Evaluation of drivers of treatment switch in relapsing multiple sclerosis: a study from the Italian MS Registry

BACKGROUND

Active relapsing-remitting (RR) and secondary progressive (SP) multiple sclerosis (MS) are currently defined as "relapsing MS" (RMS). The aim of this cross-sectional study was to assess drivers of treatment switches due to clinical relapses in a population of RMS patients collected in the Italian MS and Related Disorders Register (I-MS&RD).

METHODS

RRMS and SPMS patients with at least one relapse in a time window of 2 years before of data extraction were defined as RMS. Factors associated with disease-modifying therapy (DMT) switching due to clinical activity were assessed through multivariable logistic regression models in which treatment exposure was included as the last recorded DMT and the last DMT's class [moderate-efficacy (ME), high-efficacy (HE) DMTs and anti-CD20 drugs].

RESULTS

A cohort of 4739 RMS patients (4161 RRMS, 578 SPMS) was extracted from the I-MS&RD. A total of 2694 patients switching DMTs due to relapses were identified. Switchers were significantly (p < 0.0001) younger, less disabled, more frequently affected by an RR disease course in comparison to non-switcher patients. The multivariable logistic regression models showed that Alemtuzumab (OR 0.08, 95% CI 0.02-0.37), Natalizumab (0.48, 0.30-0.76), Ocrelizumab (0.1, 0.02-0.45) and Rituximab (0.23, 0.06-0.82) exposure was a protective factor against treatment switch due to relapses. Moreover, the use of HE DMTs (0.43, 0.31-0.59), especially anti-CD20 drugs (0.14, 0.05-0.37), resulted to be a protective factor against treatment switch due to relapses in comparison with ME DMTs.

CONCLUSIONS

More than 50% of RMS switched therapy due to disease activity. HE DMTs, especially anti-CD20 drugs, significantly reduce the risk of treatment switch.

The Epidemiology, Treatment Patterns and Economic Burden of Different Phenotypes of Multiple Sclerosis in Italy: Relapsing-Remitting Multiple Sclerosis and Secondary Progressive Multiple Sclerosis

PURPOSE

A retrospective analysis of real-world data was performed to assess the epidemiology and economic burden of multiple sclerosis (MS), relapsing-remitting MS (RRMS), and secondary-progressive MS (SPMS) in Italy.

PATIENTS AND METHODS

An observational study on administrative databases from a sample of Italian entities was carried-out. Between 01/2010-12/2017, patients with ≥1 MS diagnosis code (ICD-9-CM:340 and/or exemption code:046) and/or ≥1 disease-modifying therapies (DMTs) prescription, were included. Among MS-cohort, SPMS patients were identified by ≥2 hospitalizations or by ≥2 drug prescriptions related to MS progression. MS patients not fulfilling SPMS criteria were included as RRMS. Mean annual healthcare costs were reported during follow-up and stratified by DMT treatment/untreatment.

RESULTS

Overall, 9543 MS patients were included; 8397 with RRMS and 1146 with SPMS. Estimated prevalence of MS was 141.6/100,000 inhabitants (RRMS 124.4/100,000 and SPMS 17.2/100,000). Mean annual cost for untreated and treated patient was respectively: €3638 and €11796 (MS-cohort), €3183 and €11486 (RRMS-cohort), €6317 and €15511 (SPMS-cohort). The first-line DMT treatment duration averaged 27.4 ± 22.8 months; the mean cost was 19004€ for the whole period. The second-line DMT treatment lasted on average 31.1 ± 24.5 months; the mean cost was 47293€ for the whole period.

CONCLUSION

This study provided insights into the MS epidemiology in Italy and its economic burden. Healthcare costs associated with MS management were mainly driven by DMTs expenditure. A trend of higher healthcare-resource consumption was observed among SPMS-cohort.

Towards a validated definition of the clinical transition to secondary progressive multiple sclerosis: A study from the Italian MS Register

BACKGROUND

Definitions for reliable identification of transition from relapsing-remitting multiple sclerosis (MS) to secondary progressive (SP)MS in clinical cohorts are not available.

