The Profile of Multidrug Tuberculosis Regimen and Treatment Outcomes in Pulmonary MDR-TB Patients at the Tertiary Referral Hospital Dr. Soetomo, East Java, Indonesia: A Seven-Year Retrospective Study on Bedaquiline

BACKGROUND

The use of bedaquiline has been reported to minimize the number of lost to follow-up and fewer rejections from the patients. This study is the first to depict the use of bedaquiline. It aims to provide information related to the profile of the MDR-TB drug regimen in the last 7 years with the treatment outcomes of pulmonary MDR-TB patients at a tertiary referral hospital in East Java.

METHODS

This study was a retrospective, descriptive, and data analysis on 1053 pulmonary MDR-TB patients in tertiary referral hospital Dr Soetomo, East Java, Indonesia, with the SPSS software version 25 and Microsoft Excel 2021.

RESULTS

The study analyzed the  MDR-TB treatment regimen following the latest guidelines from WHO (2020) at a tertiary referral hospital in East Java. This study shows that a bedaquiline-containing regimen started in January 2015 to July 2022 with the percentage of distribution (1, 3, 11, 4, 18, 13, 29, 21)% consecutively in the regimen. The treatment outcome profile of MDR-TB patients shows the average percentage of cured (15%), died (12%), lost-to-follow-up cases (27%), moved to an individualized regimen or a different health facility (42%), and currently in the evaluation stage (4%). Overall from January 2017 to July  2022, the number of LTFU cases decreased (42, 46, 29, 19, 8, 4)%. However, the cured case fluctuated between 2017-2022 (16, 28, 26, 32)%  respectively after Bdq started to be included in the regimen regularly for treating RR/MDR-TB.

CONCLUSION

After seven years of study, we revealed an association between adding bedaquiline to the regimen and the treatment success and decreasing lost-to-follow-up cases.

Antibodies against native proteins of Mycobacterium tuberculosis can detect pulmonary tuberculosis patients

Accurate point-of-care testing (POCT) is critical for managing tuberculosis (TB). However, current antibody-based diagnosis shows low specificity and sensitivity. To find proper antigen candidates for TB diagnosis by antibodies, we assessed IgGs responsiveness to Mycobacterium tuberculosis proteins in pulmonary TB (PTB) patients. We employed major secreted proteins, such as Rv1860, Ag85C, PstS1, Rv2878c, Ag85B, and Rv1926c that were directly purified from M. tuberculosis. In the first screening, we found that IgG levels were significantly elevated in PTB patients only against Rv1860, PstS1, and Ag85B among tested antigens. However, recombinant PstS1 and Ag85B from Escherichia coli (E. coli) couldn't distinguish PTB patients and healthy controls (HC). Recombinant Rv1860 was not checked due to its little expression. Then, the 59 confirmed PTB patients from Soetomo General Academic Hospital, Surabaya, Indonesia, and 102 HC were tested to Rv1860 and Ag85B only due to the low yield of the PstS1 from M. tuberculosis. The ROC analysis using native Ag85B and Rv1860 showed an acceptable area under curve for diagnosis, which is 0.812 (95% CI 0.734-0.890, p < 0.0001) and 0.821 (95% CI 0.752-0.890, p < 0.0001). This study indicates that taking consideration of native protein structure is key in developing TB's POCT by antibody-based diagnosis.

Mental Health Status and Its Associated Factors Related to Pulmonary Tuberculosis Patients in Primary Health Care Centre in Surabaya, Indonesia

BACKGROUND

Mental disorders in TB patients are due to long-term treatment, drug side effects, and relapse. This study aimed to analyse the mental health status among TB patients and its associated factors.

METHODS

The study was carried out on 107 Pulmonary TB patients from 5 Primary Healthcare centres in Surabaya, Indonesia. Furthermore, Mental Health Inventory (MHI-18) was used to measure the mental health status. The MHI-18 has four subscales including, anxiety, depression, behaviour control, and positive affection. In addition, the score range of MHI and its subscales is 0-100, where the higher score showed a better mental health status.

RESULTS

The results showed no difference in the score of mental health status, anxiety, depression, and positive affect in all factors. However, behaviour control depicted a significant difference between sex and marital status. In conclusion, mental health problems can occur in all TB patients irrespective of their characteristics.

CONCLUSION

Screening is required for the prevention of severe disease in the early treatment phase and various factors related to mental health should be considered during the implementation of TB management to optimize treatment outcomes.

Mycobacterium tuberculosis - atpE gene profile of bedaquiline-treated pulmonary tuberculosis patients at the referral hospital Dr. Soetomo, Indonesia

Background

The atpE gene is a target for bedaquiline (Bdq)-activating drug action and mutations in the gene are fixed to cause resistance. However, changes in the amino acid of ATPase have been little reported from a clinical setting since it was first used in 2015 in Indonesia. This study aims to observe the sequence of nucleotide and amino acid from rifampicin-resistant (RR) pulmonary tuberculosis (TB) patients, both new and relapse cases treated with Bdq.

Methods

This is an observational descriptive study performed in the referral hospital Dr Soetomo, Indonesia, at August 2022-November 2022. We performed Sanger sequencing and comparison of the atpE gene from the patient's sputum from August to November 2022 to wild-type Mycobacterium tuberculosis H37Rv and species of mycobacteria using BioEdit version 7.2 and BLAST NCBI software. We also conducted an epidemiological study on patients' characteristics. This study uses a descriptive statistic to show the percentage of data.

Results

The total of 12 M. tuberculosis isolates showed that the atpE gene sequence was 100% similar to the wild-type M. tuberculosis H37Rv. No single-nucleotide polymorphisms or mutations were found, and no change in the amino acid structure at position 28 (Asp), 61 (Glu), 63 (Ala), and 66 (Ile). The percentage identity of atpE to M. tuberculosis H37Rv and M. tuberculosis complex was 99%-100%, while the similarity with the other mycobacteria species other than TB (Mycobacterium avium complex, Mycobacterium abscessus, and Mycobacterium lepraemurium) was 88%-91%.

Conclusions

This study revealed M. tuberculosis -atpE gene sequence profile of RR-TB patients had no mutations, as the specific gene region, and no change in the amino acid structure. Therefore, Bdq can be continually trusted as an effective anti-tubercular drug in RR-TB patients.

Characteristics of Previous Tuberculosis Treatment History in Patients with Treatment Failure and the Impact on Acquired Drug-Resistant Tuberculosis

Tuberculosis (TB) treatment failure is a health burden, as the patient remains a source of infection and may lead to the development of multi-drug resistance (MDR). Information from cases of treatment failure that develop into MDR, which is related to a history of previous TB treatment, in accordance with the pharmacokinetic aspect, is one important thing to prevent TB treatment failure and to prevent drug resistance. This was an observational descriptive study in an acquired MDR-TB patient who had a prior history of treatment failure. A structured questionnaire was used to collect information. The questionnaire consisted of a focus on the use of TB drug formulas during the treatment period, as well as when and how to take them. This study included 171 acquired MDR-TB patients from treatment failure cases. An amount of 64 patients received the separated TB drug, and 107 patients received the fixed dose combination (FDC) TB drug. An amount of 21 (32.8%) patients receiving separated TB drug and six (5.6%) patients receiving FDC TB drug took their drug in divided doses. In addition, three (4.7%) patients receiving separated TB drug and eight (7.5%) patients receiving FDC TB drug took their drug with food. An amount of 132 out of 171 (77.2%) patients had a history of incorrect treatment that developed into MDR-TB. Education on how to take the correct medication, both the separate version and the FDC TB drug, according to the pharmacokinetic aspect, is important before starting TB treatment.

The effect of isolated probiotics from Indonesian <em>passiflora edulis</em> sims. on interferon gamma (ifn-γ) levels in peripheral blood mononuclear cell of adult tuberculosis patients <em>in vitro</em>

Background: Mycobacterium tuberculosis (M.tb) is unique because the bacteria live intracellularly and hide in macrophages so that they can escape from phagocytosis. This is one of the factors that complicate the treatment of M.tb infections. Interferon-gamma (IFN-γ) is a compound that plays an important role in macrophage activation to control intracellular pathogens. Objective: The purpose of this research is to analyze the concentration of IFN-γ in peripheral blood mononuclear cells of adult Tuberculosis patients (TB) after in vitro administration of multistrain probiotics from indigeneous Indonesian red passion fruit (Passiflora edulis Sims.). Method: The probiotics isolated from red passion fruit were introduced into Peripheral Blood Mononuclear Cell (PBMC) adult TB patients who were undergoing Anti-tuberculosis Drug Therapy (ATD) category one at the Trosobo Primary Health Center (Sidoarjo, East Java, Indonesia), and the patients who were undergoing ATD category one treatment were willing to be involved in this study. Result: The probiotics isolated from fermentation-broth of Indonesian red passion fruit were able to increase IFN-γ levels in PBMC of adult TB patients. Conclusion: The red passion fruit probiotics isolated can increase IFN-γ of adult TB patients increased from 0.82% to 23.17% after in vitro administration.

Development of population pharmacokinetics model and Bayesian estimation of rifampicin exposure in Indonesian patients with tuberculosis

BACKGROUND

Interindividual variability in the pharmacokinetics (PK) of anti-tuberculosis (TB) drugs is the leading cause of treatment failure. Herein, we evaluated the influence of demographic, clinical, and genetic factors that cause variability in RIF PK parameters in Indonesian TB patients.

METHODS

In total, 210 Indonesian patients with TB (300 plasma samples) were enrolled in this study. Clinical data, solute carrier organic anion transporter family member-1B1 (SLCO1B1) haplotypes *1a, *1b, and *15, and RIF concentrations were analyzed. The population PK model was developed using a non-linear mixed effect method.

