Microorganisms

Tuberculosis (TB) remains a leading cause of infectious-disease-related morbidity and mortality worldwide, including in low-incidence, high-income countries, where cases increasingly cluster among vulnerable populations. In these settings, persistent diagnostic and treatment delays, rather than a lack of therapeutic options, drive preventable morbidity, ongoing transmission, and inappropriate antimicrobial use. We argue that TB antimicrobial stewardship must extend beyond treatment adherence and resistance containment to encompass the entire diagnostic continuum. Emerging evidence demonstrating a substantial burden of subclinical and asymptomatic TB challenges symptom-based diagnostic paradigms and reveals an underrecognized “asymptomatic delay”, during which radiologic or microbiologic disease is present but undetected. Failure to identify TB during this interval represents a critical stewardship failure, perpetuating empirical broad-spectrum antibiotic exposure while allowing disease progression and transmission. We review diagnostic challenges across the early clinical spectrum of pulmonary and extrapulmonary TB in low-incidence settings, with particular emphasis on migrants and other high-risk populations disproportionately affected by structural and healthcare system barriers. We propose a stewardship-oriented framework integrating targeted screening, enhanced clinical vigilance, front-loaded and parallel diagnostic pathways, and early referral to specialized TB centers. Explicit incorporation of asymptomatic delay into TB diagnostic frameworks can strengthen system accountability, reduce inappropriate antibiotic use, improve patient outcomes, and accelerate progress toward TB elimination in high-income, low-incidence countries.

Monkeypox (Mpox), a zoonotic viral disease caused by the Monkeypox Virus (MPXV), has gained significant attention in recent years due to its increasing incidence and the grave threat it poses to global health. MPXV has spread at a rapid pace during the COVID-19 pandemic, causing 10,000+ confirmed cases and ~300 fatalities in 122 countries. This virus comprises two major clades, Clade I (Central African), which is evidently more virulent, and Clade II (West African), which has caused the recent outbreaks across the world and caused fewer deaths. Clinically, Mpox presents as a milder form with fever, lymphadenopathy, and vesiculopustular rash similar to smallpox. Diagnostic measures such as polymerase chain reaction (PCR) are the main diagnostic confirmatory tools. Advanced diagnostics involve electronic microscopy, serology, and immunohistochemistry. Alternative drugs like tecovirimat and brincidofovir have demonstrated potential for treating smallpox, but there is scanty evidence on their efficacy against MPXV. Most recent advancements in the study of vaccines have resulted in the creation and introduction of MVA-BN (JYNNEOS/Imvanex/Imvamune) and ACAM2000 vaccines, which conferred cross-protection against MPXV. MVA-BN is suggested to perform better than other types due to its enhanced safety and immunogenicity. Researchers are also developing DNA and protein subunit vaccines against Mpox to induce specific immune responses by presenting viral proteins. The discovery of novel vaccine candidates and antiviral treatments will be needed to prevent future outbreaks and reduce the global health burden of Mpox. This review focuses on the characterization of MPXV, summarizing current knowledge on its genomic structure, pathogenesis, replication, potential targets of anti-MPXV drugs, clinical features, and epidemiological patterns, along with recent advances in vaccine development.

Heat-killed Enterococcus faecalis EF-2001 (EF-2001) is a postbiotic preparation reported to modulate host immunity. However, its specific impact on host immune responses and virological outcomes during the early phase of influenza infection remains insufficiently characterized. Female BALB/c mice received oral EF-2001 (16 mg/kg/day) for either 4 days or 14 days prior to intranasal inoculation with influenza A/H3N2 (A/Aichi/2/68). On day 2 post-infection, splenic T-cell subsets (CD3⁺, CD4⁺, CD8⁺) were quantified by flow cytometry. Cytokines released from PMA/ionomycin-stimulated splenocytes were measured using a cytometric bead array assay to assess functional polarization. Lung viral titers (TCID₅₀) and interferon-α (IFN-α) concentrations were assessed to evaluate local antiviral efficacy. EF-2001 administration significantly increased the proportions of splenic CD3⁺ T cells, including both CD4⁺ and CD8⁺ subsets, compared to controls. The 14-day pretreatment regimen significantly enhanced IFN-γ production while reducing IL-10, IL-4, and IL-2 secretion, consistent with a distinct systemic Th1-skewed immune activation. In contrast to these systemic effects, EF-2001 did not significantly reduce lung viral titers (difference < 0.2 log₁₀ TCID₅₀) and did not increase lung IFN-α concentrations at day 2 post-infection. Oral EF-2001 pretreatment promoted systemic immune activation characterized by T-cell expansion and a Th1-biased cytokine profile. However, this systemic priming showed no detectable antiviral effect on lung viral burden at the early evaluation time point. EF-2001 may be better positioned as an adjunctive immunomodulatory approach rather than a direct antiviral agent, warranting further studies that include clinical outcomes and multi-time-point antiviral and mucosal immune assessments.