Oxidative stress, microparticles, and E-selectin do not depend on HIV suppression

BACKGROUND

Oxidative stress and inflammation are considered predictors of diseases associated with aging. Markers of oxidative stress, inflammation, and endothelial activation were investigated in people with HIV on antiretroviral treatment to determine whether they had an immunosenescent phenotype that might predispose to the development of premature age-related diseases.

PATIENTS AND METHODS

This study was conducted on 213 subjects with HIV. The control groups consisted of healthy HIV-negative adults. The level of oxidative stress was measured by assessing the production of malondialdehyde levels, which were detected by thiobarbituric acid reactive substance (TBARS) assay. The level of microparticles indicated the presence of inflammation and endothelial activation was measured by E-selectin levels. Significant differences were determined by appropriate statistical tests, depending on the distribution of variables. Relationships between continuous variables were quantified using Spearman's rank correlation coefficient.

RESULTS

TBARS, and microparticle and E-selectin levels were significantly higher in untreated and treated subjects with HIV compared with HIV-negative controls (P<0.001). The levels of the investigated markers were not significantly different between untreated and treated patients and no significant correlation of these markers was found with CD4+ count, CD4+/CD8+ ratio, and the number of HIV-1 RNA copies.

CONCLUSIONS

Elevated markers of oxidative stress, inflammatory and endothelial activation were independent of the virologic and immunologic status of people with HIV. These results support the hypothesis that residual viremia in cellular reservoirs of various tissues is a key factor related to the premature aging of the immune system and predisposition to the premature development of diseases associated with aging.

Interim 2023/24 influenza A vaccine effectiveness: VEBIS European primary care and hospital multicentre studies, September 2023 to January 2024

Influenza A viruses circulated in Europe from September 2023 to January 2024, with influenza A(H1N1)pdm09 predominance. We provide interim 2023/24 influenza vaccine effectiveness (IVE) estimates from two European studies, covering 10 countries across primary care (EU-PC) and hospital (EU-H) settings. Interim IVE was higher against A(H1N1)pdm09 than A(H3N2): EU-PC influenza A(H1N1)pdm09 IVE was 53% (95% CI: 41 to 63) and 30% (95% CI: -3 to 54) against influenza A(H3N2). For EU-H, these were 44% (95% CI: 30 to 55) and 14% (95% CI: -32 to 43), respectively.

Effectiveness of the adapted bivalent mRNA COVID-19 vaccines against hospitalisation in individuals aged ≥ 60 years during the Omicron XBB lineage-predominant period: VEBIS SARI VE network, Europe, February to August, 2023

We conducted a multicentre hospital-based test-negative case-control study to measure the effectiveness of adapted bivalent COVID-19 mRNA vaccines against PCR-confirmed SARS-CoV-2 infection during the Omicron XBB lineage-predominant period in patients aged ≥ 60 years with severe acute respiratory infection from five countries in Europe. Bivalent vaccines provided short-term additional protection compared with those vaccinated > 6 months before the campaign: from 80% (95% CI: 50 to 94) for 14-89 days post-vaccination, 15% (95% CI: -12 to 35) at 90-179 days, and lower to no effect thereafter.

The Challenges of Vaccine Trial Participation among Underserved and Hard-to-Reach Communities: An Internal Expert Consultation of the VACCELERATE Consortium

Underserved and hard-to-reach population groups are under-represented in vaccine trials. Thus, we aimed to identify the challenges of vaccine trial participation of these groups in member countries of the VACCELERATE network. Seventeen National Coordinators (NC), each representing their respective country (15 European countries, Israel, and Turkey), completed an online survey. From 15 eligible groups, those that were more frequently declared underserved/hard-to-reach in vaccine research were ethnic minorities (76.5%), persons experiencing homelessness (70.6%), illegal workers and refugees (64.7%, each). When prioritization for education on vaccine trials was considered, ethnic groups, migrants, and immigrants (5/17, 29.4%) were the groups most frequently identified by the NC as top targets. The most prominent barriers in vaccine trial participation affecting all groups were low levels of health literacy, reluctance to participate in trials due to engagement level, and low levels of trust in vaccines/vaccinations. This study highlighted population groups considered underserved/hard-to-reach in countries contained within the European region, and the respective barriers these groups face when participating in clinical studies. Our findings aid with the design of tailored interventions (within-and across-countries of the European region) and with the development of strategies to overcome major barriers in phase 2 and phase 3 vaccine trial participation.