RESULTS

A one-compartment model with allometric scaling adequately described the PK of RIF. Age and SLCO1B1 haplotype *15 were significantly associated with variability in apparent clearance (CL/F). For patients in their 40s, each 10-year increase in age was associated with a 10% decrease in CL/F (7.85 L/h). Patients with the SLCO1B1 haplotype *15 had a 24% lower CL/F compared to those with the wild-type. Visual predictive checks and non-parametric bootstrap analysis indicated good model performance.

CONCLUSION

Age and SLCO1B1 haplotype *15 were significant covariates of RIF CL/F. Geriatric patients with haplotype *15 had significantly greater exposure to RIF. The model could optimize TB pharmacotherapy through its application in therapeutic drug monitoring (clinical trial no. NCT05280886).

The Usefulness of Bronchoscopy in the Diagnosis of Mycobacterium tuberculosis Complex Species Infection

BACKGROUND: Pulmonary tuberculosis is an active chronic infection of the lungs. It is still a public health problem globally caused by the Mycobacterium tuberculosis Complex (MTBC). These species are difficult to determine only by conventional tests. The clinical manifestations are almost similar between the strains and cause diagnosis delays. Prolonged and intolerable MTBC therapy inhibits infection control. AIM: This study aims to evaluate the usefulness of bronchoscopy in diagnosing the MTBC species infection. METHODS: This study recruited patients with difficulty expectorating sputum. Pulmonary tuberculosis was diagnosed with the Xpert MTB/RIF assay. This study assessed sputum Acid Fast Bacilli (AFB) staining, chest X-rays with active pulmonary tuberculosis, characteristics of Bronchoalveolar lavage (BAL), and bronchoscopic findings based on the Chung classification. The BAL of polymerase chain reaction analysis using RD9 and TbD1 primers to determine MTBC species. RESULTS: Out of the 30 cases, M. tuberculosis and Mycobacterium bovis 24 (80.0%) and 6 (20.0%) were identified in BAL fluid. There were 12 cases (40.0%) with AFB sputum test, and 25 (83.3%) of the Xpert MTB/RIF detected tuberculosis cases. All chest X-rays showed infiltrated and 22 (73.3%) pulmonary ectasis. There was a significant difference in MTBC species between sputum and BAL fluid (p < 0.05). The ulcerative type of bronchoscopy findings was significantly different in MTBC species (p < 0.05) and there was no macroscopic BAL fluid difference (p > 0.05). CONCLUSIONS: Bronchoscopy is a specimen collection technique that is beneficial in determining the diagnosis of MTBC. Analysis of BAL with molecular methods contributes to identifying MTBC species quickly and accurately.

Epidemiology of Escherichia coli as a Critical Pathogen of Bloodstream Infection Patients in Tertiary Referral Hospital

Bloodstream infections (BSI), caused primarily by multidrug-resistant Escherichia coli, are a significant cause of morbidity and mortality worldwide. This study aims to evaluate the epidemiology of E. coli as a critical pathogen in patients with bloodstream infections in a tertiary referral hospital. This is a retrospective study using a  descriptive observational research design. This study used a medical record instrument for bloodstream patients in Dr. Soetomo Hospital's inpatient ward with Gram-negative bacteria results of blood cultures in the Clinical Microbiology Laboratory from April 2021 to September 2021. The observed variables include; antimicrobial sensitivity, patient clinical characteristics, demographic data, clinical diagnosis, and clinical outcome. In 6 months, 276 Gram-negative bloodstream infection patients were treated at Dr. Soetomo Hospital. The proportion of E. coli was 17 %.  The main characteristics of patients were over 60 years old (28%), and 54% were female. 63% of E. coli were ESBL, and 9% were carbapenem-resistant microorganisms. High antimicrobial resistance was found in quinolones (100%), ampicillin (93%), piperacillin (74%), tetracycline (72%), ceftriaxone (66%), cefotaxime (65%), ceftazidime (60%), cefazolin (65%), and trimethoprim-sulfamethoxazole (65%). The most common potential determinant profile discovered was linked to immunocompromised status due to malignancy.  The high number of antimicrobial-resistant bacteria showed the importance of strict infection control and updated epidemiology data as a guide for empirical antimicrobial therapy.

Line probe assay test in new cases of tuberculosis with rifampicin resistance not detected by Xpert MTB/RIF

Background

In Indonesia, the National guideline for tuberculosis only recommended taking the DST to check INH resistance only for re-treatment cases of rifampicin-susceptible TB (RS-TB) detected by Xpert MTB/RIF. This study was conducted mainly to evaluate the proportion of isoniazid resistance in new cases of RS-TB according to the Xpert MTB/RIF.

Methods

This was an observational descriptive study in RS-TB new patients diagnosed by Xpert MTB/RIF. Sputum samples were examined using first-line LPA and evaluated by culture-based DST. Results of first-line LPA and culture-based DST were compared and presented.

Results

Fifty-four new cases of RS-TB (according Xpert MTB/RIF) were enrolled in this study. INH resistance was detected in 4 (7.4%) using FL-LPA and in 5 (9.3%) using culture-based DST. RIF resistance was also found in 1 (1.9%) using FL-LPA and in 2 (3.7%) using culture-based DST. Ethambutol resistance was also detected in 4 (7.4%) using culture-based DST.

Conclusion

First-line LPA successfully revealed 4 (7.4%) of Hr-TB in new RS-TB cases detected by the Xpert MTB/RIF. In new cases with RS-TB detected by the Xpert MTB/RIF, FL- LPA can be used as rapid molecular DST to detect RIF and INH resistance followed by culture-based DST to examine other drug resistance.

Comparison Epidemiology between Tuberculosis and COVID-19 in East Java Province, Indonesia: An Analysis of Regional Surveillance Data in 2020

Tuberculosis and COVID-19 are among the infectious diseases that constitute a public health concern. Therefore, this study aims to examine the recent epidemiology of tuberculosis and COVID-19 in East Java Province, Indonesia, in 2020. Case-based surveillance data were acquired with a retrospective design between January and December 2020 by the East Java Health Officer. The data were analyzed using Quantum Geographic Information System (QGIS) for mapping, and Microsoft Excel for recording. Furthermore, the statistical analysis (Spearman correlation test) was carried out via Statistical Package for Social Science (SPSS) applications. A total number of 38,089 confirmed cases of tuberculosis was recorded, with an incidence rate of 95.49/100,000 population, a case fatality rate (CFR) of 3.6%, and an average treatment success rate of 87.78%. COVID-19 is a new viral disease, with a total of 84,133 confirmed COVID-19 cases in East Java, with an incidence rate of 232.9/100,000 population. The highest incidence rate was found in Mojokerto city, while the lowest was found in Sampang. Furthermore, the CFR values of tuberculosis and COVID-19 were 1.4% and 6.8%, respectively. The regional survey in East Java Province showed that the incidence of tuberculosis remains high. This indicated that the search for active cases and preventive promotion was not completed. Therefore, inter-sectoral collaboration can be adapted to provide suitable tuberculosis health care.

Antibiotic Resistance in Non-Typhoidal Salmonella enterica Strains Isolated from Chicken Meat in Indonesia

The increase in antibiotic resistance in non-typhoidal Salmonella enterica (NTS) has been confirmed in Indonesia by this study. We confirmed the virulence genes and antimicrobial susceptibilities of clinical NTS (n = 50) isolated from chicken meat in Indonesia and also detected antimicrobial resistance genes. Of 50 strains, 30 (60%) were non-susceptible to nalidixic acid (NA) and all of them had amino acid mutations in gyrA. Among 27 tetracycline (TC) non-susceptible strains, 22 (81.5%) had tetA and/or tetB. The non-susceptibility rates to ampicillin, gentamicin or kanamycin were lower than that of NA or TC, but the prevalence of blaTEM or aadA was high. Non-susceptible strains showed a high prevalence of virulence genes compared with the susceptible strains (tcfA, p = 0.014; cdtB, p < 0.001; sfbA, p < 0.001; fimA, p = 0.002). S. Schwarzengrund was the most prevalent serotype (23 strains, 46%) and the most frequently detected as multi-antimicrobial resistant. The prevalence of virulence genes in S. Schwarzengrund was significantly higher than other serotypes in hlyE (p = 0.011) and phoP/Q (p = 0.011) in addition to the genes above. In conclusion, NTS strains isolated from Indonesian chicken had a high resistance to antibiotics and many virulence factors. In particular, S. Schwarzengrund strains were most frequently detected as multi-antimicrobial resistant and had a high prevalence of virulence genes.

Development of population pharmacokinetics model of isoniazid in Indonesian patients with tuberculosis

OBJECTIVES

No population pharmacokinetics (PK) model of isoniazid (INH) has been reported for the Indonesian population with tuberculosis (TB). Therefore, we aimed to develop a population PK model to optimize pharmacotherapy of INH on the basis of therapeutic drug monitoring (TDM) implementation in Indonesian patients with TB.

MATERIALS AND METHODS

INH concentrations, N-acetyltransferase 2 (NAT2) genotypes, and clinical data were collected from Dr. Soetomo General Academic Hospital, Indonesia. A nonlinear mixed-effect model was used to develop and validate the population PK model.

RESULTS

A total of 107 patients with TB (with 153 samples) were involved in this study. A one-compartment model with allometric scaling for bodyweight effect described well the PK of INH. The NAT2 acetylator phenotype significantly affected INH clearance. The mean clearance rates for the rapid, intermediate, and slow NAT2 acetylator phenotypes were 55.9, 37.8, and 17.7 L/h, respectively. Our model was well-validated through visual predictive checks and bootstrapping.

CONCLUSIONS

We established the population PK model for INH in Indonesian patients with TB using the NAT2 acetylator phenotype as a significant covariate. Our Bayesian forecasting model should enable optimization of TB treatment for INH in Indonesian patients with TB.

