[Campylobacteriosis at the Department of Infectious Diseases of the University Hospital Brno in 2011-2013: a retrospective study]

OBJECTIVE

To provide basic clinical, laboratory, and microbiological characteristics of adult patients with campylobacteriosis admitted to the Department of Infectious Diseases University Hospital Brno (UHB), in 2011-2013.

MATERIALS AND METHODS

A retrospective analysis of clinical and laboratory parameters of 160 patients hospitalized with campylobacteriosis at the Department of Infectious Diseases, UHB from 1 January 2011 to 31 December 2013.

RESULTS

There was no lethality or bacteremia reported in the study group of 160 adult patients (n=160) with campylobacteriosis. A more severe form of the disease with signs of systemic inflammatory response syndrome (SIRS) occurred in 24 patients, i.e. 15% of the study population. Transient mild to moderate leukocytopenia and thrombocytopenia were seen in 16 (10.0%) and 24 patients (15.0%), respectively, and seven patients (4.4%) had bicytopenia. The following factors correlated statistically significantly with the intestinal form of the disease and SIRS: age under 70 years (p=0.037), absence of arterial hypertension (p=0.044), immunosuppressive treatment (p=0.008), leukocyte count in the peripheral blood over 12.0×10(9)/l (p=0.023), and body temperature over 38.0 °C (p<0.001). Antibiotic treatment was used in 96.3% of patients with the intestinal form and in 100.0% of patients with SIRS. The average duration of antibiotic treatment was 8.8 and 9.3 days, respectively. Postantibiotic colitis due to Clostridium difficile occurred in seven patients (4.4%). There were no organ or autoimmune complications observed.

CONCLUSIONS

Campylobacteriosis with SIRS occurs preferentially in persons under 70 years of age. Empirical antibiotic treatment is used too frequently without being adequately deescalated.

[Hepatitis E--overview of the latest knowledge]

Hepatitis E (HE) is a ubiquitous infection, occurring both in developing and in developed countries. It is caused by the hepatitis E virus (HEV), a small, non-enveloped RNA virus. The reported incidence in the Czech Republic in 2013 was 2 cases per 100,000 inhabitants and the number of HE cases has been growing over the past years. Besides the long known fecal-oral transmission, zoonotic and blood product transmission of HEV has recently been observed in industrialized countries. Most infections are asymptomatic. Symptomatic infection may present as acute hepatitis with nonspecific flu-like symptoms and liver enzymes elevation. In immunocompromised patients, HEV can lead to chronic hepatitis E and can even cause acute liver failure in pregnant women. Several extrahepatic manifestations have also been reported. Antiviral therapy has been successfully used in chronic hepatitis E. The first vaccine available for clinical use is licensed in China so far.

[When should empirical antibiotic therapy be indicated in acute community-onset diarrhea of suspected bacterial etiology]

BACKGROUND

The aims of this study were to describe the basic parameters of adult patients with acute community-onset salmonellosis or campylobacteriosis responsible for more than 90 % of all cases of community-onset diarrhea in the Czech Republic, and, according to the results of this analysis, to update the diagnostic and therapeutic algorithms.

MATERIALS AND METHODS

The data were collected retrospectively between January 1, 2011 and December 31, 2013. Patients with systemic signs of infection having at least 2 signs of systemic inflammatory response syndrome (SIRS) or with elevated serum procalcitonin levels (more than 0.5 ng/ml) were classified as being at risk for the invasive form of the disease. The remaining patients were classified as having the simple intestinal form of the disease. Patients with community-onset post-antibiotic diarrhea were excluded. The data were statistically processed.

RESULTS

The following clinical factors were statistically significantly correlated with the high-risk form of the disease: duration of illness of less than 3 days before admission and any of the following (some of them are part of the SIRS classification), even after being adjusted for age: body temperature above 38 °C, peripheral blood white cell count (WBC) above 12 × 10⁹/l, neutrophil count above 9 × 10⁹/l and CRP level above 150 mg/l. The risk form of the disease occurred in 60 cases (18.7 %). The mean WBC was 9.4 × 10⁹/l (median, 8.4; range, 1.7-89.0). The WBC within the normal range was seen in 194 cases (60.4 %). The mean CRP level was 92.9 mg/l (median, 77.0; range, 1.0-342.0). An elevated procalcitonin level was seen in 21 patients; the marker was not routinely measured. Positive blood culture results were obtained in 2 persons with salmonellosis; the examination was not routinely performed. There were 34 patients (10.6 %) with documented immune system dysfunction; the risk form of salmonellosis or campylobacteriosis was seen in only 11 of them (3.4 %). A total of 306 patients (95.3 %) were treated with antibiotics; the mean duration of antibiotic therapy was 8.7 days (median, 7; range, 2-31).