Vaccine effectiveness against COVID-19 hospitalisation in adults (≥ 20 years) during Omicron-dominant circulation: I-MOVE-COVID-19 and VEBIS SARI VE networks, Europe, 2021 to 2022

IntroductionThe I-MOVE-COVID-19 and VEBIS hospital networks have been measuring COVID-19 vaccine effectiveness (VE) in participating European countries since early 2021.AimWe aimed to measure VE against PCR-confirmed SARS-CoV-2 in patients ≥ 20 years hospitalised with severe acute respiratory infection (SARI) from December 2021 to July 2022 (Omicron-dominant period).MethodsIn both networks, 46 hospitals (13 countries) follow a similar test-negative case-control protocol. We defined complete primary series vaccination (PSV) and first booster dose vaccination as last dose of either vaccine received ≥ 14 days before symptom onset (stratifying first booster into received < 150 and ≥ 150 days after last PSV dose). We measured VE overall, by vaccine category/product, age group and time since first mRNA booster dose, adjusting by site as a fixed effect, and by swab date, age, sex, and presence/absence of at least one commonly collected chronic condition.ResultsWe included 2,779 cases and 2,362 controls. The VE of all vaccine products combined against hospitalisation for laboratory-confirmed SARS-CoV-2 was 43% (95% CI: 29-54) for complete PSV (with last dose received ≥ 150 days before onset), while it was 59% (95% CI: 51-66) after addition of one booster dose. The VE was 85% (95% CI: 78-89), 70% (95% CI: 61-77) and 36% (95% CI: 17-51) for those with onset 14-59 days, 60-119 days and 120-179 days after booster vaccination, respectively.ConclusionsOur results suggest that, during the Omicron period, observed VE against SARI hospitalisation improved with first mRNA booster dose, particularly for those having symptom onset < 120 days after first booster dose.

Vaccine effectiveness against COVID-19 hospitalisation in adults (≥ 20 years) during Alpha- and Delta-dominant circulation: I-MOVE-COVID-19 and VEBIS SARI VE networks, Europe, 2021

IntroductionTwo large multicentre European hospital networks have estimated vaccine effectiveness (VE) against COVID-19 since 2021.AimWe aimed to measure VE against PCR-confirmed SARS-CoV-2 in hospitalised severe acute respiratory illness (SARI) patients ≥ 20 years, combining data from these networks during Alpha (March-June)- and Delta (June-December)-dominant periods, 2021.MethodsForty-six participating hospitals across 14 countries follow a similar generic protocol using the test-negative case-control design. We defined complete primary series vaccination (PSV) as two doses of a two-dose or one of a single-dose vaccine ≥ 14 days before onset.ResultsWe included 1,087 cases (538 controls) and 1,669 cases (1,442 controls) in the Alpha- and Delta-dominant periods, respectively. During the Alpha period, VE against hospitalisation with SARS-CoV2 for complete Comirnaty PSV was 85% (95% CI: 69-92) overall and 75% (95% CI: 42-90) in those aged ≥ 80 years. During the Delta period, among SARI patients ≥ 20 years with symptom onset ≥ 150 days from last PSV dose, VE for complete Comirnaty PSV was 54% (95% CI: 18-74). Among those receiving Comirnaty PSV and mRNA booster (any product) ≥ 150 days after last PSV dose, VE was 91% (95% CI: 57-98). In time-since-vaccination analysis, complete all-product PSV VE was > 90% in those with their last dose < 90 days before onset; ≥ 70% in those 90-179 days before onset.ConclusionsOur results from this EU multi-country hospital setting showed that VE for complete PSV alone was higher in the Alpha- than the Delta-dominant period, and addition of a first booster dose during the latter period increased VE to over 90%.