Correlation of Moxifloxacin Concentration, C-Reactive Protein, and Inflammatory Cytokines on QTc Interval in Rifampicin-Resistant Tuberculosis Patients Treated with Shorter Regimens

BACKGROUND

Drug-resistant tuberculosis (DR-TB) is a global health concern. QTc prolongation is a serious adverse effect in DR-TB patients receiving a shorter regimen. This study aimed to evaluate the correlation of moxifloxacin concentration, CRP, and inflammatory cytokines with QTc interval in DR-TB patients treated with a shorter regimen.

METHODS

This study was performed in 2 groups of rifampicin-resistant (RR-TB) patients receiving shorter regimens. Correlation for all variables was analyzed.

RESULTS

CRP, IL-1β, and QTc baseline showed significant differences between 45 RR-TB patients on intensive phase and continuation phase with p-value of <0.001, 0.040, and <0.001, respectively. TNF-α and IL-6 between RR-TB patients on intensive phase and continuation phase showed no significant difference with p=0.530 and 0.477, respectively. CRP, TNF-α, IL-1 β, and IL-6 did not correlate with QTc interval in intensive phase (p=0.226, 0.281, 0.509, and 0.886, respectively), and also in continuation phase (0.805, 0.865, 0.406, 0.586, respectively). At 2 hours after taking the 48th-dose, moxifloxacin concentration did not correlate with QTc interval, both in intensive phase (p=0.576) and in continuation phase (p=0.691). At 1 hour before taking the 72nd-hour dose, moxifloxacin concentration also did not correlate with QTc interval in intensive phase (p=0.531) and continuation phase (p=0.209).

CONCLUSION

Moxifloxacin concentration, CRP, and inflammatory cytokines did not correlate with QTc interval in RR-TB patients treated with shorter regimens. The use of moxifloxacin is safe but should be routinely monitored and considered the presence of other risk factors for QTc prolongation in RR-TB patients who received shorter regimens.

The espD full gene as a potential biomarker in active pulmonary tuberculosis

Background

Pulmonary tuberculosis (PTB) is still a major health problem worldwide. The espD has a potential to be a new biomarker because it is important for the espA, espC, and ESX-1 protein secretion system that are actively expressed in active multiplication of Mycobacterium tuberculosis complex.

Methods

A total of 55 sputum samples and 41 culture isolates from newly diagnosed PTB patients at Dr. Soetomo Academic Hospital were collected from September 2016 to April 2019. The tested samples using polymerase chain reaction targeted 555 bp of espD gene and sequencing. Clone Manager Version 6 and NCBI BLAST were used to align the gene sequence against wild-type M. tuberculosis. The prediction of T-cell epitope in espD gene was detected by GENETYX. The three-dimensional (3D) structure of espD was modeled by SWISS-MODEL and I-TASSER and was visualized with PyMOL.

Results

From 55 sputum samples, 43 (78.18%) showed positive results, and all culture isolates showed positive results. In addition, all sequenced samples showed 100% homolog with M. tuberculosis H37Rv gene without detected variant or mutation. There were four T-cell epitopes that could be obtained. The 3D model had a I-TASSER confidence score of 3.91 with estimated RMSD of approximately 14.5 Å. The structure consists of a main fold of a three-stranded antiparallel β-sheet and a long α-helix surrounded by several minor secondary structures.

Conclusions

This study provides a brief information about the sequence, epitope prediction, and 3D structure of EspD protein from M. tuberculosis strains in Indonesia.

Predictive Score Model of Clinical Outcomes Sepsis in Intensive Care Unit Tertier Referral Hospital of Eastern Indonesia

AIM: This study aimed to design a predictive score model of clinical outcome sepsis and bacterial profiles of blood and sputum cultures in the intensive care unit (ICU) of a tertiary referral hospital. METHODS: An observational retrospective study was conducted in 2017–2020 using medical record data in the ICU of Dr. Soetomo Hospital as tertiary referral hospital. The predictor of sepsis prognosis was Acute Physiology and Chronic Health Evaluation II (APACHE II), blood and sputum culture results, procalcitonin (PCT) levels, and antimicrobial resistance in blood and sputum cultures. The model was prepared by logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS: Data from 355 subjects showed that predictor score was APACHE II, blood and sputum culture results; besides PCT levels were found to contribute significantly to predictive score of sepsis clinical output (p<0.05), while the predictor test of antimicrobial resistance in blood and sputum cultures was not significant to predictive score of sepsis clinical output (p > 0.05). The resulting scores to predict sepsis clinical outcomes include PCT level >2 ng/mL (1.61), APACHE score >20 (1), sputum culture as true pathogen (1.1), and blood culture as true pathogen (1.35). When the total score ≥3, the patient will die, while when the score <3, the patient will survive. ROC curves analysis obtained area under curve 0.859 (p < 0.05) which indicates that the equation is statistically significant in predicting the sepsis clinical outcome. Probability scores and death outcomes indicate that the higher the predictive score, the higher the probability of dying, with a score >3 the probability of dying is above 95.27%, whereas if the score is 5, the probability of dying is above 99%. The bacterial profile of blood cultures leading to mortality is predominately Gram-positive (34.4%), consisting of coagulase-negative Staphylococcus (22.9%), and Staphylococcus aureus (4.3%), while Gram-negative is only 14.7%, which consists of Enterobacteriaceae group (8.7%), Acinetobacter baumannii (4%), polymicrobial infection (2%), Burkholderia cepacia (0.8%), and Pseudomonas aeruginosa (0.4%). Sputum culture profile of patients with sepsis who died in the ICU of a tertiary referral RSUD Soetomo is dominated by Gram-negative, namely, A. baumannii (22.1%), Enterobacteriaceae group (20.6%), P. aeruginosa (11.1%), while Gram-positive is S. aureus (22.9%). CONCLUSION: The predictive score model for sepsis clinical outcomes in the ICU of a tertiary referral hospitals can be used as a basis for determining of patient management and the profile of the bacteria that causes sepsis that results in death.

Determinant factors for loss to follow-up in drug-resistant tuberculosis patients: the importance of psycho-social and economic aspects

Background

Drug-resistant tuberculosis (DR-TB) is the barrier for global TB elimination efforts with a lower treatment success rate. Loss to follow-up (LTFU) in DR-TB is a serious problem, causes mortality and morbidity for patients, and leads to wide spreading of DR-TB to their family and the wider community, as well as wasting health resources. Prevention and management of LTFU is crucial to reduce mortality, prevent further spread of DR-TB, and inhibit the development and transmission of more extensively drug-resistant strains of bacteria. A study about the factors associated with loss to follow-up is needed to develop appropriate strategies to prevent DR-TB patients become loss to follow-up. This study was conducted to identify the factors correlated with loss to follow-up in DR-TB patients, using questionnaires from the point of view of patients.

Methods

An observational study with a cross-sectional design was conducted. Study subjects were all DR-TB patients who have declared as treatment success and loss to follow-up from DR-TB treatment. A structured questionnaire was used to collect information by interviewing the subjects as respondents. Obtained data were analyzed potential factors correlated with loss to follow-up in DR-TB patients.

Results

A total of 280 subjects were included in this study. Sex, working status, income, and body mass index showed a significant difference between treatment success and loss to follow-up DR-TB patients with p-value of 0.013, 0.010, 0.007, and 0.006, respectively. In regression analysis, factors correlated with increased LTFU were negative attitude towards treatment (OR = 1.2; 95% CI = 1.1–1.3), limitation of social support (OR = 1.1; 95% CI = 1.0–1.2), dissatisfaction with health service (OR = 2.1; 95% CI = 1.5–3.0)), and limitation of economic status (OR = 1.1; 95% CI = 1.0–1.2)).

Conclusions

Male patients, jobless, non-regular employee, lower income, and underweight BMI were found in higher proportion in LTFU patients. Negative attitude towards treatment, limitation of social support, dissatisfaction with health service, and limitation of economic status are factors correlated with increased LTFU in DR-TB patients. Non-compliance to treatment is complex, we suggest that the involvement and support from the combination of health ministry, labor and employment ministry, and social ministry may help to resolve the complex problems of LTFU in DR-TB patients.

The role of C-Reactive protein as an inflammatory marker to predict prolonged QTc interval in rifampicin-resistant tuberculosis patients: A case-control study

Background

long-term use of anti-tuberculosis drugs (ATD) increases the risk of QTc prolongation, while C-reactive protein (CRP) can be used as an inflammatory marker of Mycobacterium tuberculosis infection.

Objective: correlation of CRP on the QTc interval in Rifampicin-resistant tuberculosis (RR-TB) patients with the short regimen.

Methods

An observational study was conducted in Rifampicin-resistant tuberculosis (RR-TB) patients from 2 groups, patients on intensive phase and patients on continuation phase. CRP levels were measured from blood samples and measured automatically using the immunoturbidimetric assay. QTc interval was calculated using electrocardiography. Levels of CRP levels and QTc interval between the 2 groups were analyzed. The statistical analysis used includes the independent t-test, Mann Whitney test, and Rank Spearman test with p = 0.05.

Results

Forty-five eligible RR-TB patients were included in this study. CRP levels and QTc intervals between 2 groups (intensive and continuation phase) showed significant difference with p < 0.001 but found no significant correlation of CRP levels and QTc interval in both intensive and continuation phase with p = 0.226 and 0.805, respectively. A higher level of CRP strongly indicated the inflammation caused by RR-TB infection at the early phase of the disease, but not correlated with QTc interval in RR-TB patients.

Conclusion

Levels of CRP and QTc interval do not correlate in RR-TB patients and can not be used to be the marker of QTc prolongation in RR-TB Patients.

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CRP levels are markers used for diagnosis and monitoring in RR-TB patients.

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Decrease CRP levels in RR-TB patients are don't a marker of QTc prolongation.