CONCLUSIONS

Antibiotic treatment in salmonellosis/campylobacteriosis should not be indicated only due to elevated CRP levels but rather after comprehensive evaluation of the duration of symptoms, individual risk factors and dynamic changes in markers of inflammation. Blood culture tests should be carried out more frequently.

[Diagnosis and therapy of chronic hepatitis B: Czech national guidelines]

The new recommendations reflect the increase in knowledge that has been reported since the release of previous Czech guidelines in April 2009. According to qualified estimates, there are 350-400 million people with chronic hepatitis B (HBV) infection worldwide. The Czech Republic is among the countries with a low prevalence of HBV infection. According to the latest seroprevalent study, 0.56 % of the Czech citizens were chronically infected with HBV in 2001. HBV infection can lead to serious life-threatening liver damage - fulminant hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC). The goals of treatment are to prolong the length of life and improve its quality by preventing the progression of chronic hepatitis to cirrhosis, cirrhosis decompensation and development of HCC. The goals can be achieved if HBV replication is suppressed in a sustained manner. Then, the accompanying reduction in histological activity lowers the risk of cirrhosis and HCC, particularly in non-cirrhotic patients. Currently, two different strategies for treating chronic hepatitis B are available. Treatment of finite duration is with pegylated interferon (PEG-IFN), entecavir (ETV), or tenofovir (TDV). A 48-week course of PEG-IFN is mainly recommended for HBeAg-positive patients with the best chance of anti-HBe seroconversion. Finite-duration of ETV or TDV treatment is available for HBeAg-positive patients who seroconvert to anti-HBe on treatment. However, treatment duration is unpredictable prior to the therapy as it depends on the timing of anti-HBe seroconversion and the treatment continuation following anti-HBe seroconversion (therapy should be prolonged for additional 12 months after anti-HBe seroconversion). Long-term ETV or TDV therapy is necessary for HBeAg-positive patients who do not develop anti-HBe seroconversion and for HBeAg-negative patients. This strategy is also recommended for patients with cirrhosis irrespective of the initial HBeAg status or anti-HBe seroconversion on treatment. The advantage of ETV and TDV is based on their high potency and optimal resistance profile.

[Infections caused by non-typhi serovars of Salmonella at the Infectious Diseases Clinic of the University Hospital Brno in 2011-2013]

INTRODUCTION

The aim of the study is to describe the basic clinical, laboratory, and microbiological characteristics in adult patients with salmonellosis hospitalized at the Infectious Diseases Clinic of the University Hospital Brno in 2011-2013.

MATERIALS AND METHODS

A retrospective analysis of clinical and laboratory parameters of 161 patients hospitalized at the Infectious Diseases Clinic of the University Hospital Brno from 1 January 2011 to 31 December 2013.

RESULTS

Invasive salmonellosis was seen in 22.4% of the study group. The overall lethality rate reached 3.1%. Treatment with antibiotics was used in 93.8% of patients. Transient mild to moderate leukocytopenia was reported in 4.3% of patients and thrombocytopenia in 9.3% of patients. Transient changes in white blood cells as well as in the thrombocyte count were not clinically important. Long-term treatment with proton pump inhibitors is a risk factor for salmonellosis (p=0.128), but not for invasive salmonellosis. Long-term use of opioids (p=0.003) and/or acetylsalicylic acid (p=0.015) is a risk factor for invasive salmonellosis. Other risk factors for invasive disease are: age over 70 years (p=0.011), arterial hypertension (p=0.004), disease duration of less than three days (p=0.006), serum creatinine level above 250 μmol/l (p=0.01), peripheral leucocyte count above 12x10(9)/l (p=0.001), and body temperature above 38 °C (p=0.001). Hypokalemia does not represent a risk factor for invasive salmonellosis.

CONCLUSIONS

Aged patients on long-term opioids or acetylsalicylic acid, with disease duration of less than three days, and meeting the criteria for systemic inflammatory response syndrome are at the highest risk for invasive salmonellosis. Empirical antibiotics are prescribed too often and the treatment is not properly de-escalated.