OBJECTIVES

To compare diagnostic performances of two different data-driven SPMS definitions.

METHODS

Data-driven SPMS definitions based on a version of Lorscheider's algorithm (DDA) and on the EXPAND trial inclusion criteria were compared, using the neurologist's definition (ND) as gold standard, in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Akaike information criterion (AIC) and area under the curve (AUC).

RESULTS

A cohort of 10,240 MS patients with ⩾5 years of follow-up was extracted from the Italian MS Registry; 880 (8.5%) patients were classified as SPMS according to the neurologist definition, 1806 (17.6%) applying the DDA and 1134 (11.0%) with the EXPAND definition. The DDA showed greater discrimination power (AUC: 0.8 vs 0.6) and a higher sensitivity (77.1% vs 38.0%) than the EXPAND definition, with similar specificity (88.0% vs 91.5%). PPV and NPV were higher using the DDA than considering EXPAND definition (37.5% vs 29.5%; 97.6% vs 94.0%).

CONCLUSION

Data-driven definitions demonstrated greater ability to capture SP transition than neurologist's definition and the global accuracy of DDA seems to be higher than the EXPAND definition.

Patients with multiple sclerosis: a burden and cost of illness study

Background

Multiple sclerosis (MS) is a chronic neuroinflammatory and neurodegenerative disease negatively impacting patients’ physical, psychological and social well-being with a significant economic burden.

Objectives

The study estimates MS burden and cost of illness in Italy from a societal perspective in 2019.

Methods

Information on the impact of the disease on daily activities, symptoms, employment, resource utilization and the role of caregivers was collected through questionnaires completed by 944 patients and caregivers. Results were stratified according to both disease severity and payer. Mean costs and overall costs were extrapolated from the sample to the Italian MS population considering published distribution of severity.

Results

The study showed a great impact of the disease on daily and work activities increasing with the disability. The overwhelming burden of fatigue emerged. Mean annual costs were estimated at €39,307/patient (€29,676, €43,464 and €53,454 in mild, moderate and severe cases, respectively). Direct healthcare costs were the major component (€21,069), followed by indirect costs (€15,004). The overall cost of the disease in Italy was €4.8 billion. The National Healthcare System (NHS) sustained most of the costs (80%), most notably direct healthcare costs, while patients paid almost all non-healthcare expenses.

Conclusions

This study confirmed that MS carries a substantial burden to patients and society, highlighting the need for awareness of this disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11169-w.

Cost-effectiveness and budget impact analysis of siponimod in the treatment of secondary progressive multiple sclerosis in Italy

Background

Siponimod is an effective treatment for patients with secondary progressive multiple sclerosis (SPMS), with active disease evidenced by relapses or imaging features characteristic of multiple sclerosis inflammatory activity, however there is a need to evaluate its economic value and sustainability compared to other disease modifying-therapies (DMTs).

Objective

To estimate the siponimod cost-effectiveness profile and its relative budget impact compared with other DMTs, by using the Italian National Healthcare System perspective.

Methods

We performed: 1) a cost-effectiveness analysis (CEA) vs interferon beta-1b using an analytical Markov model and a life time-horizon, and 2) a budget impact analysis by using 3-years time-horizon. The results were reported as incremental cost-effectiveness ratio (ICER) and net-monetary benefit (NMB) for CEA, using a willingness to pay threshold of €40,000 per QALY gained, and as difference in the overall budget (Euro) between the scenario with and without siponimod for budget impact.

Results

In the base case scenario siponimod resulted cost-effective compared with interferon beta-1b 28,891€ per QALY. Overall, the market access of siponimod was associated to an increased budget of about 3€ millions (+0.9%) in the next 3 years simulated.

Conclusion

Compared to interferon beta-1b, siponimod seems to be cost-effective in SPMS patients and sustainable, with less than 1% overall budget increased in the next 3 years. Future studies need to confirm our results in the real word setting and in other countries.

Effectiveness of fingolimod in real-world relapsing-remitting multiple sclerosis Italian patients: the GENIUS study

Background

Fingolimod is the first oral agent approved for treatment of relapsing-remitting multiple sclerosis (RRMS). We aimed to evaluate fingolimod effectiveness in a real-world sample of RRMS patients.

