Volume 28, Issue 1, 2020
Editorial
History is repeating itself, a probable zoonotic spillover as a cause of an epidemic: the case of 2019 novel Coronavirus
Rodriguez-Morales Alfonso J.,
Bonilla-Aldana D. Katterine,
Balbin-Ramon, Graciela Josefina,
Rabaan Ali A.,
Sah Ranjit,
Paniz-Mondolfi Alberto,
Pagliano Pasquale,
Esposito Silvano
Pathogen transmission from a vertebrate animal to a human, also known as zoonotic spillover, represents a global public health burden, which while associated with multiple outbreaks, still remains a poorly understood phenomenon.
Coronaviruses, like influenza viruses, circulate in nature in various animal species. Alpha-coronaviruses and beta-coronaviruses can infect mammals and gamma-coronaviruses and delta-coronaviruses tend to infect birds, but some of them can also be transmitted to mammals.
Although still preliminary, current data suggest that bats are the most probable initial source of the current 2019 novel CoV (2019nCoV) outbreak, that begun on December 2019 in Wuhan, China, apparently spreading from a “wet market” to multiple cities and provinces in China.
This epidemic of 2019nCoV, already reaching more than 6,000 cases to-day (end of January 2020) (>90% in China), will not be the last one linked to zoonotic spillover events.
Review
Serum Procalcitonin as an adjunct in diagnosing prosthetic joint infection in total knee replacement and total hip replacement
Dhyana Fransiska,
Mumith Aadil,
Saeed Kordo
There are still many unknowns regarding the potential application of Procalcitonin (PCT) as an adjunct to aid the diagnosis of Prosthetic Joint Infection. A systematic review searching scientific articles was performed with keywords “Procalcitonin”, “Total Hip Replacement”, and “Total Knee Replacement” (n=123). After review of the abstract and full text for relevance, ten articles were included (n=10). Serum PCT levels for chronic Total Hip Replacement (THR) and Total Knee Replacement (TKR) have a range of mean values from 1.5 ng/ml to 14.2 ng/ml. Specificity ranges from 0.27 to 0.98, while sensitivity is from 0.33 to 0.9. On primary THR/TKR with confirmation of non-infected status, serum PCT peaks between 1-3 days post-operatively, with peak levels varying from 0.12 - 0.79 ng/ml. Based on this review, serum PCT is not a good adjunct in diagnosing Prosthetic Joint Infection (PJI). Synovial fluid PCT fluid may add better clinical support but requires further studies. There were several limitations with this review: the studies are small and heterogeneous, there was a variable definition of PJI, and there was a wide range of mean values, sensitivity and specificity.
Management of acute febrile diseases in limited resource settings: a case-based approach
Gupta Nitin,
Nischal Neeraj
There is a massive burden of acute febrile diseases during the post-monsoon season in tropical countries. Despite this, there is a lack of clarity amongst the primary care physicians and travel medicine experts on how to approach such patients in a syndromic fashion. In this review, the authors summarize a case-based approach in the management of acute febrile diseases.
HIV policy in Italy and recommendations across the HIV care continuum
Galli Massimo,
Borderi Marco,
Viale Pierluigi
The HIV epidemic has not yet ended, and there are ever more challenges: the recent Italian National Plan of Interventions against HIV and AIDS (Piano Nazionale di Interventi Contro HIV e AIDS (PNAIDS) 2017-2019) was hailed for its comprehensiveness. Its likelihood of success across the HIV care continuum was therefore assessed. Awareness interventions are sporadic and continue to miss high risk populations; if effectively implemented, the prescriptive detail in PNAIDS may help address this. Combined prevention needs greater focus and investment. However, there has been recent progress: free anonymous testing is available at multiple settings although improvements to provide access to key vulnerable populations are needed. Clinical management is available to a high standard across the country, with some areas for improvement in ensuring equality of access. Long-term management of people living with HIV is often effective, but discrepancies exist across regions and settings of care. It is recommended to enable implementation of PNAIDS as a matter of urgency, develop integrated awareness and testing interventions for STIs and HIV, make condoms free for high-risk populations, and develop a network of multidisciplinary services for long-term holistic care of people living with HIV.