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The significant between intensive and continuation phase of CRP and QTc interval in RR-TB patients.

Correlation of inflammatory cytokines on corrected QT interval in rifampicin-resistant tuberculosis patients

Background

The cases of Rifampicin-Resistant Tuberculosis (RR-TB) in our country have increased every year and RR-TB deaths are thought to be caused by prolongation of the QTc interval due to side effects of anti-tuberculosis drugs. Thus, cytokines are needed to be used as early markers of prolongation of the QTc interval in RR-TB patients.

Objective

This study aims to analyze the correlation of inflammatory cytokines on QTc interval in RR-TB patients who received shorter regimens.

Methods

This study uses a case-control study with a time series conducted in the period September 2019 to February 2020 in one of the referral hospitals for Tuberculosis in Indonesia. Cytokines levels from blood samples were measured using the ELISA method, while QTc intervals were automatically recorded using an electrocardiography machine. The statistical analysis used was the Chi-square test, Man Whitney test, Independence t-test, and Spearman-rank test with p < 0.05.

Results

There was no significant correlation between inflammatory cytokines and QTc prolongation in intensive phase which TNF-α value (6.8 pg/ml; r = 0.207; p = 0.281), IL-1β (20.13 pg/ml; r = 0.128; p = 0.509), and IL-6 (43.17 pg/ml; r = -0.028; p = 0.886). Meanwhile, in the continuation phase, the values for TNF-α (4.79 pg/ml; r = 0.046; p = 0.865), IL-1β (7.42 pg/ml; r = -0.223; p = 0.406), and IL- 6 (40.61 pg/ml; r = -0.147; p = 0.586).

Conclusion

inflammatory cytokines (TNF-α, IL-1β, and IL-6) cannot be used to identify QTc interval prolongation in RR-TB patients who received shorter regimens.

Microbiome in sputum as a potential biomarker of chronicity in pulmonary resistant to rifampicin-tuberculosis and multidrug-resistant-tuberculosis patients

Background

Cases of tuberculosis (TB) and multidrug-resistant TB (MDR-TB) in South-east Asia including Indonesia are still high. The presence of mixed infections in TB cases has been reported. Several studies revealed the role of the human microbiome in TB. This study purposes to characterize microbiome which can be a potential biomarker of chronicity in TB or MDR-TB.

Methods

Sputum samples of pulmonary TB patients confirmed MDR-TB and resistant to rifampicin TB (RR-TB) were conducted Metagenomic next-generation sequencing. Principal coordinate analysis of UniFrac's showing the community structure of microbiome in MDR-TB comorbid diabetes mellitus (DM) is different from RR-TB noncomorbid DM (P = 0.003).

Results

Proteobacteria microbiome in MDR-TB comorbid DM was more abundant than in RR-TB noncomorbid DM. Actinobacteria found in the small quantity in RR-TB and MDR-TB. Diversity of microbiome genera was greater in RR-TB. The linear discriminant analysis effect size analysis represents a genus biomarker whose abundance shows significant differences between groups, genus Rothia as a potential biomarker for RR-TB noncomorbid DM.

Conclusions

Interesting findings is the community structure of microbiome in MDR-TB and RR-TB. In chronic TB such as recurrent, associated MDR-TB should attention to the findings of a small number of Actinobacteria could be a biomarker of TB which is also a determinant in patient taking combined anti-TB drugs of choice.

Antimicrobial Activities of Laurus nobilis Leaves Ethanol Extract on Staphylococcus aureus, Salmonellae typhi, and Escherichia coli

Laurus nobilis is one of the most well-known, most frequently used plants is from Lauraceae family which contains up 2.500 species that grow in the subtropics and tropics of the Mediterranean region and Indonesia. This study was supposed to investigate the antimicrobial eff ect of L.nobilis leaves ethanol extract on Staphylococcus aureus, Salmonellae typhi, and Escherichia coli. This preliminary study examined the antimicrobial eff ect of L.nobilis leaves ethanol extract. The method used Agar-well diff usion for determination of the zone of inhibition and the minimum bactericidal concentration to investigate the activity of L.nobilis leaves ethanol extract at 100% concentration . The results revealed that extract of L. nobilis leaves had the antibacterial activity against Staphylococcus aureus with a zone of inhibition (16.3 ±1.5 mm), Staphylococcus aureus with (14.5±0.5 mm), and weak antimicrobial activity against Escherichia coli (11.3±1.1mm). Also, through the minimum bactericidal concentration experiment, the L.nobilis leaves ethanol extract had activity on Staphylococcus aureus and Salmonellae typhi, it’s killed the bacteria in all concentration start it from 5×107 to 5×104. But the activity on Escherichia coli just weaken concentration 5×107 and 106. This research has concluded that the L.nobilis leaves ethanol extract exhibited a signifi cant antimicrobial eff ect against Staphylococcus aureus and Salmonellae typhi then Escherichia coli that is considered a kind of multidrug-resistant bacteria.

The effect of red passion fruit (Passiflora edulis Sims.) fermentation time on its activity against Extended Strain Methicillin-Resistant (ESBL) Escherichia coli and Methicillin-Resistant Staphylococcus aureus (MRSA)

OBJECTIVES

The purpose of this study is to determine the effect of fermentation techniques on the inhibitory activity of red passion fruit (Passiflora edulis Sims.) fermentation filtrate in De Man Rogosa Sharpe-broth (MRS-B) media against Extended Strain Methicillin-Resistant (ESBL) Escherichia coli and Methicillin-Resistant Staphylococcus aureus (MRSA).

METHODS

The fruit pulp was wrapped in banana leaves before compared to direct fermentation processes. This study was divided into three treatment groups. Group 1 was the fruit pulp (5 g) fermented in 45 mL of MRS-B medium for 24 h. Group 2 was the fruit pulp wrapped in banana leaves for 3 days before fermented in MRS-B for 24 h. Group 3 was the fruit pulp wrapped in banana leaves for 3 days before fermentation in MRS-B for 48 h. Fermentation broth of each condition was taken and then filtered using millipore (0.2 µm). As many as 50 µL of filtrates was tested for its inhibitory activity against E. coli ESBL and MRSA using the Kirby Bauer method.

RESULTS

Group 2 showed the best antibacterial activity against E. coli ESBL and MRSA with the average zone of inhibition of 38.3 and 37.6 mm respectively. These values were higher than the first and group 3s activities.

CONCLUSIONS

The inhibitory activity of group 1s against ESBL and MRSA is categorized as a moderate potency with a diameter of growth inhibition zone of 16-20 mm, whereas the other groups are categorized as strong potency with a diameter higher than 20 mm.

Validity of Method for MTBC and NTM Detection in FNAB Specimens from Tuberculous Lymphadenitis Using Microscopy, XPERT MTB / RIF and Culture Method

Mycobacterium tuberculosis and Nontuberculous Mycobacteria usually cause infection in tuberculous lymphadenitis. To improve accuracy of the detection MTB and NTM bacteria it is necessary to select valid methods. This study aims to compare validity of diagnostic methods from FNAB specimens for determining tuberculous lymphadenitis patients. a descriptive observational laboratory study involved 35 samples were obtained from tuberculous lymphadenitis patients in Dr. Soetomo Hospital Surabaya East Java. All specimens examined Ziehl-Neelsen staining microscopy, Xpert MTB/RIF , culture method Middlebrook7H10 solid media and  MGIT as Gold standard. Identification of MTB dan NTM with SD Bioline TB Ag MPT64 and niacin paper strip BD . Used diagnostic test 2x2 to analyze sensitivity, specificity, negative predictive value and positive predictive value. Ziehl-Neelsen staining microscopy Sensitivity 83,33 %  and Specificity 95,65% of  , PPV  90,91%and NPV 91,67%, Diagnostic Accuracy 91,43 % . Xpert MTB/RIF Sensitivity 75% and Specificity 95,65% , PPV  90 % and NPV 88 %, Diagnostic Accuracy 88,57 % with 95% CI (Confidence Interval ) . Characteristics female dominated 23/35 (65.7%) while Male numbered 12/35 (34.3%), age range distribution of TB lymphadenitis patients is highest in young adults 17 years to 25 years as many as 15/35 (42.9%) the second highest is the age group of 36 years to 45 years by 8/35 (22.9%), Clinicial presentation are mostly lymph node enlargement in cervical  37% patients other locations supraclavicular ,mamae. Clinical symptoms mostly lymphadenopathy 31,5% and other lymphadenopathy with fever. Microscopy method still have the good validity shoul be conjunction with the  molecular rapid tests and culture as gold standard in determining the diagnosis of TB lymphadenitis.

Diagnosis Based on Detection of CXCL10 in Urine as Biomarker for The Determining Diagnosis of Active Lung Tuberculosis

Tuberculosis diagnosis is an important component in decreasing TB incidence and prevalence. Because of the difficulty to collect sputum in some cases, urine specimens are used as it is easier to garner. One of the biomarkers in urine that can be used to diagnose pulmonary TB is IP-10, which can be represented by the CXCL10 gene. The study aims to determine the accuracy of diagnosis based on detection of the CXCL10 gene in urine as a biomarker for the patients with suspected pulmonary TB in Dr. Soetomo Hospital in Surabaya from November 2019 until March 2020. Thus, this is an observative laboratory research with a cross-sectional study. CXCL10 gene was examined using PCR for 36 urine samples, and then, the data, together with the medical records of clinical manifestations of pulmonary TB, GeneXpert MTB /RIF, blood count, and thorax radiograph, were processed using IBM SPSS Statistics 26. The results of the GeneXpert MTB/RIF and thorax radiograph criteria show positive results of pulmonary TB, which were 44.4% and 69.4% respectively. CXCL10 gene was not found in all urine of healthy people (negative), while 2.8% (1/36 samples) positive CXCL10 gene was found in a patient with positive GeneXpert, also with negative clinical manifestations and urine culture. In this study, the accuracy of diagnosis based on detection of the CXCL10 gene in urine for diagnosis of active pulmonary TB was 2.8%. Future research is needed to improve the methods, among them are bigger size of urine samples and clearer medical history of patients. 