Methods

A retrospective, multicentre study in patients treated with fingolimod, whom clinical and radiological data were collected in the 2 years preceding and following the initiation of fingolimod.

Results

Out of 414 patients, 56.8% received prior first-line injectable disease-modifying therapies, 25.4% were previously treated with natalizumab, 1.2% with immunosuppressant agents, and 16.7% were treatment naive. The annualized relapse rate decreased by 65% in the first year and by 70% after two years of treatment. Age ≤ 40 years, ≥ 1 relapse in the 24 months before fingolimod initiation and previous treatment with natalizumab were risk factors for relapses. Overall, 67.9% patients had no evidence of disease activity (NEDA-3) after 1 year and 54.6% after 2 years of treatment. A higher proportion of naïve (81.2% in 1 year and 66.7% after 2 years) or first-line injected patients (70.2% and 56.6%) achieved NEDA-3 than those previously treated with natalizumab (54.3% and 42.9%).

Conclusions

Fingolimod appeared to be effective in naive patients and after first-line treatment failure in reducing risk of relapse and disease activity throughout the 2-year follow-up.

Electronic supplementary material

The online version of this article (10.1007/s10072-020-04380-y) contains supplementary material, which is available to authorized users.

Epidemiology and determinants of chronic migraine: A real-world cohort study, with nested case-control analysis, in primary care in Italy

BACKGROUND

The proper identification of chronic migraine is one of the mainstays for general practitioners. This study therefore aims to assess the epidemiology and determinants of chronic migraine in primary care in Italy by testing five operational case definition algorithms.

METHODS

Five case definition algorithms defining chronic migraine were developed to estimate the prevalence and incidence rate of chronic migraine in the Health Search database. For each algorithm, we conducted a nested case-control analysis to quantify the level of association between certain determinants and incident cases of chronic migraine.

RESULTS

Considering a cohort of 1,091,032 patients (52% were females), the prevalence rate of chronic migraine increased from the first to the fifth case definition algorithm ranging from 0.03 to 0.28%. No 95% confidence interval overlapped the others, and every confidence interval reliably maintained 2% precision. Incidence rates showed a growing trend (0.008-0.056 per 100,000 person-years) as well. All case definition algorithms were able to capture sex (i.e. female) and nonsteroidal anti-inflammatory drug (NSAID) overuse as statistically significant determinants of incident cases of chronic migraine. Depression was associated with a statistically significant increase of incidence rate of chronic migraine only for two case definition algorithms.

CONCLUSION

Our findings show that prevalence and incidence rate of chronic migraine are underestimated when compared with current literature. On the other hand, we found acceptable correctness of chronic migraine definition in the light of the association with well-known determinants.

[Heart failure in Apulia Region - Italy (Local Health Unit Barletta-Andria-Trani): analysis of the therapeutic pathways, healthcare resource consumption and related costs.]

BACKGROUND

Heart failure (HF) is commonly reported, it is estimated to affect 10% of subjects aged over 70 years. Objectives of this study were to describe clinical and demographic characteristics of patients with HF diagnosis, to analyze therapeutic pathways and to estimate healthcare resources consumption.

METHODS

Data on patients aged ≥18 years with a hospitalization discharge diagnosis of HF between 01/01/2010 and 31/12/2014 and in treatment with HF-related drugs were extracted from the administrative databases of the Italian Local Health Unit of Barletta-Andria-Trani (BT). We described the pharmacological treatment prescribed and the use of drugs in combination both at the beginning and at the end of the 12-month follow-up period. The costs analysis was conducted with the perspective of the Italian National Health System.