Original article
Usefulness of infection biomarkers for diagnosing bacteremia in patients with a sepsis code in the emergency department
Varela-Patiño María,
López-Izquierdo Raúl,
Velayos-García Paula,
Álvarez-Manzanares Jesús,
Ramos-Sánchez Carmen,
Carbajosa-Rodríguez Virginia,
Martín-Rodríguez Francisco,
Eiros Jose Maria,
The objective of this study was to assess the usefulness of the biomarkers lactate, C-reactive protein (CPR) and procalcitonin for the diagnosis of bacteremia in patients with suspected sepsis in the emergency department (ED) and according to the focus of infection. We conducted a retrospective study among patients included in the sepsis code of our ED between November 2013 and December 2017. We analyzed demographic variables, co-morbidity according to the Charlson Index and focus of infection, blood cultures and classification according to Gram staining. We determined the diagnostic performance of the biomarkers quantitatively and calculated the area under the curve (AUC) for global bacteremia and as a function of the focus of infection. We included 653 patients with a median age of 79 years (interquartile range: 66-86), of whom 287 (44.0%) were women. The most frequent infectious focus was respiratory (36.1%]. Blood cultures were requested in 87.5% (569 cases). Of the tested samples, 31.3% were positive, of which 63.5% revealed Gram-negative (GN) bacteria. Procalcitonin obtained globally the best AUC 0.70 (95% CI: 0.65-0.75). The values with the best sensitivity and specificity were 2.54 ng/mL for procalcitonin, 4.1 mmol/L for lactate and 156 mg/L for CRP. We found an association between the median procalcitonin value and GN bacteria (6.02; IQR: 1.39-39.40) and Gram-positive bacteria (1.74; IQR: 0.22-15.61). Procalcitonin is the biomarker with the greatest capacity to diagnose bacteremia, particularly in GN infection. Stratification by focus is important since not all biomarkers discriminate in the same way.
Effectiveness of procalcitonin-guided antibiotic therapy to shorten treatment duration in critically-ill patients with bloodstream infections: a systematic review and meta-analysis
Robati Anaraki Mahmoud,
Nouri-Vaskeh Masoud,
Abdoli Oskouie Shahram
Evaluation of serum procalcitonin (PCT) levels has been suggested for diagnosis of infection, precise medical decision making and guidance for prescribing antibiotics in critically-ill patients. The aim of this study was to assess the effectiveness of PCT to shorten antibiotic treatment in critically-ill patients with bloodstream infections. Furthermore, the mortality and ICU length of stay (LOS) in such patients were secondary outcomes. Medline/PubMed, EMBASE, Scopus and Cochrane Databases were searched from January 1, 2007 to September 1, 2018. Randomized controlled trials (RCTs) on using PCT to guide antibiotic therapy compared with routine treatments for administration of antibiotics in critically-ill adult patients published in English were included. Two reviewers assessed the methodology of the studies included and extracted their data using the CONSORT checklist. Inverse-variance weighting and fixed and random effects meta-analyses were performed using the length of antibiotic treatment, LOS in an intensive care unit (ICU) and all-cause mortality. No significant reduction was found in the length of antibiotic treatment: although the cut-off point of 0.25<CT<0.5ng/mL resulted in the reduced length of antibiotic treatment, this effect was not significant. Moreover, there was no significant reduction in ICU LOS and mortality. The analysis showed the effectiveness of the PCT cut-off level of 0.25<PCT<0.5ng/mL in decreasing the length of antibiotic treatment and ICU LOS, although this effect was not significant. Further studies are required to evaluate the results of this study on patients with recurrent infections, super-infections and also multidrug-resistant infections.