Global prevalence, cascade of care, and prophylaxis coverage of hepatitis B in 2022: a modelling study

BACKGROUND

The 2016 World Health Assembly endorsed the elimination of hepatitis B virus (HBV) infection as a public health threat by 2030; existing therapies and prophylaxis measures make such elimination feasible, even in the absence of a virological cure. We aimed to estimate the national, regional, and global prevalence of HBV in the general population and among children aged 5 years and younger, as well as the rates of diagnosis, treatment, prophylaxis, and the future burden globally.

METHODS

In this modelling study, we used a Delphi process with data from literature reviews and interviews with country experts to quantify the prevalence, diagnosis, treatment, and prevention measures for HBV infection. The PRoGReSs Model, a dynamic Markov model, was used to estimate the country, regional, and global prevalence of HBV infection in 2022, and the effects of treatment and prevention on disease burden. The future incidence of morbidity and mortality in the absence of additional interventions was also estimated at the global level.

FINDINGS

We developed models for 170 countries which resulted in an estimated global prevalence of HBV infection in 2022 of 3·2% (95% uncertainty interval 2·7-4·0), corresponding to 257·5 million (216·6-316·4) individuals positive for HBsAg. Of these individuals, 36·0 million were diagnosed, and only 6·8 million of the estimated 83·3 million eligible for treatment were on treatment. The prevalence among children aged 5 years or younger was estimated to be 0·7% (0·6-1·0), corresponding to 5·6 million (4·5-7·8) children with HBV infection. Based on the most recent data, 85% of infants received three-dose HBV vaccination before 1 year of age, 46% had received a timely birth dose of vaccine, and 14% received hepatitis B immunoglobulin along with the full vaccination regimen. 3% of mothers with a high HBV viral load received antiviral treatment to reduce mother-to-child transmission.

INTERPRETATION

As 2030 approaches, the elimination targets remain out of reach for many countries under the current frameworks. Although prevention measures have had the most success, there is a need to increase these efforts and to increase diagnosis and treatment to work towards the elimination goals.

FUNDING

John C Martin Foundation, Gilead Sciences, and EndHep2030.

VACCELERATE Site Network: Real-time definition of clinical study capacity in Europe

BACKGROUND

The inconsistent European vaccine trial landscape rendered the continent of limited interest for vaccine developers. The VACCELERATE consortium created a network of capable clinical trial sites throughout Europe. VACCELERATE identifies and provides access to state-of-the-art vaccine trial sites to accelerate clinical development of vaccines.

METHODS

Login details for the VACCELERATE Site Network (vaccelerate.eu/site-network/) questionnaire can be obtained after sending an email to. Interested sites provide basic information, such as contact details, affiliation with infectious disease networks, main area of expertise, previous vaccine trial experience, site infrastructure and preferred vaccine trial settings. In addition, sites can recommend other clinical researchers for registration in the network. If directly requested by a sponsor or sponsor representative, the VACCELERATE Site Network pre-selects vaccine trial sites and shares basic study characteristics provided by the sponsor. Interested sites provide feedback with short surveys and feasibility questionnaires developed by VACCELERATE and are connected with the sponsor to initiate the site selection process.

RESULTS

As of April 2023, 481 sites from 39 European countries have registered in the VACCELERATE Site Network. Of these, 137 (28.5 %) sites have previous experience conducting phase I trials, 259 (53.8 %) with phase II, 340 (70.7 %) with phase III, and 205 (42.6 %) with phase IV trials, respectively. Infectious diseases were reported as main area of expertise by 274 sites (57.0 %), followed by any kind of immunosuppression by 141 (29.3 %) sites. Numbers are super additive as sites may report clinical trial experience in several indications. Two hundred and thirty-one (47.0 %) sites have the expertise and capacity to enrol paediatric populations and 391 (79.6 %) adult populations. Since its launch in October 2020, the VACCELERATE Site Network has been used 21 times for academic and industry trials, mostly interventional studies, focusing on different pathogens such as fungi, monkeypox virus, Orthomyxoviridae/influenza viruses, SARS-CoV-2, or Streptococcus pneumoniae/pneumococcus.