The Risk Factors of Multidrug-Resistant Organisms in Hospitalized Patients with Community-Acquired Pneumonia in Dr. Soetomo Hospital Surabaya, Indonesia

BACKGROUND

multidrug-resistant organisms (MDRO) caused pneumonia has become a crucial case. MDRO infection has been a problem concern to community-acquired pneumonia (CAP). A lot of factors play roles in CAP with MDRO infection. This study aimed to analyze MDRO as the etiology of hospitalized patients with CAP along with its risk factors in Dr. Soetomo Hospital as one of the top referral hospitals in east Indonesia.

METHODS

this retrospective cohort study was conducted from January 2016 to December 2018. Data were collected from patients' medical records. Automatic Rapid Diagnosis (Phoenix TM) was used as a standard method for culture and susceptibility test. Various risk factors were analyzed for MDRO infection.

RESULTS

five most common pathogens in hospitalized patients with CAP were Acinetobacter baumannii 244/1364 (17.9%), Klebsiella pneumoniae 134/1364 (9.8%), Pseudomonas aeruginosa 91/1364 (6.7%), Escherichia coli 58/1364 (4.3%), and Enterobacter cloacae 45/1364 (3.3%). There were 294/1364 (21.5%) MDROs isolated from patients with CAP. MDRO infection was linked to previous hospitalization, malignancy, cardiovascular disease, and structural lung disease with p values of 0.002, <0.001, 0.024, and <0.001, respectively.

CONCLUSION

the incidence of MDRO in CAP is high (21.5%). The risk factors related were previous hospitalization, malignancy, cardiovascular disease, and structural lung disease.

CLONING, EXPRESSION AND T CELL EPITOPE PREDICTION OF FBPA AND FBPB GENES OF MYCOBACTERIUM TUBERCULOSIS CLINICAL ISOLATES

The effective treatment and accurate diagnosis of tuberculosis (TB) are not established yet. The Bacillus Chalmette-Guerin vaccine did not provide significant results in the prevention of TB and had only 0-80% efficacy. The fbpA and fbpB genes of M. tuberculosis are antigenic proteins and considered to be virulence factors. They are capable of stimulating immune responses in TB patients. In this study, we observed cloning, expression and T-cell epitope prediction of fbpA and fbpB genes from clinical isolates. The isolates of MultiDrug-Resistant (MDR-TB) were cultured and extracted. The fresh Polymerase Chain Reaction (PCR) products of the fbpA and fbpB genes were inserted into pET SUMO plasmids and transformed into Escherichia coli BL21 (DE3), then expressed in LB medium induced by 1.0 μM of IPTG. Sample sequences were analyzed by ClustalW and NCBI BLAST programs. The T-cell epitope prediction was analyzed by GENETYX vers 8.0. The PCR results were 1071 bp (fbpA gene) and 978 bp (fbpB gene). The SDS-PAGE and Western blotting weighed 48-kDa (fbpA gene) and 46-kDa (fbpB gene). We obtained seven specific T-cell epitopes based on IAd Pattern Position on both genes. Based on Rothbard/Taylor Pattern Position, we discovered twenty-three and sixteen specific T-cell epitopes for fbpA and fbpB genes, respectively. The fbpA and fbpB genes that encode Ag85A and Ag85B proteins have epitopes that are recognized by lymphocyte T-cells and are potentially subunit TB vaccine candidates in the future.

RISK FACTORS OF LATENT TUBERCULOSIS INFECTION IN HEALTHCARE WORKERS AT HOSPITALS IN JEMBER CITY INDONESIA

Background:

Healthcare workers in Tuberculosis (TB) and non-TB units in hospitals have a high risk of experiencing Latent Tuberculosis Infection (LTBI), because of exposure to droplets containing Mycobacterium tuberculosis. This study aims to prove LTBI incidence and risk factors to healthcare workers at the hospital in Jember City.

Material and Methods:

a cross-sectional study, from January to March 2020 in two hospitals in Jember City. Healthcare workers in the TB care and non-TB care unit were examined using Tuberculin skin test (TST) with a cut off ≥ 10 mm for positive LTBI. Chest x-ray and clinical examination to rule out active TB and a standardized questionnaire were also used.

Results:

128 healthcare workers completed the questionnaires, clinical, tuberculin skin test (TST), and chest x-ray data. LTBI incidence of positive results 61.7% (n = 79). Contacts TB in the workplace (p value = 0.219; OR = 1.643; CI = 0.742-3.641) and a unit of work (p value = 0.102; OR = 0.760; CI = 0.559-1.031) has no relationship with LTBI. The profession (p value = 0.020; OR = 1.112; CI = 0.896-1.403), the duration of the work (p value = 0.039; OR = 2.984; CI = 1.067-8.342), and BCG immunization (p value =0.000; OR = 0.151; CI = 0.052-0.438) have important relationships with LTBI.

Conclusion:

TB infection with a high incidence, a risk of transmission to healthcare workers, and a relationship between occupational risk factors and LTBI among healthcare workers in Jember City, Indonesia have been established in this study.

GeneXpert MTB/RIF and Mycobacterium tuberculosis Sputum Culture in Establishing the Diagnosis of Pulmonary Tuberculosis and Rifampicin Resistance in Suspected Childhood Pulmonary Tuberculosis in Soetomo Hospital

The diagnosis of childhood tuberculosis remains a challenge worldwide. The GeneXpert MTB/RIF test, a rapid Mycobacteria tuberculosis diagnostic tool, was recommended for use in children. No pediatric studies of GeneXpert MTB/RIF assessing pulmonary tuberculosis within a hospital setting has been done in Indonesia. We evaluated the performance of the GeneXpert MTB/RIF test compared with sputum culture on Lowenstein-Jensen (LJ) for the diagnosis of childhood pulmonary tuberculosis. This study was conducted in pediatric respirology inpatient and outpatient Dr. Soetomo Hospital, a tertiary care facility in Surabaya between June and August 2015 with a cross-sectional design. We consecutively enrolled 27 children aged 3 months to 14 years who had history of close contact with adult tuberculosis patients and showed symptoms of pulmonary tuberculosis. Sputum collection was performed by induced sputum and three examination methods were performed (microscopic, GeneXpert MTB/RIF and sputum culture) simultaneously followed by a drug sensitivity test for specimens detected with MTB growth. The GeneXpert MTB/RIF test had a sensitivity of 100% (95% CI 100-100) and a specificity of 95% (95% CI 85-100). The positive predictive value for diagnosing pulmonary TB was 89% (95% CI 68-100), the negative predictive value was 100% (95% CI 100-100) and positive likelihood ratio was 20 (95% CI 2.82-128). The GeneXpert MTB/RIF test on one sputum sample rapidly and correctly identified all children with culture-confirmed pulmonary tuberculosis with high specificity. Similar results were obtained between GeneXpert MTB/RIF and sputum culture based on age groups and clinical manifestations. Rifampicin resistance were both detected in GeneXpert MTB/RIF and MTB sensitivity test

Factors Affecting Tuberculosis Patients' Quality of Life in Surabaya, Indonesia

PURPOSE

Patients with tuberculosis need to religiously take medication daily. However, they experience several side effects from these medications. The main reason for measuring the quality of life is to explain closely related factors that affect the patient's daily life that have been compromised with illness, while considering a patients' well-being that has associations with individual characteristics.

PATIENTS AND METHODS

This study included 157 patients with tuberculosis at 5 primary health-care centers and 2 hospitals in Surabaya. Quality of life is determined based on eight domains: general health, pain, social functioning, physical functioning, role limitation due to physical health, role limitation due to emotional problems, energy, and emotional well-being. The research instrument used to measure the quality of life is the RAND-36 Item Health Survey, whereas that used to measure mental distress is the Self-Reporting Questionnaire.

RESULTS

Our study results show that, of the eight domains measuring the quality of life, only age exhibited a significant effect on general health (P = 0.018); sex did not significantly affect the quality of life in all domains. The level of education exhibited a significant effect only on role limitation due to emotional problems (P = 0.014). Mental distress demonstrated a significant effect on the quality of life in all domains.

CONCLUSION

There are several factors affecting TB patients' quality of life. The study found that age, level of education, and comorbidity affect quality of life in several domains. However, mental distress affects quality of life in all domains.

The role of Mycobacterium tuberculosis complex species on apoptosis and necroptosis state of macrophages derived from active pulmonary tuberculosis patients

Objective

The role of Mycobacterium tuberculosis complex (MTBC) species in tuberculosis (TB) infection in human is still questioned. The aim of this study was to determine whether M. tuberculosis and M. bovis is associated with apoptosis and necroptosis by measuring the expression of specific signaling pathways components (Fas-associated protein with death domain (FADD) and receptor interacting protein 3 (RIP3)), and the level of apoptosis.

Results

We recruited 30 patients with pulmonary TB; 24 patients were infected with M. tuberculosis Beijing strain and six patients with M. bovis BCG strain. M. tuberculosis-infected patients were more likely to have severe lung damage compared to those infected with M. bovis (odds ratio [OR] 7.60; 95% confidence interval [CI] 1.07–54.09). M. tuberculosis infection was associated with lower expression of FADD and lower apoptosis level of macrophages compared to M. bovis. No significant different of RIP3 between MTBC species groups. In conclusion, M. tuberculosis Beijing strain was associated with severe pulmonary damage, inhibited FADD expression and reduced apoptosis level of macrophages derived from pulmonary TB patients. This suggests that the M. tuberculosis Beijing strain is potentially to be used as determinant of disease progressivity and tissue damage in TB cases.