RESULTS

A total of 2 669 patients with HF were enrolled in the study, 1 960 as primary and 709 as secondary diagnosis (average age 77.0±10.4/76.5±11.1 years respectively, 49% and 55% were male, respectively). Mortality during 12 months of follow-up was 46% and 43% respectively. Mostly prescribed pharmacological treatments were diuretics (90.4% of patients with primary HF diagnosis and 79.4% of patients with secondary HF diagnosis), beta-blockers (53.7% and 58.8%, respectively) and aldosterone antagonists (57.5% and 42.5%, respectively); moreover, during the follow-up period, half of the patients presented a switch from the original therapy and 10% of the patients required an add-on. Healthcare resource consumption for patients discharged alive was € 11 872.4 for patients with primary diagnosis and € 12 493.7 for patients with secondary diagnosis of HF. Cost for hospitalizations during follow-up was around € 3 800 (32.3% of total costs) and € 3 600 (29.0% of total costs), respectively.

CONCLUSIONS

Our findings are in accordance with what already published, both in a National and International context, on mortality rates in HF patients and related costs for the National Healthcare System. Results from the present study highlight the under-prescriptions of ACEi/ARBs, aldosterone antagonists and beta-blockers in HF patients.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Bulgaria, Romania, Serbia and Croatia

Objectives

To determine antibiotic susceptibility of isolates of Streptococcus pneumoniae (n = 573) and Haemophilus influenzae (n = 345) collected in 2014-16 from Bulgaria, Romania, Serbia and Croatia.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

Among S. pneumoniae, susceptibility was generally lowest in Romania and Serbia and highest in Bulgaria. Rates of susceptibility to penicillin (CLSI oral or EUCAST) were 22.3% and 21.8% in Romania and Serbia respectively, 57% in Croatia and 86.6% in Bulgaria. Similarly, macrolide susceptibility using CLSI/EUCAST breakpoints was low in Romania and Serbia (∼28% and 34.5%, respectively), higher in Croatia (55.9%) and highest in Bulgaria (∼75%). Only fluoroquinolones were active against all isolates in all four countries. Susceptibility was higher and variability across countries less pronounced for H. influenzae. Susceptibility by CLSI criteria to amoxicillin/clavulanic acid, azithromycin, cefuroxime, ceftriaxone and fluoroquinolones was ≥98% in all countries. Ampicillin susceptibility ranged from 85.3% in Romania to 100% in Bulgaria. Much greater variability was seen across breakpoints. Susceptibility to azithromycin and cefuroxime using CLSI criteria was ≥98% in all four countries, but was 0%-1% by EUCAST criteria.

Conclusions

The variability in antimicrobial susceptibility using different breakpoints makes it difficult for clinicians to interpret antimicrobial resistance data, and efforts should be made to harmonize breakpoints. The variability found across the four neighbouring countries demonstrates the need to monitor and publish national and local resistance patterns. These findings provide information critical for the selection of appropriate antimicrobial agents for the treatment of S. pneumoniae and H. influenzae.

Explorative analysis of gender-specific characteristics in patients with heart failure in an Italian hospital

Sex-related differences have been shown to deeply affect health-related aspects of patients. However, the lack of gender-specific analysis makes it difficult to advance personalized medicine in terms of a gender-based approach. The aim of the present study was to describe gender-specific features of patients diagnosed with heart failure (HF), with a focus on the clinical presentation. Data were collected from a properly designed database and referred to an Italian hospital. Patients aged ≥18 years with a primary or secondary diagnosis of HF between 1 January 2012 and 31 December 2016 were included, and their demographic and clinical characteristics were analyzed according to gender. Of the 719 HF patients included, 317 (44.1%) were male and 402 (55.9%) were female. Women tended to be older compared to men (82.4±8.8 years and 77.1±10.6 years, respectively). As for clinical presentation, 62.1% of female and 38.3% of male patients had preserved ejection fraction, and 56.1% of men and 58.2% of women suffered from atrial fibrillation. The left atrium was partially compromised in 62.4% of male and 63% of female patients, while right atrium dysfunction tended to be more frequent in male patients compared to female patients (29.1% and 25.5%, respectively). In conclusion, gender-specific features of a cohort of HF patients from a clinical setting were accurately described.