[Diagnosis and therapy of Clostridium difficile infection: Czech national guidelines]

Clostridium difficile infection (CDI) is a disease of varying severity. Its manifestations range from mild diarrhea to life-threatening paralytic ileus, painful distension of the large bowel, and sepsis. Another possible manifestation of the disease is recurring colitis that can exhaust the patient. For establishing the diagnosis, the patient's stool should be examined with two or three different microbiological methods (testing for clostridial toxins A and B; testing for clostridial glutamate dehydrogenase, anaerobic culture with specific media, or PCR detection of genes for production of clostridial toxins). An alternative way of assessing the etiology is colonoscopic examination; the disease is confirmed if characteristic patchy pseudomembranes are present in the bowel mucosa. Optimal treatment depends on severity of the disease and on the risk of recurrence. Metronidazole, vancomycin and fidaxomicin are used as basic drugs. Fecal transplantation is effective in recurrent disease. In the hospital setting, patients suffering from CDI should be isolated for the entire duration of diarrhea. Surveillance rules also should be applied, together with early treatment of symptomatic patients and prevention of the spread of the infection. Higher incidence of CDI in a ward implies that the local antibiotic prescription habits should be revised.

[Campylobacteriosis]

Campylobacteriosis belongs to the most frequent bacterial gastrointestinal infections worldwide. In the past several years, an increasing trend in the prevalence of campylobacteriosis has been observed in many countries. The rapid spread of antibiotic resistance in Campylobacter spp. also poses a major challenge. The authors review current knowledge on the microbiology of Campylobacter spp., complex pathogenetic as well as pathophysiological mechanisms in the development and course of campylobacteriosis and related complications such as Guillain-Barré syndrome.

Historical epidemiology of hepatitis C virus (HCV) in selected countries

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm

The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.

Strategies to manage hepatitis C virus (HCV) disease burden

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

Randomized comparison of tenofovir disoproxil fumarate vs emtricitabine and tenofovir disoproxil fumarate in patients with lamivudine-resistant chronic hepatitis B

BACKGROUND & AIMS

Tenofovir disoproxil fumarate (TDF) is active against lamivudine-resistant hepatitis B virus (HBV) infection, but data to support its clinical efficacy in this setting are limited.

METHODS

In a prospective, double-blind, 96-week trial, patients were randomly assigned (1:1) to groups given TDF (300 mg, n = 141) or a combination of emtricitabine (FTC, 200 mg; n = 139) and TDF (300 mg, FTC/TDF). Patients were hepatitis B e antigen (HBeAg)-positive or HBeAg-negative, with levels of HBV DNA ≥3 log10 IU/mL and lamivudine resistance mutations (HBV polymerase or reverse transcriptase amino acid substitutions rtM204I/V ± rtL180M by INNO-LiPA Multi-DR v3; Innogenetics, Inc, Alpharetta, GA). The primary end point was proportion with HBV DNA <69 IU/mL (Roche COBAS Taqman assay; Roche Molecular Systems, Inc, Pleasanton, CA).

RESULTS

Patient groups were well matched for demographic and disease characteristics, including region (60% from Europe), HBV genotype (45% genotype D), HBeAg status (47% HBeAg-positive), and duration of lamivudine treatment (mean, 3.8 years). At week 96 of treatment, 89.4% of patients in the TDF group and 86.3% in the FTC/TDF group had levels of HBV DNA <69 IU/mL (P = .43). HBeAg loss and seroconversion did not differ between groups; only 1 patient (0.7%) in the FTC/TDF group lost hepatitis B surface antigen. Treatment was well tolerated; confirmed renal events (creatinine increase of ≥0.5 mg/dL [>44 umol/L], creatinine clearance <50 mL/min, or level of PO4 <2 mg/dL [<0.65 mmol/L]) were generally mild and infrequent (<1%). Small reductions (<2%) in mean bone mineral density of hip and spine were detected by dual-energy x-ray absorptiometry in both groups. No TDF resistance developed through 96 weeks of treatment.

CONCLUSIONS

TDF alone is safe and effective for treatment of patients with lamivudine-resistant, chronic HBV infection. Clinical Trials.gov No, NCT00737568.