FIRST LINE ANTI-TUBERCULOSIS DRUG RESISTANCE PATTERN IN MULTIDRUG-RESISTANT PULMONARY TUBERCULOSIS PATIENTS CORRELATE WITH ACID FAST BACILLI MICROSCOPY GRADING

Multidrug-resistant tuberculosis (MDR-TB) is a global public health crisis. Acid-fast bacilli (AFB) gradation in sputum examination is an important component in Pulmonary Tuberculosis (PTB) diagnosis and treatment outcome monitoring. Previously treated pulmonary TB patients with a higher AFB smear gradation may have higher rates of acquired resistance. Patients with a higher AFB grade indicate a higher bacillary load and had higher rates of acquired resistance. This study aims to evaluate the correlation between AFB gradation and first-line anti-TB drug resistance patterns in MDR pulmonary TB patients. This was a retrospective study conducted from August 2009 to April 2018 in Dr. Soetomo Hospital. Sputum samples were taken from MDR PTB patients. Sputum smear examination was done using Ziehl–Neelsen staining and gradation was measured according to IUATLD criteria. Samples with positive smear were evaluated for resistance patterns based on culture and resistance tests using the MGIT 960 BACTEC System. There were 433 sputum samples with AFB positive collected from MDR PTB patients. Resistance to RHES was found in 22 (14%) AFB +1, 19 (15%) AFB +2, and 29 (20%) AFB +3. Resistance to RHS was found in 22 (14%) AFB +1, 12 (9%) AFB +2, and 13 (9%) AFB +3. Resistance to RHE was found in 39 (25%) AFB +1, 38 (29%) AFB +2, and 35 (24%) AFB +3. Resistance to RH was found in 74 (47%) AFB +1, 61 (47%) AFB +2, and 69 (47%) AFB +3. Statistic analysis by Spearman test showed that there was no significant correlation between AFB gradation and first-line anti-TB drug resistance patterns. Acquired resistance to RHES can also found in lower bacillary load AFB +1.

ASSOCIATION BETWEEN SEPSIS RISK CALCULATOR AND INFECTION PARAMETERS FOR NEONATES WITH RISK OF EARLY ONSET SEPSIS

C-reactive protein (CRP) is an acute-phase reactant protein that is primarily induced by the IL-6 action during the acute phase of an inflammatory or infectious process. Bacterial infection is a potent stimulus, leading to a rapid elevation of CRP levels within hours while the CBC and symptom are often misleading and/or absent. American Academy of paediatrics (AAP) is recommended routine blood examination test Complete Blood Count (CBC), C-reactive protein (CRP), and blood culture along with empirical antibiotic in neonates with early onset sepsis risk (EOS) risk even asymptomatic. Previous study is showed there were no correlation of CRP and EOS risk. The aim of this study is to evaluate the CRP and CBC profile in neonate with risk of EOS.  Methods of this study is using the sepsis risk calculator (SRC) to calculate the probability of neonatal early onset sepsis (EOS) based on maternal risk and infant’s clinical presentation. Neonates with ≥34 weeks of gestation who were started on antibiotic treatment after laboratory examination and blo odculture were taken. EOS risk estimation were compared including CRP, leukocyte, and thrombocyte count. ANOVA applied to distinguished laboratory examination between stratified risk groups. The result is showed using 82 subjects who met the inclusion and exclusion criterias, EOS risk level was stratified into green, yellow, and red group. The p value of CRP level, platelets, white blood cell were 0.35,0.54 and 0.48 where p value was considered as significant if < 0.5. The conclusion of this study is there were no correlation of CRP level and EOS riskASSOCIATION BETWEEN SEPSIS RISK CALCULATOR AND INFECTION PARAMETERS FOR NEONATES WITH RISK OF EARLY ONSET SEPSIS

Diagnostic test accuracy of Xpert MTB/RIF for tuberculous pericarditis: a systematic review and meta-analysis

Introduction: Xpert MTB/RIF is a rapid diagnostic instrument for pulmonary tuberculosis (TB). However, studies reported varied accuracy of Xpert MTB/RIF in detecting Mycobacterium tuberculosis in pericardial effusion. Methods: We performed a systematic review of literature in PubMed, published up to February 1, 2020, according to PRISMA guidelines. We screened cross-sectional studies, observational cohort studies, and randomized control trials that evaluated the accuracy of Xpert MTB/RIF in diagnosing TB pericarditis. Papers with noninterpretable results of sensitivity and specificity, non-English articles, and unpublished studies were excluded. The primary outcomes were the sensitivity and specificity of Xpert MTB/RIF. We conducted a quality assessment using QUADAS-2 to evaluate the quality of the studies. A bivariate model pooled the overall sensitivity, specificity, positive likelihood ratios (PLRs), and negative likelihood ratios (NLRs) of included studies. Results: In total, 581 subjects from nine studies were analyzed in this meta-analysis. Our pooled analysis showed that the overall sensitivity, specificity, PLRs and NLRs of included studies were 0.676 (95% CI: 0.580-0.759), 0.994 (95% CI: 0.919-1.000), 110.11 (95% CI: 7.65-1584.57) and 0.326 (95% CI: 0.246-0.433), respectively. Conclusions: Xpert MTB/RIF had a robust specificity but unsatisfactory sensitivity in diagnosing TB pericarditis. These findings indicated that although positive Xpert MTB/RIF test results might be valuable in swiftly distinguishing the diagnosis of TB pericarditis, negative test results might not be able to rule out TB pericarditis. Registration: PROSPERO CRD42020167480 28/04/2020.

Gene expression tryptophan aspartate coat protein in determining latent tuberculosis infection using immunocytochemistry and real time polimerase chain reaction

Background

Tuberculosis (TB) remains a major cause of morbidity and mortality worldwide. Problem of Latent Tuberculosis Infection (LTBI) is increasing in number especially in countries with high TB incidence rate, such as Indonesia. Although not every LTBI will become active TB, if untreated and not handled appropriately it can still be a source of transmission and may increase the rate of resistance to the first-line TB drugs. Mycobacterium tuberculosis as a cause of tuberculosis disease is an intracellular pathogens that survives within the phagosome of host macrophages. Several host factors are involved in this process, including the Tryptophan Aspartate-containing Coat Protein (TACO). TACO is a protein recruited and retained by viable Mycobacterium tuberculosis on the surface of the phagosome membrane to maintain its survival in phagosome, because the presence of TACO plays an important role in inhibiting the fusion of phagosomes and lysosomes.

Objective

the aim of this studyis to assess the difference of gene expression TACO protein in Latent Tuberculosis Infection (LTBI) and healthy people.

Method

A preliminary studyof mRNA examination of TACO protein using Immunocytochemistry (ICC) and Real Time-Polimerase Chain Reaction (RT-PCR) method by a PCR Light Cycler 2.0 machine (Roche) in LTBI and healthy groups.

Results

18 samples of peripheral blood monocyte cells (PBMCs) were collected and divided into 2 groups. We found that there was a significantly difference between the 2 groups of samples.

Conclusion

Further research is required to consider that the measurement of TACO expression using RT-PCRcan used as one of the other method to determine LTBI.

Fungal isolates findings of sputum samples in new and previously treated cases of pulmonary tuberculosis in dr. soetomo hospital surabaya, Indonesia

BACKGROUND

Fungal infections generally occur in immunosuppressive patients. Long-term tuberculosis (TB) treatment facilitates the occurrence of fungal infections, such as long-term antibiotics administration which is immunosuppressive agents and increases the opportunity of infections. Other factors may be correlated with fungal infection such as age, sex, malnutrition, smoking, diabetes mellitus, lung lesion severity, and the presence of multidrug-resistant TB. This study aims to identify and analyze the proportion of fungal isolates findings in the sputum of new and previously treated cases of pulmonary TB patients.

METHODS

This was an observational analytic study with a cross-sectional design of all pulmonary TB patients who were hospitalized in Dr. Soetomo Hospital Surabaya. Sputum samples were inoculated on Sabouraud's dextrose agar medium. The growth of visible colonies was identified by Lactophenol Cotton Blue staining using direct microscopy.

RESULTS

Fungal isolates were found in 148/193 (77%) pulmonary TB patients. Candida species was found 99% among 148 fungal positive culture. Candida albicans was the most common found fungal species (54.05%), followed by Candida sp (26.35%), Candida glabrata (10.13%), Candida krusei (5.4%), and Candida tropicalis (1.35%). Previously treated cases, sex, malnutrition, and smoking were variables correlated with fungal isolates finding with P value of 0.015, 0.006, 0.010, and <0.001, respectively.

CONCLUSION

The proportion of fungal positive cultures in previously treated cases was higher than in new cases. C. albicans was the most common fungal species both in previously treated cases and new cases of pulmonary TB.

Cloning and Protein Expression of eccB5 Gene in ESX-5 System from Mycobacterium tuberculosis

Mycobacterium tuberculosis (M. tuberculosis) is the causative agent of tuberculosis in human. One of the major M. tuberculosis virulence factors is early secretory antigenic target of 6-kDa (ESAT-6), and EccB5 protein encoded by eccB5 is one of its components. EccB5 protein is a transmembrane protein in ESX-5 system. The aim of this study is to explore the characteristics of wild-type EccB5 and its mutant form N426I. We expressed the EccB5 protein by cloning the mutant and wild-type eccB5 gene in Escherichia coli (E. coli). We compared the protein structure of wild type and mutant form of EccB5 and found changes in structure around Asn426 (loop structure) in wild type and around Ile426 (β-strand) in the mutant. The truncated recombinant protein of EccB5 was successfully cloned and expressed using plasmid pCold I in E. coli DH5α and E. coli strain Rosetta-gami B (DE3) and purified as a 38.6 kDa protein by using the affinity column. There was no detectable adenosine triphosphatase activity in truncated forms of EccB5 and its mutant. In conclusion, our study reveals successful cloning and protein expression of truncated form of eccB5 gene of M. tuberculosis. EccB5 protein in ESX-5 system may be an important membrane component involved in the transport machinery of type VII secretion system, which is essential for growth and virulence.