Correlation between biofilm formation and antibiotic resistance in Pseudomonas aeruginosa: a meta-analysis
Hadadi-Fishani Mehdi,
Khaledi Azad,
Fatemi-Nasab Zahra Sadat
Biofilm formation is one of the important resistance mechanisms in Pseudomonas aeruginosa. This study aimed to consider the correlation between biofilm formation and antibiotic resistance in Pseudomonas aeruginosa through a systematic review and meta-analysis. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) strategies. Scientific databases were searched by MeSH terms and keywords such as “Pseudomonas aeruginosa”, “biofilm formation”, “antibiotic resistance”, “prevalence” AND “Iran”, to obtain articles published from 1st January 2016 to 30th November 2019. Studies recording biofilm formation and antibiotic resistance in P. aeruginosa recovered from clinical samples of Iranian patients were included. Data analysis was performed using CMA software. The combined biofilm formation rate was reported as 87.6 % (95% CI: 80-92.5). The heterogeneity index among the selected articles was Q2=96.5, I2=85.5, and t=0.26 (p=0.16). The pooled occurrences of strong, moderate and weak biofilms were 47.7% (95% CI: 28.7-67.3), 30.2% (95% CI: 19.4-43.8), and 27.4% (95% CI: 8.8-59.8), respectively. The pooled prevalence of MDR P. aeruginosa strains was as follows: 62.5% (95% CI: 40-77.2). The highest combined rates of antibiotic resistance were against ceftriaxone and tobramycin with the rates of 79.2.9% (95% CI: 54.2-96.2) and 64.4% (95% CI: 36.3-92), respectively. Also, the lowermost antibiotic resistance rates were against colistin and polymyxin B, with the prevalence of 2.1% (95% CI: 0.2-18.1), and 3% (95% CI: 0.5-17.3), respectively. More than half of the studies included in the present review showed a significant correlation between biofilm formation and antibiotic resistance pattern.
Yield and clinical impact of blood cultures in patients admitted to an internal medicine ward
Fortini Alberto,
Faraone Antonio,
Bettucchi Michael,
Poggi Alice,
Filetti Simona,
Boccadori Costanza,
Sbaragli Serena
The purpose of this prospective observational study was to evaluate the yield and clinical impact of blood cultures in a 78-bed Internal Medicine ward of a medium-sized Italian acute care hospital. During a two-month study period, 154 (mean age: 75.2 + 12.2 years; 94 males) out of 620 (24.8%) hospitalized patients underwent 174 blood cultures and were enrolled in the study. The rate of true-positive cultures was 11.5% (20/174) and the rate of false-positive (contaminants) was 5.7% (10/174). A total of 23 microorganisms (5 multidrug resistant strains), most frequently Escherichia coli (n = 10), Klebsiella pneumoniae (n = 3) and Staphylococcus aureus (n = 3), were isolated. The positivity rate was significantly higher in patients with urinary tract infection (31%) and abdomen infection (26.1%) than in patients with pneumonia (4.9%; p<0.01). Although the positivity rate in patients exposed to antibiotics was lower than in those not exposed, the difference was not statistically significant. Therapy changes due to blood culture positivity were observed in 7.1% of the patients overall. In-hospital death was observed in nine of the 136 patients with negative blood cultures (6.6%) and in none of the 18 patients with positive blood cultures. These results indicate that the yield and clinical impact of blood cultures is quite low in patients admitted to an Internal Medicine ward and suggest the need to improve the adequacy of the indications to perform the test.
Antibiotic resistance patterns and prevalence of class I, II and III Integrons among clinical isolates of Klebsiella pneumoniae
Delarampour Abasali,
Ghalehnoo Zahra Rashk,
Khademi Farzad,
Vaez Hamid
Klebsiella pneumoniae is a well-known pathogen and contributes to different types of infection. To investigate the antibiotic resistance profiles and prevalence of class I, II, and III integrons among clinical isolates of K. pneumoniae, a total of 142 non-duplicate clinical isolates were collected. Antibiotic susceptibility was assessed using Kirby-Bauer’s disk diffusion method and Clinical and Laboratory Standards Institute (CLSI) guidelines. Polymerase chain reaction (PCR) method was used to identify class I, II and III integrons. The isolates were mostly resistant against streptomycin (62 strains, 43.7 %) and ceftriaxone (42 strains, 29.6 %). Twenty-six (18.3%) isolates were found to be multi-drug resistant (MDR). Class I and II integrons were detected in 65 isolates (45.8%) and 1 (0.7%) isolate, respectively. The findings of this study revealed that the prevalence of streptomycin-resistant isolates is high, and its use must be restricted. Also, our results revealed that class I integrons are widely prevalent in clinical isolates of K. pneumoniae and a significant association was observed between resistance against imipenem, ciprofloxacin, gentamicin and streptomycin and the presence of integrons, necessitating appropriate infection control programs.