CONCLUSIONS

The VACCELERATE Site Network enables a constantly updated Europe-wide mapping of experienced clinical sites interested in executing vaccine trials. The network is already in use as a rapid-turnaround single contact point for the identification of vaccine trials sites in Europe.

Enhancing public health communication of vaccine trials: The pan-European VACCELERATE Toolkit

BACKGROUND

The pan-European VACCELERATE network aims to implement the first transnational harmonised and sustainable vaccine trial Volunteer Registry, serving as single entry-point for volunteers willing to participate in large scale vaccine clinical studies across the European region. The present work exhibits a set of harmonised vaccine trial educational and promotional tools for the general public, designed and disseminated by the pan-European VACCELERATE network.

OBJECTIVE

The main objectives of the present study are the design and creation of a standard toolkit to increase positive attitudes, and access to trustful information for better access and increased recruitment to vaccine trials for the public community. More specifically, the produced tools are focused on inclusiveness, equity, and they are targeting different population groups, including underserved ones, as potential volunteers for the VACCELERATE Volunteer Registry (elderly, migrants, children and adolescents). The promotion/education material is aligned with the main objectives of the Volunteer Registry, to increase public literacy and awareness regarding vaccine clinical research/trials and trial participation, such as informed consent and legal issues, side effects and frequently asked questions on vaccine trial design.

METHODS

The tools' development has followed the aims and principles of the VACCELERATE project, focusing on trial inclusiveness and equity and they are adjusted to the local country requirements to improve public health communication. The selection of the produced tools has been based on the cognitive theory, inclusiveness and equity of different aged and under-represented groups, and standardised material from several official trustful sources (e.g. COVAX, ECDC, EUPATI, GAVI and WHO). In addition, team of specialists from different fields (infectious diseases, vaccine research, medicine, education) edited and reviewed the subtitles and scripts for the educational videos, extended brochures, interactive cards and puzzles. Graph designers also selected the colour palette, audio settings and dubbing for the video story-tales and implementation of QR codes.

RESULTS

This study presents the first set of harmonised promotional and educational materials/tools (i.e. educational cards, educational and promotional videos, extended brochures, flyers, posters, and puzzles) for vaccine clinical research (e.g. COVID-19). The developed tools inform the public about possible benefits and disadvantages of trial participation, but also build the confidence of participants about the safety and efficacy for COVID-19 vaccines and healthcare system. The present material has been translated into several languages and meant to be freely and easily accessible to facilitate dissemination among the participating countries of the VACCELERATE network, as well as among the European and global scientific, industrial, and public community, in general.

CONCLUSIONS

The produced material could also be useful for filling knowledge gaps of healthcare personnel and providing the appropriate future patient education for vaccine trials, as well as to tackle vaccine hesitancy and parents' concerns for potential participation of children in vaccine trials.

Implications of highly suppressive treatment HIV infection

Treatment of HIV infection has modified the initially fatal infection into a typically chronic disease requiring lifelong treatment. However, there is no complete normalization of immune activation, signs of inflammation and prothrombotic state in treated patients. This condition is the result of many factors, but the main cause is thought to be the residual production of HIV-1 RNA and viral proteins by infected cells in cellular reservoirs. Persistence of immune activation/inflammation/prothrombotic state leads to the pathophysiology of "sterile inflammation" and so-called non-AIDS diseases, which manifest one to two decades earlier in those infected. Despite all the pitfalls and unwanted secondary manifestations of antiretroviral drugs, the treatment of HIV infection has managed to reverse the trajectory of a fatal pandemic and has made it possible to approach therapeutic modalities that were absolutely unimaginable just a few years ago. Solid organ transplantation is now a completely legitimate therapeutic method for patients living with HIV, and highly suppressive treatment even allows transplantation from an HIV-infected donor. The text below presents a brief overview of the basic pitfalls, but also of the successes, of the current highly suppressive treatment of HIV infection.