[Pathophysiology and pathogenesis of Salmonella sepsis]

The authors present a review of current knowledge about complex pathogenetic and pathophysiologic mechanisms involved in the development of sepsis in salmonellosis. Mechanisms such as lipopolysacharide-induced NOD-like receptor activation, escaping lysosomal degradation, intracellular replication niche formation, cytoskeleton reorganization, proapoptotic mechanism induction, changes in cytokine levels (IL-1β, TNF-α) and function of omptin proteases are discussed.

[A case report of ocular complications of leptospirosis]

Ocular complications are very frequent in leptospirosis and may develop in both the acute (bacteriemic) and the second (immunologic) phases of the disease. A delayed onset of these complications, even after months or years, is also possible. Keratoconjunctivitis and panuveitis belong to the most frequent signs. Targeted search for patients suspected of having leptospirosis and regular ophthalmological examinations even after cure of the acute illness may lead to early detection of ocular complications and to their specific treatment. Presented are a case report of complicated uveitis due to infection with Leptospira grippotyphosa and a literature overview.

Epidemiological factors influencing the development of relapsing and severe Clostridium difficile infection

INTRODUCTION

Clostridium difficile infection (CDI) is currently the most frequent cause of nosocomial infectious diarrhea in adults in the developed countries. The goal of the study was to evaluate risk factors for relapsing and severe CDI in a set of patients hospitalized at the Clinic of Infectious Diseases at the University Hospital Brno.

MATERIALS AND METHODS

A retrospective analysis of epidemiological, clinical and laboratory data of 281 patients with proved CDI diagnosis hospitalized in the period from 1. 1. 2007 to 31. 12. 2010.

RESULTS

Patient age over 65 is a risk for severe CDI (OR 2.95, p < 0.001) and extends hospitalization at the first episode of CDI by about 3.2 days on average. Patients with 2 or more comorbidities (p < 0.05) or with a history of recent hospitalization (p 0.001) are at risk for both relapsing CDI and severe CDI. The use of proton pump inhibitors may increase the number of relapses (OR 1.94, p < 0.05). If the CDI symptoms appear within 7 days of taking antibiotics, there is a greater risk of relapse (OR 2.32, p < 0.05). If the symptoms occur after a longer period, a mild or moderate course of the disease can be expected (OR 0.31, p < 0.05).

CONCLUSIONS

To determine the risk level for development of relapsing or severe CDI, focus on risk factors from the patients medical history and their clinical and laboratory status is appropriate at the outset of CDI patients treatment. An early intensive monitoring of vital functions and administration of aggressive treatment can reduce complications, mortality and relapses of CDI.

[Dengue fever cases in Czech workers returning from the Maldives]

AIM

The objective of this study is to present epidemiological characteristics and clinical symptoms of dengue fever cases in Czech workers who acquired the infection while working on the island of Fushivelavaru, Maldives. Furthermore, the study compares the sensitivity of novel direct detection assays, i.e. Real-Time Polymerase Chain Reaction (RT-PCR) and detection of Dengue NS1 antigen.

MATERIAL AND METHODS

The retrospective study evaluated the clinical course of dengue fever cases in Czech workers returning from a job in the Maldives who were diagnosed with dengue virus infection from September 1 to October 31, 2012. The laboratory diagnosis of dengue fever was based on the serological detection of IgM and IgG antibodies, detection of dengue NS1 antigen by enzyme-linked immunosobent assay (ELISA), and detection of dengue virus DNA by RT-PCR.

RESULTS

The infection with dengue virus was confirmed in 18 males with a median age of 40 years (IQR 36-47) who returned from a job in the Maldives. Only one patient required admission to the hospital while the others were treated on an outpatient basis. The most frequently observed symptoms were fever (18), headache (9), muscle and joint pain (8 and 7, respectively), and rash (9). Typical laboratory findings were leukocytopenia and thrombocytopenia, a low CRP level, and elevated aminotransferase activity. The clinical course was uncomplicated in all patients. The dengue NS1 antigen detection (positive in all 10 patients with acute dengue fever) showed significantly higher sensitivity than the detection of viral RNA using RT-PCR (positive in 4 patients), p = 0.011.

CONCLUSION

Although the vast majority of dengue fever cases are diagnosed among travellers returning from the tropics, the presented study points out the risks posed by dengue fever to long-term workers in endemic areas. The infection in the serologically naïve hosts is usually uncomplicated; however, infected persons are at significant risk of developing a severe complicated clinical course if challenged by another serotype. Furthermore, sick leaves or premature departures cause a considerable economic burden to employers. In the diagnosis of acute dengue fever, preference should be given to highly sensitive and specific tests for the direct detection of dengue virus (NS1 antigen and RT-PCR assays).