THE SURGICAL TREATMENT OF CHONDROBLASTIC OSTEOSARCOMA - A CASE REPORT

Osteosarcoma is the most common primary malignant bone tumor, with a higher prevalence among children and young adults. Its most frequent localization is in the distal femur, followed by the proximal humerus and the proximal femur. In this article, we will describe the case of a 25-year-old male patient who presented to our medical facility, accusing spontaneous pain and swelling, both originating from the left knee. The X-ray of the distal femur showed a heterogeneous mass around the left femoral metaphysis with massive periosteal reaction. The computerized tomography (CT) analysis revealed cortical destruction, with extra-compartmental localization. The patient has later undergone to an incisional biopsy. The histopathology report showed the presence of a chondroblastic osteosarcoma. According to the multidisciplinary diagnosis, the tumor was finallyclassified as type IIB on the Enneking classification. In such cases, the elective surgical procedure is reconstructive surgery, consisting of wide resection of the distal femur, followed by modular reconstruction. After the surgery, the patient’s condition improved significantly and the functional outcome of the reconstructed joint was also satisfying.

Increasing incidence of HIV- associated tuberculosis in Romanian injecting drug users

BACKGROUND

A high prevalence of tuberculosis (TB) among HIV-positive injecting drug users (IDUs) may fuel the TB epidemic in the general population of Romania. We determined the frequency and characteristics of TB in HIV-infected IDUs referred to a national centre.

METHODS

Prospective observational cohort study of all newly-diagnosed HIV-positive IDUs admitted to Victor Babes Hospital, Bucharest, between January 2009 and December 2014. Socio-demographics, clinical characteristics and outcomes of HIV/TB co-infected IDUs were compared to HIV-positive IDUs without TB.

RESULTS

170/598 (28.5%) HIV-infected IDUs were diagnosed with TB. The prevalence increased from 12.5% in 2009 to 32.1% in 2014 (P < 0.001). HIV/TB co-infected individuals had lower median CD4 cell counts 75 (vs. 450/mm³ , P < 0.0001) and higher median HIV viral loads 5.6 log₁₀ (vs. 4.9 log₁₀ , P < 0.0001) when presenting to healthcare services. 103/170 (60.6%) HIV/TB co-infected IDUs were diagnosed with pulmonary TB. Resistant Mycobacterium tuberculosis strains were common, with 18/105 (17.1%) of patients having Multi-Drug Resistant (MDR) disease. Higher mortality rate was associated with TB co-infection (P < 0.0001), extra-pulmonary TB (P = 0.0026) and extensively drug resistant TB (P = 0.024).

CONCLUSIONS

Tuberculosis (TB) is an increasing problem in HIV-infected IDUs in Romania. Presentation is often with advanced HIV, significant TB drug resistance and consequent outcomes are poor.

No substantial gender differences in suspected adverse reactions to ACE inhibitors and ARBs: results from spontaneous reporting system in Campania Region

BACKGROUND

Today, there is a poor knowledge about gender differences in adverse drug reactions (ADRs) to cardiovascular drugs such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Therefore, the aim of this study was to analyze spontaneous reports of suspected ADRs induced by ACE-inhibitors and ARBs, between January 2001 and June 2015, recorded in a Region of Southern Italy (Campania Region).

METHODS

We performed a descriptive gender-related analysis of regional safety data, obtained from the spontaneous reporting system.

RESULTS

In the considered period, 772 suspected ADRs to ACE inhibitors and ARBs (in monotherapy or in combination) were reported with a slightly higher frequency in men compared with women. In both genders, the most involved category was ARBs in combination, whereas the most prescribed active substance was ramipril. General and administration site conditions, vascular disorders and modification of laboratory parameters were more common in men, while respiratory disorders were most common in women. In 88.2% of cases, not serious ADRs were described more by men than women.

CONCLUSIONS

This analysis suggested no substantial gender differences. Further studies such as randomized population studies or meta-analysis of ACE inhibitors and ARBs randomized studies are needed to clarify whether gender differences exist in the safety profile of these drugs.

Gender differences in the adverse events' profile registered in seven observational studies of a wide gender-medicine (MetaGeM) project: the MetaGeM safety analysis

Background

MetaGeM is a wide gender-medicine project comprising post hoc and meta-analyses by gender of clinical outcomes, therapeutic approaches, and safety data from previously conducted observational studies to explore possible gender differences in real-life clinical settings. We report the results of the safety meta-analysis of seven MetaGeM studies, evaluating gender differences in adverse event (AE) incidence and severity.