Difference of Phenotype and Genotype Between Human and Environmental: Isolated Vibrio cholerae in Surabaya, Indonesia

Cholera due to Vibrio cholerae has been spreading worldwide, although the reports focusing on Indonesian V. cholerae are few. In this study, in order to investigate how V. cholerae transmitted to human from environment. We extended an epidemiological report that had investigated the genotype of V. cholerae isolated from human pediatric samples and environmental samples. We examined 44 strains of V. cholerae isolated from pediatric diarrhea patients and the environment such as shrimps or oysters collected in three adjacent towns in Surabaya, Indonesia. Susceptibilities were examined for 11 antibiotics. Serotype O1 or O139 genes and pathogenic genes including cholera toxin were detected. Multi-locus sequence typing (MLST) and enterobacterial repetitive intergenic consensus (ERIC)-PCR were also performed to determine genetic diversity of those isolates. Serotype O1 was seen in 17 strains (38.6%) with all pathogenic genes among 44 isolates. Other isolates were non-O1/non-O139 V. cholerae. Regarding antibiotic susceptibilities, those isolates from environmental samples showed resistance to ampicillin (11.4%), streptomycin (9.1%) and nalidixic acid (2.3%) but those isolates from pediatric stools showed no resistance to those 3 kinds of antibiotics. MLST revealed sequence type (ST) 69 in 17 strains (38.6%), ST198 in 3 strains (6.8%) and non-types in 24 strains (54.5%). All the ST69 strains were classified to O1 type with more than 95% similarity by ERIC-PCR, including all 6 (13.6%) isolates from environmental samples with resistance to streptomycin. In conclusion, V. cholerae O1 ST69 strains has been clonally spreading in Surabaya, exhibiting pathogenic factors and antibiotic resistance to streptomycin, especially in the isolates from environment.

SEVERITY OF TB CLASSIFIED BY MODIFIED BANDIM TB SCORING ASSOCIATES WITH THE SPECIFIC SEQUENCE OF ESXA GENES IN MDR-TB PATIENTS

Background:

The severity of pulmonary TB and detection of multidrug-resistant (MDR-TB) TB strains as potential causative agents could be crucial for the determination of treatment success. This study aimed to analyze the association between the specific sequences of the full esxA gene from MDR-TB sputum isolates and the severity class of MDR-TB patients.

Material and Methods:

A total of 98 sputum samples that were suspected to be MDR-TB were collected from Dr. Soetomo, Surabaya, Indonesia, from September to December 2016. A total of 24 isolates from the 98 patients were confirmed to have positive MDR-TB based on the GeneXpert test. MDR-TB isolates were tested using PCR targeting 580 bp encompassing the full esxA gene, and the resulting amplicon was sequenced. The severity class of the pulmonary TB patients was assessed using modified Bandim TB scoring.

Results:

The patient severity classification resulted in a moderate and severe degree of TB in 38% and a mild degree of TB in 63% of patients. Visualization of the PCR results showed that all MDR-TB samples were positive for the 580 bp band, and the sequence results showed 100% homology with that of the virulent wild-type M. tuberculosis H37Rv (NC_000962.3).

Conclusions:

In the current study, an association between the characteristics of the full esxA gene and the severity class of MDR-TB patients is yet to be found. However, the homologous sequence of all samples, associated with various degrees of disease severity, possess 100% identity with that of wild-type M. tuberculosis H37Rv.

Characteristic profile of antibody responses to PPD, ESAT-6, and CFP-10 of Mycobacterium tuberculosis in pulmonary tuberculosis suspected cases in Surabaya, Indonesia

Accurate and rapid diagnostic tools are important aspects of managing tuberculosis (TB) cases appropriately. However, the sensitivity and specificity of diagnostic kits based on immune response such as the tuberculin skin test (TST) and interferon gamma release assay (IGRA) are still debated. Thus, the exploration and assessment of specific biomarker-targeted antibodies are needed for the development of an accurate and rapid diagnostic tool. The present study was conducted in patients with a respiratory problem suspected to be TB at Dr. Soetomo Hospital, Surabaya, Indonesia. Among 102 patients tested by GeneXpert and AFB, 59 serum samples were from cases retrospectively determined to have active TB. A total of 102 serum of healthy controls (HC) was also collected. The PPD antigen and the recombinant CFP-10 and ESAT-6 proteins were prepared. Antibody responses against these proteins were evaluated by ELISA. All samples were also screened for the possibility of Mycobacterium avium-intracellulare complex (MAC) infection using Capilla MaC kit. The results showed that TB patients had a significantly higher concentration of IgG antibody in response to PPD than the HC. In addition, the receiver operating characteristic (ROC) curve analysis showed that PPD was acceptable for diagnostic purposes with an AUC value of 0.835 (95% CI 0.770-0.900, p < 0.0001). However, ESAT-6 and CFP-10 had low AUCs, and 32 samples from both groups showed a low concentration of IgA antibody against all antigens. The MAC detection results also showed that the concentration of IgA in the HC group was the highest. The current results indicate that PPD is a better antigen for antibody-based detection of TB than ESAT-6 and CFP-10. Based on the MAC detection assay, 53 people in the HC group were probably infected with rapidly growing nontuberculous mycobacteria (NTM), although antibody response to PPD was low.

EXPRESSION OF IMMUNOGLOBULIN, GRANZYME-B AND PERFORIN AGAINST Ag85A AND Ag85B PROTEINS OF MYCOBACTERIUM TUBERCULOSIS IN BALB/C MICE

Background:

Ag85 is a protein that may maintain survival of M. tuberculosis in intracellular parts of host cells and is considered as a virulence factor. The expression of Ag85 protein can stimulate proliferation and differentiation of B- cells and T-cells in patients with tuberculosis. This research aimed to determine the ability of Ag85A and Ag85B proteins in activating the response of antibodies, granzyme-B and perforin in Balb/c mice.

Materials and Methods:

Twenty-five male Balb/c mice were assigned into five groups. Group I was treated with adjuvant, group II with Bacillus Calmette-Guerin (BCG) vaccine, group III with a combination of BCG and Ag85A, group IV with a combination of BCG and Ag85B and group V with a combination of BCG, Ag85A and Ag85B. Concentrations of immunoglobulin G, granzyme-B and perforin were examined using ELISA and the number of CD8+ T-cells and NK T-cells were checked by flow cytometry.

Results:

The highest concentration of immunoglobulin G was found in group V with 62.49±5.4327 ng/ml. The highest mean number of CD8+ T-cells, NK T-cells, granzyme-B and perforin was found in group IV with 4.32%, 1.03%, 35.11±1.7789 pg/ml and 6.19±0.2235 pg/ml, respectively. The results of One-Way ANOVA test showed that there were significant differences in immunoglobulin responses, with p<0.05. The expressions of granzyme-B and perforin were higher in mice treated with combination of BCG and recombinant proteins.

Conclusions:

Ag85 protein can be combined with the BCG vaccine to improve protection against M. tuberculosis infection.

Application of serial tests for Mycobacterium tuberculosis detection to active lung tuberculosis cases in Indonesia

Objective

Rapid detection and accurate diagnosis are very important in managing active tuberculosis because they provide an advantage in preventing further disease transmission. In accordance with the recommendation of the World Health Organization, the Indonesian Tuberculosis Control Program uses the acid fast bacilli (AFB) smear and Chest X-ray methods as the primary methods for detecting tuberculosis, especially in new cases of suspected tuberculosis. The genus Mycobacterium has many species, strains, and variants, and their natural differences may affect the clinical outcome of the diseases they induce. The purpose of this study was to assess different tuberculosis detection methods as part of serial tests and determine the best diagnostic approach for detecting active lung tuberculosis in Indonesia.

Results

This study used clinical samples from tuberculosis patients and assessed them using a series of tests, aiming to increase the sensitivity of active tuberculosis detection. Some samples that yielded negative results in the AFB smear test were detected as positive for Mycobacterium tuberculosis using the nucleic acid amplification test, with a sensitivity of 83.1%. Additionally, nucleic acid amplification also detected positive results among samples assessed as M. tuberculosis-negative using the culture method, this method yielded the same results as the Gene Xpert test.

ACID-FAST BACILLI CONVERSION OF BEIJING AND NON-BEIJING STRAIN OF PULMONARY TUBERCULOSIS IN SOUTH SULAWESI

Beijing strains are a major part of the Mycobacterium tuberculosis Asian phylogenetic lineage. Beijing strains represent about 50% of all TB strains in East Asia and at least 13% of strains worldwide. Beijing strain of Mycobacterium tuberculosis is presumed as the factor of the increase in bacteria virulence and drug resistance, and the contributor in treatment failure. The aim of this study was to analyze the association between acid-fast bacilli conversion with strain genotipe Beijing and non-Beijing of pulmonary tuberculosis in South Sulawesi. The design of research was observational analytic with prospective approach. The sampling technique used consecutive sampling. Data were taken from active pulmonary tuberculosis patients’ medical record in Balai Besar Kesehatan Paru Masyarakat Makassar (Pulmonary Health Center of Makassar) and Community Health Center in Gowa Regency, South Sulawesi from March to June 2018. Collected sputum samples were screened for AFB and identified as Beijing strain and non Beijing strains using Multiplex PCR in Tropical Disease Institute of Universitas Airlangga. The results is showed that the characteristics of the respondents consisted of 12 respondents (33.3%) aged 56-65 years, 25 respondents (69.4%) men and 28 respondents (77.8%) had low category gradation of AFB smear. Univariate analysis showed 6 respondents (16.7%) with Beijing strains, 30 respondents (83.3%) with non-Beijing strains, 32 respondents (88.9%) conversion sputum AFB and 4 respondents (11.1%) non conversion sputum AFB. Bivariate analysis with Chi-Square statistical test shows that p value 0.022 < 0,05, that means there was association of Beijing strains with BTA conversion. Microscopic examination of BTA can be used to monitor and evaluate the treatment of new pulmonary TB patients undergoing treatment and the Beijing Mycobacterium tuberculosis strain has a significant correlation with the treatment failure of anti-tuberculosis drugs in South Sulawesi.