Influenza vaccine acceptance by healthcare workers in Saudi Arabia: A questionnaire-based analysis
Rabaan Ali A.,
Wyse Richard,
Al-Tawfiq Jaffar A.,
Alahmed Shamsah H.,
Aljeldah, Mohammed M.,
Bazzi Ali M.,
Asseri Abdullah M.,
Binjomah, Abdulwahab Z.,
Haque Shafiul
The aim of this study was to gauge the reasons for accepting or declining influenza vaccine in healthcare staff in Saudi Arabia. A questionnaire was administered to healthcare workers in Saudi Arabia. In all, 633 respondents who provided gender, nationality and profession were included. Reasons for vaccine uptake or refusal were assessed according to profession and educational level. Uptake of vaccine was lower in the period from 2010 to 2014 (3-13.3%) compared to pre-2010 figures (20.7%), rising to 44.1% in 2015. Comparing data for ‘never having been vaccinated’ to ‘being vaccinated in 2015’, there was no significant difference in distribution between nurses (9.27% v 38.8%), physicians (13.9% v 56.0%) and laboratory technicians (15.9% v 33.5%) (p= 0.08). The top reason for vaccination was protection of self and family, while the top reason for refusal was not considering the vaccine to be necessary. Education level had no significant effect on the likelihood of being vaccinated. Improvement of healthcare worker vaccination levels in Saudi Arabia might be achieved by addressing staff concerns on vaccine safety and efficacy, emphasizing the potential dangers of influenza and capitalizing on the staff’s focus on protecting themselves and their families.
Case report
An isolated testicular tuberculosis mimicking testicular cancer in north-central Nigeria
Agbo Christian A.,
Lawal Mudashiru,
Jibrin Dalhatu,
Enjugu Jephthah Esla
Testicular tuberculosis (TB) is a rare presentation of extrapulmonary TB. A 46-year-old man presented to our Urology clinic with a painless swelling of the right testis. Examination revealed a hard, non-tender swelling on the inferior pole of the testis that measured 3 x 2 cm. Scrotal ultrasound scan showed a complex mass with multiple hypoechoic lesions at the inferior pole of the right testis with dimension 2.4 x 1.7cm. Laboratory data showed elevated alpha fetoprotein and beta hcG and lymphocytosis. A diagnosis of right testicular cancer was made and the patient had a right transinguinal radical orchidectomy. Histopathology result showed tuberculous granulomata with caseous necrosis surrounded by multinucleated giant cells (Langerhan`s type). The patient subsequently had anti-TB medications. The rarity of this condition makes these findings important to report.
First case report of tuberculous meningitis secondary to endometrial tuberculosis following a clandestine abortion.