Methods

Data were collected between February 2002 and July 2013. Male and female patients were compared for the main safety variables, using Student’s t-test, χ² test, or Fisher’s exact test as appropriate. As supportive analysis, a logistic regression model was estimated to evaluate associations between gender and outcome.

Results

In total, 4,870 patients (46% females, 54% males) were included in the analysis; age was higher for females (mean ± standard deviation 61.2±18.3 years) than males (56.3±16.6 years). Overall, 264 AEs were reported (59.1% in males). There were no significant gender differences in the percentage of patients with at least one AE: 3.0% for females versus 3.9% for males, χ² test P>0.05. According to the logistic regression model results, no association between gender and AEs occurrence seems to exist. A statistically significant gender difference in the percentage of drug-related AEs emerged (37.6% in females vs 20.8% in males, χ²P=0.0039). Slightly significantly more AEs in females were addressed with treatment compared with males (78.1% vs 66.7%, χ²P=0.0485). Total serious AEs (SAEs) were 47 (72% in males). The frequency of patients with ≥1 SAE was 0.6% in females versus 1.2% in males (χ² test P=0.0246).

Conclusion

This safety analysis on a large sample of almost 5,000 patients with different diseases and treated with a wide range of different drugs provides a useful overview on possible gender differences in drug tolerability, which may be helpful in more accurately designing future clinical trials from a gender-specific perspective.

Literature review of gender differences in respiratory conditions: a focus on asthma and Chronic Obstructive Pulmonary Disease (COPD)

BACKGROUND

Gender differences are evident in many common health conditions, especially respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD). The aim of this review was to identify published studies describing gender differences in asthma and COPD, in particular regarding pathophysiology, diagnosis and treatment, with a focus on Italian data.

METHODS

a literature review was performed from April to November 2015, using the PubMed scientific database and the following ??eywords: "gender differences" and "asthma" for the asthma review and "gender differences" and "COPD" for the COPD review.

RESULTS

Gender differences in asthma are related to age groups. In the female population, asthma is generally more severe and disabling, and presents higher mortality rates with respect to same-age males. COPD prevalence is growing and is underestimated in women, because it tends to be diagnosed with difficulty and at a delayed stage. The same findings were observed when restricting the review to Italian data.

CONCLUSION

Clinicians should collaborate to develop a more gender-oriented approach towards diagnosis and treatment of asthma and COPD. In Italy, this would also facilitate measures to improve compliance, particularly among women.

Dinamic of resistance to antibiotics for the most frequent potential pathogen bacterial isolates in “Dr. V. Babes” Clinical Hospital of Infectious and Tropical Diseases (2000-2015)

Objective. Analyzing the dynamycs of global antibiotic resistance of some bacterial species isolated from patients admitted to the „Dr. V. Babes” Hospital for Infectious and Tropical Diseases, between the years 2000 to 2015. Material and methods. Antibiotic resistance profiles of bacteria isolated from inpatients, were identified by the standard diffusion method and MIC values by VITEK2C and E-test methods. (CLSI and EUCAST standards). Screening of carbapenemases – producing isolates were performed by phenotipic methods, and the confirmation by RealTimePCR: “MasterPure™ Complete DNA and RNA Purification Kit” (Epicentre), „Primer Design™ Kit” (blaOXA48; blaKPC, blaNDM, blaVIM)/ LightScanner 32 Instrument/LS32 (Idaho Technology), and GeneXpert. Internal quality control: Staphylococcus aureus ATCC29213, Streptococcus pneumoniae ATCC49619, E. coli ATCC25922, Pseudomonas aeruginosa ATCC27853. Results. The incidence of St. aureus meticilino-rezistent (MRSA) highlights an increase from 12.2% (2002) to 40.4% (2015). In the past 3 years SVB microbiology lab found a sharp increase in the incidence of erytromycin resistant strains of Streptococcus pyogenes. In 2015 we registered 20.3% of macrolide resistant strains. Global resistance to penicillin G for Str. pneumoniae (non-meningeal infections) was 45.3%- 54.5% until 2009, and 2.7% in 2013. Enterococcus faecium strains showed 0% resistance to vancomycin between 2000 and 2012. A significant growth was recorded in 2015 of 11%. Isolation rate of Klebsiella pneumoniae ESBL producing strains has increasewd progressively from 17.6 in 2000 to 57% in 2015. Carbapenems – resistant K. pneumoniae isolated strains were 18,8% in 2015. Carbapenemases types identified by phenotypic and genetic methods where: 35/ Oxa48, 8 KPC and 21/MBL (NDM-1). Resistance to carbapenems recorded an upward trend: 23.9% in 2004 to 37.9% in 2015, and for Acinetobacter baumannii 69%. Conclusions. Antibiotic resistance of bacteria is a major challenge for public healts. Therapeutic solutions are extremely limited.

