establishing healthy food preferences early in life. He said: “Developing a healthy balanced diet from an early age is crucial for healthy growth. To foster the development of a healthy balanced diet, both families and schools should offer a diverse range of nutritious meals and cultivate an environment that supports their physical and mental health.”
New research has found a significant association between participating in low to moderate intensity exercise and reduced rates of depression. Researchers carried out an umbrella review of studies carried out across the world to examine the potential of physical activity as a mental health intervention.
The analysis, published in the journal Neuroscience and Biobehavioural Reviews, found that physical activity reduced the risk of depression by 23% and anxiety by 26%. A particularly strong association was found between low and moderate physical activity, which included activities such as gardening, golf and walking, and reduced risk of depression. But this was not strongly observed for high intensity exercise.
Physical activity was also significantly associated with reduced risk of severe mental health conditions, including a reduction in psychosis/schizophrenia by 27%. The results were consistent in both men and women, and across different age groups and across the world.
Lead author Lee Smith, Professor of Public Health at Anglia Ruskin University (ARU), said: “Preventing mental health complications effectively has emerged as a major challenge, and an area of paramount importance in the realm of public health. These conditions can be complex and necessitate a multi-pronged approach to treatment, which may encompass pharmacological interventions, psychotherapy, and lifestyle changes.
“These effects of physical activity intensity on depression highlight the need for precise exercise guidelines. Moderate exercise can improve mental health through biochemical reactions, whereas high-intensity exercise may worsen stress-related responses in some individuals.
“Acknowledging differences in people’s response to exercise is vital for effective mental health strategies, suggesting any activity recommendations should be tailored for the individual.
“The fact that even low to moderate levels of physical activity can be beneficial for mental health is particularly important, given that these levels of activity may be more achievable for people who can make smaller lifestyle changes without feeling they need to commit to a high-intensity exercise programme.”
By Lisa Swaine, Partner & Bronwyn Singh, Associate at Webber Wentzel
Lisa Swaine (L), Partner & Bronwyn Singh (R), Associate at Webber Wentzel
In a recent case of MM obo GM v the North West Province’s Department of Health MEC, (782/2022) [2024] ZASCA 52, an appellant’s claim for certain damages was struck from the roll by the Supreme Court of Appeal and her claim for personal damages was remitted to the trial court for determination.
The appeal arose from a medical negligence claim by the appellant (MM), a mother of a child (GM), who was born on 16 October 2010 and later diagnosed with cerebral palsy. MM alleged that the respondent’s staff at the two hospitals where she had been admitted for obstetric treatment and care were negligent, resulting in GM’s cerebral palsy. MM claimed compensation for her own emotional shock and trauma and, in her representative capacity on behalf of GM, she claimed for future medical expenses as well as future loss of earnings and general damages for pain and suffering. Her claims made in her representative capacity were dismissed by the trial court which found, that whilst the staff at the hospitals were negligent in certain aspects of MM’s treatment and care prior to GM’s birth, their negligence did not cause GM’s cerebral palsy. The trial court determined that GM’s cerebral palsy was caused by placental abruption – a complication that results in the placenta gradually separating from the uterus, thus reducing the foetus’ oxygen. MM appealed against this finding to a full bench and subsequently to the Supreme Court of Appeal (SCA). The issue on appeal was limited to causation, in other words, whether or not the negligence of the hospital staff caused GM’s cerebral palsy.
Prior to the hearing of the appeal in November 2023, it was discovered that GM passed away in August 2022. In light of GM’s passing, the SCA had to consider the effect of GM’s passing on the claims made by MM on his behalf.
MM’s personal claim for compensation for emotional shock and trauma
MM alleged that witnessing her first child with cerebral palsy had left her severely shocked and traumatised. She claimed to have suffered general damages for anguish, psychological trauma and loss of amenities of life. However, no evidence of a detectable psychiatric injury at the hearing in the trial court was presented on her behalf.
The SCA reiterated the legal principles set out in Road Accident Fund v Sauls[1]and Komape v Minister of Basic Education[2] that a plaintiff may only claim damages for emotional shock if a detectable psychiatric injury has been sustained and can be proven by way of evidence.
In the absence of evidence of a detectible psychiatric injury, MM failed to discharge this burden of proof. The judgment of the trial court focused solely on the issue of negligence and its causal relationship to GM’s cerebral palsy. The trial court ought to have dismissed MM’s claim for emotional shock or granted absolution from the instance, however, it did neither. MM’s claim in this regard appears not to have been dealt with by the trial court.
As the appeal was restricted to the issue of causation and the trial court failed to deal with MM’s personal claim, the SCA did not have the power to make a finding on her claim and had no option but to remit it to the trial court for determination.
The effect of GM’s death on the claims pursued on his behalf
In light of GM’s passing, the claims for future medical expenses and future loss of earnings fell away.
Non-pecuniary claims for general damages transfer to a deceased’s estate once Iitiscontestatio has been reached. The SCA found that the claim for general damages was transmissible to GM’s estate as litis contestatio had been reached well before GM’s death. However, since the claim was transmitted to GM’s estate, only the executor of his estate could prosecute the claim. Because MM had not reported GM’s death to the Master, an executor was not appointed. MM therefore had no authority to act and lacked the necessary locus standi to pursue the claim for general damages. The claim for general damages had to be stayed pending the appointment of an executor. Due to this, the only viable order for the SCA under these circumstances was to strike the matter from the court roll. Following this, MM was ordered to pay the costs of the appeal.
This case serves as a harsh reminder of some of the intricacies of litigation. It underscores the fundamental principles of locus standi, the legal right to sue, and the burden of proof. One’s mind must be applied before separating or limiting the issues to be heard by the court.
For MM, the delay but perhaps not the denial of justice has probably come with a hefty price tag.
[1] Road Accident Fund v Sauls [2001] ZASCA 135; 2002 (2) SA 55 (SCA).
[2] Komape and Others v Minister of Basic Education [2019] ZASCA 192; 2020 (2) SA 347 (SCA).