Rodriguez Edinson Dante Meregildo,
Villegas Chiroque Miguel,
Rodríguez Llanos Juan Roberto,
Sánchez Carrillo Halbert Christian,
Vilchez Rivera Stalin,
Delgado Sánchez Marcela Cecilia
Tuberculous meningitis (TBM) is a medical emergency: it is the most severe, lethal and disabling clinical form of tuberculosis. We report the case of a 44-year-old woman who had undergone a clandestine abortion six weeks before admission. One week later, she had abnormal vaginal discharge. Three weeks prior to admission, headache, hyperpyrexia and mental alteration were added. At admission, a transvaginal ultrasound showed abnormalities of the uterine cavity. Sepsis and endometritis were diagnosed, and a hysterectomy was scheduled. During preoperative evaluation, meningeal signs were found. The first lumbar puncture (LP) showed a lymphomononuclear pleocytosis, hypoglycorrhachia and hyperproteinorrachia. After five days treatment with ceftriaxone, vancomycin and dexamethasone, only partial recovery occurred. A second LP showed AFB and PCR confirmed Mycobacterium tuberculosis. The histopathology of endometrial biopsy confirmed endometrial tuberculosis. Therapeutic response to anti-tuberculous treatment and corticosteroids was excellent. No other cause of immunosuppression apart from pregnancy was found. To the best of our knowledge, this is the first report of TBM secondary to endometrial tuberculosis and highlights an unusual clinical scenario in which severe and disseminated forms of TB could be present. TBM during and after pregnancy is rare, but compared with TBM in non-pregnant women, it has a poorer prognosis. Early diagnosis and treatment can be lifesaving in this life-threatening disease.
Atypical progressive multifocal leukoencephalopathy in a kidney transplant recipient with improving symptoms after immunocompetence recovery
Bruno Giorgia,
Miele Giuseppina,
Abbadessa Gianmarco,
Di Pietro Andrea,
Russo Camilla,
Negro Alberto,
Bonavita Simona,
Puoti Gianfranco
Progressive multifocal leukoencephalopathy (PML) is a viral infection due to John Cunningham Virus (JCV) resulting in progressive damage of brain white matter, mostly related to HIV infection or hemato-oncological malignancies. PML onset is usually multifocal with rapid neurological progression and poor prognosis. Here we report an atypical case of PML with monofocal onset and a good outcome in a 64-year-old man who received a kidney transplant for end-stage renal disease (ESRD). The applied antirejection immunosuppressive drug regimen included tacrolimus, prednisone and mycophenolic acid. Three years after the transplant, he complained of right-hand tremor and rapidly progressive right hemiparesis, with prominent involvement of the upper limb. Brain magnetic resonance imaging (MRI) showed a significant demyelinating area in the left frontal lobe, without mass effect and contrast enhancement. Real-time PCR analysis revealed the presence of JCV on cerebrospinal fluid. Consequent immunosuppressive drug suspension resulted in a global improvement of neurological symptoms and a favourable evolution of the neuroradiological findings. Subsequent eight-year follow-up MRI confirmed the stability of imaging findings over time. Therefore, early recognition of PML symptoms and MRI sign along with the rapid suspension of immunosuppressive drugs can modify the natural history of this disease after a kidney transplant.
İnce Nevin,
Kilinçel Özge,
Demirel-Güğül Tuğba,
Tanişman Işilay,
Altun Gülşah
Leptospirosis is a ubiquitous acute bacterial zoonosis. This report describes six cases presenting to our hospital with symptoms such as fever and muscle pain and diagnosed as leptospirosis. All cases presented with fever, muscle pain, and lethargy and were engaged in activities such as farming, hunting, and fishing. Thrombocytopenia and impaired liver function tests were found in all patients, increased creatine-kinase in five, and increased creatinine in four. Leptospirosis was diagnosed using polymerase chain reaction (PCR). The course of the disease resulted in cure in three cases, chronic kidney disease sequelae in one, and death in two. In conclusion, the possibility of leptospirosis should be considered in patients presenting with non-specific symptoms such as fever and muscle pain and developing thrombocytopenia, and liver and kidney function disorder. Risk factors should also be investigated when taking histories. Early diagnosis and antibiotic therapy being started as quickly as possible are important in terms of the course of the disease.
Dengue fever complicated by liver dysfunction due to possible co-infection with hepatitis E in a returning traveller from Cuba
Antinori Spinello,
Morena Valentina,
Pagani Gabriele,
Venturi Giulietta,
Giacomelli Andrea,
Milazzo Laura,
Ridolfo Anna Lisa,
Zanchetta Nadia
Dengue fever is a mosquito-borne infection that co-circulates with Chikungunya and Zika virus infection in many parts of the world. Dengue virus (DENV) is occasionally responsible for acute hepatitis and a few cases of acute hepatitis due to co-infection with DENV and hepatitis E virus have been described in India. A 37-year-old Cuban woman living in Italy was admitted to our hospital with a presumed arboviral infection upon her return to Italy short after a 15-day trip to her home-country to visit relatives. An acute infection due to DENV serotype 1 was initially diagnosed, following a clinical course characterized by signs of liver dysfunction that were possibly due to co-infection with hepatitis E virus.