Plasmodium vivax malaria in a Romanian traveller returning from Greece, August 2011

In August 2011, a Plasmodium vivax malaria infection was diagnosed in a Romanian traveller returning from Greece. This case together with several reports over the past decade of autochthonous cases in Greece highlight that malaria should be considered as differential diagnosis in symptomatic travellers returning from this country. Travellers may serve as sentinels of emerging vector-borne diseases.

Multidisciplinary management and outcome in subdural empyema--a case report

Cranial subdural empyema (SDE), a localized septic intracranial collection, occurs mostly as a complication of sinusitis, otitis or mastoiditis. Although relatively rare, SDE requires an increased attention for early recognition, cerebral imagery being mandatory in any suspected case. Any delay in treatment can lead to coma with a fatal outcome. The authors report the case of a young boy, who developed a severe, important cerebral edema, thin subdural collection with minimal displacement of the median line. Repeated cerebral MRI showed an enlarged subdural collection with higher median line shift and imposed rapid surgical intervention. The collection proved to be empyema. Other findings on MRI are pansinusitis, mild mastoiditis and transverse sinus thromboflebitis. The recovery was accompanied by the need for long course of antibiotherapy, secondary epilepsy treatment and kinetotherapy for hemiparesis. The patient also developed intracerebral cysts expanding the brain through the postoperative cranial defect which later needed surgical intervention, for both neurological and esthetic improvement. The management of the case implied strong interdisciplinary collaboration between infectionist, neurologist, neurosurgeon, microbiologist and imagist.

Plasmodium vivax malaria in a Romanian traveller returning from Greece, August 2011

In August 2011, a Plasmodium vivax malaria infection was diagnosed in a Romanian traveller returning from Greece. This case together with several reports over the past decade of autochthonous cases in Greece highlight that malaria should be considered as differential diagnosis in symptomatic travellers returning from this country. Travellers may serve as sentinels of emerging vector-borne diseases.

Prevalence of virulence genes in Escherichia coli strains isolated from Romanian adult urinary tract infection cases

A total of 78 E. coli strains isolated from adults with different types of urinary tract infections were screened by polymerase chain reaction for prevalence of genetic regions coding for virulence factors. The targeted genetic determinants were those coding for type 1 fimbriae (fimH), pili associated with pyelonephritis (pap), S and F1C fimbriae (sfa and foc), afimbrial adhesins (afa), hemolysin (hly), cytotoxic necrotizing factor (cnf), aerobactin (aer). Among the studied strains, the prevalence of genes coding for fimbrial adhesive systems was 86%, 36%, and 23% for fimH, pap, and sfa/foc,respectively. The operons coding for Afa afimbrial adhesins were identified in 14% of strains. The hly and cnf genes coding for toxins were amplified in 23% and 13% of strains, respectively. A prevalence of 54% was found for the aer gene. The various combinations of detected genes were designated as virulence patterns. The strains isolated from the hospitalized patients displayed a greater number of virulence genes and a diversity of gene associations compared to the strains isolated from the ambulatory subjects. A rapid assessment of the bacterial pathogenicity characteristics may contribute to a better medical approach of the patients with urinary tract infections.