Extracellular vesicles in infectious diseases - importance and perspectives

Extracellular vesicles (EVs) are mother cell derived transport units released into the extracellular environment. They are a new pillar of intercellular communication as they carry nucleic acids, proteins, and other signalling molecules, protecting them from degradation in the extracellular environment until fusion of the vesicle with the target cell. The transport mechanism relies on surface structures involved in cell adhesion. It is well known that all cellular organisms are capable of producing EVs. Most human cells have this capability, and EVs can be detected in all body compartments. At the time of their discovery, EVs were considered as useless waste vesicles of marginal interest. Thanks to the newly described transport mechanisms of biologically active molecules, EVs are currently known to participate in a variety of homeostatic mechanisms. In infectious diseases, the most studied area is the modulation of the immune response, where they are seen as potential biomarkers, as their production or the content they carry can be altered under pathological conditions. For microbes, interactions at the pathogen-pathogen and pathogen-host level are at the forefront of attention. EVs also have potential for use as drug delivery systems and novel targets for pharmacotherapy.

VACCELERATE Volunteer Registry: A European study participant database to facilitate clinical trial enrolment

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has evidenced the key role of vaccine design, obtention, production and administration to successfully fight against infectious diseases and to provide efficient remedies for the citizens. Although clinical trials were rapidly established during this pandemic, identifying suitable study subjects can be challenging. For this reason, the University Hospital Cologne established a volunteer registry for participation in clinical trials first in Germany, which has now been incorporated into the European VACCELERATE clinical trials network and grew to a European Volunteer Registry. As such, VACCELERATE's Volunteer Registry aims to become a common entry point for potential volunteers in future clinical trials in Europe.

METHODS

Interested volunteers who would like to register for clinical trials in the VACCELERATE Volunteer Registry can access the registration questionnaire via http://www.vaccelerate.eu/volunteer-registry. Potential volunteers are requested to provide their current country and area of residence, contact information, including first and last name and e-mail address, age, gender, comorbidities, previous SARS-CoV-2 infection and vaccination status, and maximum distance willing to travel to a clinical trial site. The registry is open to both adults and children, complying with national legal consent requirements.

RESULTS

As of May 2022, the questionnaire is available in 12 countries and 14 languages. Up to date, more than 36,000 volunteers have registered, mainly from Germany. Within the first year since its establishment, the VACCELERATE Volunteer Registry has matched more than 15,000 volunteers to clinical trials. The VACCELERATE Volunteer Registry will be launched in further European countries in the coming months.

CONCLUSIONS

The VACCELERATE Volunteer Registry is an active single-entry point for European residents interested in COVID-19 clinical trials participation in 12 countries (i.e., Austria, Cyprus, Germany, Greece, Ireland, Lithuania, Norway, Portugal, Spain, Sweden and Turkey). To date, more than 15,000 registered individuals have been connected to clinical trials in Germany alone. The registry is currently in the implementation phase in 5 additional countries (i.e., Belgium, Czech Republic, Hungary, Israel and the Netherlands).

Hepatitis E - epidemiology and clinical course in the largest cohort in the Czech Republic

INTRODUCTION

The majority of hepatitis E (HE) reports come from Western Europe. The aim of the study was to describe the typical epidemiological and clinical characteristics of HE in the Czech Republic.

METHODS

A retrospective analysis of 173 patients with HE.

RESULTS

At least 90% of cases were autochthonous (HEV-3 genotype). Seventeen patients were treated with ribavirin. Five underwent liver transplants because of fulminant HE. We noted neurological symptomatology in 9 cases. Six patients developed chronic HE.

CONCLUSIONS

There is a possibility of severe health complications caused by the hepatitis E virus in the Czech Republic.

Decreasing neutralization antibody levels following vaccination against SARS-CoV-2 in the elderly: an observational study in Southern Moravia, Czech Republic

INTRODUCTION

Understanding the immune response after SARS-CoV-2 vaccination is essential to control the COVID-19 pandemic. Recent studies indicate that vaccine-induced humoral immunity may not be long-lasting and is weaker in the elderly.