The Infections in the History of Medicine
Ioannis Kardamatis (1852-1942): Pioneer of the Anti-Malaria Battle in Greece
Michaleas Spyros N.,
Sergentaris Theodoros N.,
Tsoucalas Gregory,
Vladimiros Lazaros,
Tentolouris Nikolaos,
Papaioannou Theodore G.
Few scientists have contributed as much to medicine and society as Ioannis Kardamatis (1859-1942). Kardamatis was an important historical figure whose vast medical knowledge was recorded in a spectrum of medical publications, including monographs, bibliographic reviews, books, and experimental and statistical studies. His studies have been published in both Greek and foreign journals. He is most notably remembered for his contribution to the battle against malaria in Greece.
The destiny of Italian prisoners in Austro-Hungarian POW camps during the First World War: remembering the defeat of Caporetto 100 years on
Sabbatani Sergio,
Fiorino Sirio,
Manfredi Roberto
The living conditions of Italian prisoners during the First World War were extremely difficult. At the end of the conflict, the treatment of Italian soldiers in Austro-Hungarian POW camps and in those of the German territories was recognized as particularly harsh in comparison with that of other prisoners. The reasons may be ascribed to three main factors. The Italian prisoners paid the price of being considered traitors, since Italy was allied with the Austro-Hungarian Empire and with Germany until 1914, subsequently switching to the side of France, the United Kingdom and Russia. The Italian government and the Italian High Command considered their soldiers poorly inclined to engage in a war which became over time increasingly costly in terms of human sacrifice. The strategy pursued by the General-in-Chief Luigi Cadorna was very aggressive and showed little care for the living conditions of his troops, who were frequently thrown into the fray and exposed to potential slaughter. Due to this negative judgement on their troops’ willingness to fight, the government did not help, and even hindered, the despatch of packages of food and clothes to prisoners in the Austro-Hungarian and German camps via the Red Cross. The idea of a better life in the trenches compared with that expected in the camps as prisoners was widespread. Thirdly, the maritime blockade of the Adriatic Sea over time reduced to starvation the populations of Austria, Hungary and Germany, which obviously had grave repercussions on prisoners. It was estimated that around 100,000 Italians lost their lives in POW camps; after the defeat at Caporetto, when over 250,000 prisoners were captured, the number of deaths rose. The main causes of death were: tuberculosis, pneumonia, malnutrition and typhoid fever. At the end of the war, when coming back to Italy, former POWs were interned for months in camps (located predominantly in the Emilia region) and had to face interrogation and trials to demonstrate they were not deserters and were free to go back home. In the meantime, many lost their lives due to “Spanish” flu, pneumonia and other infectious diseases. Only the mobilization of both families and public opinion forced the Italian government to close the camps at the end of the year 1919.
Letters to the editor
Combined antibiotic therapy and patients education in the treatment of diabetic calcaneal osteomyelitis
Tsagkaris Christos,
Sevdalis Nikolaos,
Nikolakea Melina,
Kamaratos Alexandros
Not available
Biosimilar pegfilgrastim and adherence to guidelines for chemotherapy-induced neutropenia and infections in cancer patients
Danova Marco,
Antonuzzo Andrea,
Spandonaro Federico,
Pronzato Paolo
Not available
Paederus dermatitis - A bibliometric analysis of an emerging disease in travelers
Osorio-Velásquez Brahyan,
García-Zuluaga Luisa M.,
López-Bueno Isaac,
Soto-Vásquez Jessica P.,
Vásquez-Castañeda, Danna L.,
Cortés-Bonilla Isabella,
Murillo-García David R.,
Rodríguez-Morales Alfonso J.
Not available