[Colitis precipitated by Clostridium difficile - a serious current problem]

Clostridium difficile is currently considered a significant cause of nosocomial infection. The probability of a colonisation of hospitalised patients rises with the length of their stay in hospital and depends on the local epidemiologic situation. Interdisciplinary collaboration is the foundation of the effort to limit the development of this very serious, often fatal disease. The basic element is a rational antibiotic therapy which builds on the knowledge that the administration of antibiotics, even though based on a correct indication, may be fatal in an environment which is massively contaminated by spores of Clostridium difficile. Consequently, the high risk antibiotics (such as aminopenicillins, fluoroquinolones or cefalosporins) should be administered only in such cases where they cannot be substituted by antibiotics with a lower risk of CDI.

[RILPIVIRINE -- a novel HIV-1 non-nucleoside reverse transcriptase inhibitor]

The article summarizes the basic facts about the pharmacokinetic profile, metabolism and drug interactions of rilpivirine (RPV). This is the latest orally administered second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) for antiretroviral-naive patients with HIV-1 infection. Conformational flexibility and adaptability are the factors that dominantly determine the high resistance barrier of RPV and are the unique features of diarylpyrimidine inhibitors (DAPY inhibitors - 2nd generation NNRTIs). Multicentre studies ECHO and THRIVE are also reviewed. Current guidelines for the treatment of HIV/AIDS are mentioned as well as the role of RPV in current therapeutic regimens.

[Risk factors for relapsing and severe colitis caused by Clostridium difficile infection]

BACKGROUND

Describe risk factors for relapsing and severe Clostridium difficile infection (CDI) in a set of patients hospitalized at the Clinic of infectious diseases the University Hospital Brno.

MATERIAL AND METHODS

A retrospective study observing epidemiological, clinical and laboratory data of 281 patients with proven diagnosis of Clostridium difficile infection hospitalized in the period from 1. 1. 2007 to 31. 12. 2010.

RESULTS

In the first part of the evaluation were enrolled 233 patients, 87 (37.3 %) patients had a record of relapsing CDI and 146 (62.7 %) patients had nonrelapsing CDI. Factors associated with relaps included 2 or more comorbidities, previous hospitalization during the 4 weeks before CDI, the use of proton pump inhibitors. In the second part of the evaluation were enrolled all 281 patients, severe CDI during any episode of the disease was observed in 181 (64.4 %) patients, while the remaining 100 (35.6 %) patients had mild or moderate CDI. The risk factors associated with severe CDI were age older than 65 years, history of coronary heart disease, chronic renal insufficiency, a combination of 2 or more comorbidities, previous hospitalization in a period of 4 weeks.

CONCLUSIONS

Age older than 65 years is the risk for severe CDI. Patients with 2 or more comorbidities or with history of previous hospitalization are in a risk for both, relapsing and severe CDI. Use of proton pump inhibitors may lead to recurrence, probably on the basis of re-infection Clostridium difficile spores.

[Febrile pancytopenia and hepatosplenomegaly as leading symptoms of visceral leishmaniasis]

The authors present a case report of a patient with febrile pancytopenia, hepatosplenomegaly and weight loss as main symptoms of visceral leishmaniasis. Standard treatment regimen with amphothericin B led to relapse of the disease after several weeks. The definitive cure of the disease was achieved with cytostatic miltefosin (Impavido©), which is not registered in the Czech Republic. The aim of this article is to point out this imported protozoan infection and its basic clinical and laboratory features.

[Warning about risk of invasive infections in splenectomized patients. Experiences from University Hospital Brno, Czech Republic, in 2011]

Syndrome of fulminant sepsis in splenectomized (overwhelming postsplenectomy infection - OPSI) is feared and often fatal infectious complication in patients after splenectomy. The risk of syndrome of fulminant sepsis in splenectomized in these persons persists lifelong and doesn't diminish during the time. Etiologically, encapsulated bacterias like Streptococcus pneumoniae, Haemophilus influenzae group b and Neisseria meningitidis are involved. As the mortality of syndrome of fulminant sepsis in splenectomized is very high, it is indispensable to educate and vaccinate persons in risk. The authors present case reports of three splenectomized patients who were hospitalized for invasive pneumococcal infection in the University Hospital Brno, Czech Republic, in 2011.