Metformin induced autophagy in diabetes mellitus - Tuberculosis co-infection patients: A case study

Metformin (MET) is a potential combination drug to elevate anti-TB efficacy. However, the clinical effect, especially smear reversion, during metformin applied with anti-tuberculosis and insulin in patients with type 2 DM newly TB co-infection were remain unknown. An observational clinical study was done in DM newly TB co-infection outpatients at Surabaya Paru Hospital. This study evaluated MET therapy, at least 2 months, accompanying with insulin and anti-TB regimens and compared to comparison group. The smear, microtubule-associated Protein1 Light Chain 3B (MAP1LC3B) level, as the presentation of autophagy, Superoxide Dismutase (SOD) level, Interferon (IFN)-γ and Interleukin (IL)-10 levels were evaluated twice. From 42 participants in this study, 22 participants of observation group that received additional MET therapy, 100% had sputum smear reversion after 2-months intensive phase of anti-TB therapy. Whereas 25% of 20 participants of comparison group did not undergo reversion inserts sputum smear. As conclusion, MET has the potential of being an additive combination therapy to enhance the bactericidal effect of anti-TB on DM-TB coinfection patients. Metformin enhances the effects of anti-TB and insulin therapy in increasing the smear reversion by increasing autophagy.

Vitamin D, cell death pathways, and tuberculosis

BACKGROUND

Mycobacterium tuberculosis induces cellular necrosis that could promote spread of infection. The aim of this study is to analyze the effects of Vitamin D3 supplementation to improve the effectiveness of 2nd-line anti-tuberculosis (TB) drug therapy, especially in relation with cell death pathways.

METHODS

Mus musculus C3HeB/FeJ was randomly divided into four groups containing eight animals each. The 1st group (G1), consisting of mice that were intratracheally infected with multidrug-resistant strain of M. tuberculosis and sacrificed on 2-week postinfection to confirm successful infection. (G2) was a group of TB mice without therapy. Then, (G3) was a group of mice with the 2nd-line anti-TB therapy. The last group (G4) was a group of mice receiving not only the 2nd-line anti-TB therapy but also daily oral Vitamin D3 supplementation. Immunohistochemistry was used to measure expression of nuclear Vitamin D receptor, apoptosis marker cleaved caspase-3, cathelin-related antimicrobial peptide (CRAMP) and LC3B autophagy markers, necrosis marker RIPK3, and collagenase matrix metalloproteinase-1 (MMP1). The number of bacteria in the lung was calculated by colony forming units. The partial least square structural equation modeling with SmartPLS 3.2.6 software was used to analyze structural models among the variables.

RESULTS

Supplementation of Vitamin D3 on the 2nd-line anti-TB therapy increases Vitamin D3 receptor, CRAMP, LC3B, caspase-3 (P = 0.026, P = 0.000, P= 0.001), presses MMP1, and the number of bacteria (P = 0.010 and P= 0.000, respectively). The structural equation modeling analysis shows that increasing autophagy pathways reduces necrosis by lowering MMP1, whereas apoptosis reduces necrosis by decreasing the number of bacteria (each with indirect effects - 0.543 and - 0.544).

CONCLUSION

A comprehensive analysis with the partial least square structural equation modeling shows decreasing necrosis requires increasing autophagy and apoptosis.

Occurrence and characterization of carbapenem-resistant Gram-negative bacilli: A collaborative study of antibiotic-resistant bacteria between Indonesia and Japan

OBJECTIVES

To explore the occurrence and characterization of carbapenemase-producing pathogens among carbapenem-resistant Gram-negative bacilli isolated from hospitalized patients with urinary tract infection in Indonesia.

METHODS

This was a study promoted by the Japanese-Indonesian collaborative research program in the Japan Initiative for Global Research Network on Infectious Diseases. Bacterial pathogens were prospectively isolated from urine specimens of hospitalized urinary tract infection patients at Dr. Soetomo Hospital (Surabaya, Indonesia). All Gram-negative bacteria resistant to third-generation cephalosporin or carbapenem were included in this study. Carbapenemase genes were investigated for phenotype and genotype.

RESULTS

In total, 1082 Gram-negative bacilli were isolated, of which 116 strains were resistant to imipenem or meropenem (carbapenem-resistant Gram-negative bacilli), and 22 strains were carbapenemase-producing Gram-negative bacilli. Carbapenemase-producing Gram-negative bacilli consisted of Acinetobacter baumannii (n = 4), Pseudomonas aeruginosa (n = 4), Klebsiella pneumoniae (n = 5), Providencia rettgeri (n = 4) and five others. The carbapenemase-producing Gram-negative bacilli included NDM-1 (n = 18, 81.8%, in Enterobacteriaceae and Acinetobacter spp.) and IMP-7 (n = 4, 18.2%, all in P. aeruginosa). Among carbapenem-resistant Gram-negative bacilli, all four P. aeruginosa were sensitive to colistin, and all six Acinetobacter spp. were sensitive to minocycline, colistin and tigecycline. Of those patients harboring carbapenemase-producing Gram-negative bacilli, 12 (54.5%) were seriously ill at the time of admission, with longer hospital stays and three deaths (13.6% mortality rate).

CONCLUSIONS

Urinary tract infection-causing carbapenem-resistant Gram-negative bacilli are widely disseminated in Indonesia. The NDM-1 phenotype seems to be dominant, and it can be treated with colistin and tigecycline in most cases. Most patients harboring carbapenemase-producing Gram-negative bacilli are seriously ill, have a bad prognosis, with a longer hospital stay and a significant mortality rate.

T CELL EPITOPES OF THE ESXA FULL GENE OF MYCOBACTERIUM TUBERCULOSIS FROM SPUTUM OF MDR-TB PATIENTS

Background:

In 2015, World Health Organization (WHO) discovered 10.4 million tuberculosis (TB) cases around the world. Multidrug-resistant tuberculosis (MDR-TB) became a threat because it has high mortality number. There were 480,000 new MDR-TB cases in 2015. Based on those problems, diagnostic development to detect M. tuberculosis rapidly and accurately is needed. The importance of detecting epitope expression of esxA full gene because there was a potential of complexity over the protein structure and might affect the protein concentration. By knowing epitope prediction, there’s an expectation that it can help the development of TB diagnostic. This research was aimed to determine the T cell epitope prediction of esxA full gene from MDR-TB patients

Material and Methods:

Total of 24 MDR-TB sputum isolate from TB patients at Dr. Soetomo Hospital were collected from September to December 2016. Samples were confirmed as MDR-TB using GeneXpert and Bactec MGIT 960. Those samples tested using PCR targeted 580 bp of esxA gene and sequencing. Gene sequence was aligned against wild type using Bioedit program version 7.2.5 and NCBI BLAST. T cell epitope prediction was analyzed by GENETYX version 10.

Results:

Epitope predictions that could be obtained were IEAAAS, ASAIQG, VTSIHS, TKLAAA, VTGMFA based IAd Pattern Position and EAAAS based Rothbard/Taylor Pattern Position. Those prediction epitopes can determine the severity of disease, therefore full gene of esxA could be used as diagnostic target.

Conclusion:

This research discovered five specific T cell epitope prediction based on IAd Pattern Position and one epitope prediction according to Rothbard/Taylor Pattern Position.

Positivity of ExoU Gene of Type III Secretion System and Fluoroquinolone Resistance of Psedomonas aeruginosa from Sputum of Nosocomial Pneumonia Patients in Sanglah Hospital, Bali

Pseudomonas aeruginosa is one of the Gram-negative rods bacteria that frequently cause nosocomial pneumonia. One of the main virulent effector proteins on Type III secretion system (TTSS) of P. aeruginosa is Exoenzyme U ( ExoU). ExoU works as a phospholipase A2 activity and exhibits lung tissue injury effect in pneumonia. As an antibiotic that has activity against P. aeruginosa, fluoroquinolone resistance has increased as many as three fold since the last decade. Infections caused by P. aeruginosa that are fluoroquinolone resistant and positive for ExoU gene show worse clinical outcome. The aim of this study was to determine the positivity of ExoU gene TTSS and fluoroquinolone resistance of P. aeruginosa that isolated from sputum of nosocomial pneumonia patients in Sanglah Hospital, Bali. P. aeruginosa isolated from sputum of patient that diagnosed as nosocomial pneumonia, isolates had been identified phenotypically by Vitek2 Compact system (bioMérieux, Inc., Marcy-l'Etoile - France), and then continued by genotypic detection by PCR. The susceptibility testing of P. aeruginosa isolates to Ciprofloxacin were conducted by Vitek2 Compact, whereas ExoU genes were detected by PCR. Fifty-three P. aeruginosa isolates were identified in this study, in which 35 isolates (66.1%) had ExoU gene and 22 isolates (41.5%) were resistant to Ciprofloxacin. Based on nosocomial pneumonia type, the highest proportion of isolates genotipically ExoU+ and phenotypically Ciprofloxacin were on VAP group accounted for 57.1% and 54.5%, respectively. Chi-square analysis showed significant correlation between Ciprofloxacin resistance and ExoU gene (p=0.001). As a conclusion, the positivity of ExoU+ isolates were more likely found in Ciprofloxacin resistant group.