METHODOLOGY AND SAMPLE

At the turn of June and July 2021, 653 seniors (426 women and 197 men with a mean age of 74 years) were tested once for antibodies against SARS-Cov-2 in the South Moravian Region between 9 and 161 days after the second dose of vaccine (558 Pfizer -BioNTech, 28 Moderna, 36 AstraZeneca, 1 Johnson & Johnson). Samples of the whole capillary blood were tested in two point-of-care iCHROMA II immunofluorescence assays: (1) COVID-19 Ab against mix of SARS-CoV-2 nucleocapsid and spike proteins (IgM Ab, IgG Ab) and (2) COVID-19 nAb against S1-RBD protein (nAb). Results were analysed in relation to gender, age, vaccine type, and past COVID-19 disease.

RESULTS

Our results show high variability in the antibody response but indicate an overall relatively weak and decreasing antibody response in the first six months after vaccination. Only 58.4% (95% CI: 54.6-62.3) of subjects had virus neutralizing antibodies (nAb). The level of nAb decreased with time from vaccination - at post-vaccination months 4 and 5, nAb were only detected in 41.1% (95% CI: 30.9-51.3) and 15.4% (95% CI: 1.5-29.3) of subjects, respectively. Vaccinees in older age groups, those vaccinated with AstraZeneca, and naive individuals showed a lower antibody response.

CONCLUSION

The antibody response to SARS-CoV-2 vaccine in the elderly was relatively weak and decreased in the first six months after vaccination. Although humoral immunity is complex and cellular immune memory is a key element of the humoral response after exposure to the wild virus, our results suggest that vaccine-induced humoral immunity may not be long-lasting. The oldest koncenage groups who have not acquired natural SARS-CoV-2 infection are particularly at risk. This finding is relevant for adjusting vaccination strategies in selected population groups to include a booster dose. More research into the antibody response and the complex immune response after vaccination against SARS-CoV-2 over longer time is needed.

Current hepatitis C therapy

Hepatitis C virus (HCV) infection is still a major cause of chronic liver diseases, with approximately 71 million chronically infected persons worldwide. People who inject drugs currently or in the past (PWID), mostly intravenously, are the main risk group among HCV chronically infected persons. The efficacy of therapy with direct acting antivirals (DAA) is almost 100 %. Currently, the main mission is to diagnose HCV infection in the most possible number of infected persons; it is in collision with poor adherence of PWID in particular.

[Hepatitis D screening is important in the Czech Republic as well]

Only patients infected with hepatitis B virus (HBV) can contract hepatitis D virus (HDV) infection, either simultaneously (co-infection) or as a superinfection in those already infected with HBV. The routes of HDV transmission are contaminated needles or transfusion; sexual and vertical transmissions are relatively rare. Chronic hepatitis D is the most serious form of chronic viral hepatitis due to more rapid progression to decompensated cirrhosis and hepatocellular carcinoma (HCC). Liver cirrhosis may develop within five years and HCC within 10 years of dual infection. In the vast majority of cases, HDV replication suppresses HBV replication. Therefore, most patients are positive for HDV RNA in plasma while showing no or low levels of HBV DNA. At present, there is no routine screening for HDV in persons with chronic HBV infection in the Czech Republic. One of the reasons the absence of approved treatment op-tions, with the only possibility being administration of pegylated interferon alpha for 48 weeks or even longer. This approach does not provide long-term efficacy in most cases. Therapy with bulevirtide seems to be promising according to available data.

[Dual or triple combination antiretrovirals?]

Since the beginning of the antiretroviral therapy (ART) era, its extraordinary effect in terms of morbidity and mortality has been linked to a three-drug combination HIV treatment strategy, which has been perceived as a constant paradigm for many years. However, epidemiological studies over the past decade have clearly shown that ART does not result in complete normalization of all biomarkers, and some degree of systemic immune activation and inflammation, including endothelial dysfunction, persist. It is generally accepted that these pathophysiological processes are the cause of non-AIDS diseases, which are clinically manifested in people living with HIV on average 10 years earlier than in the general HIV-negative population. HIV treatment is not eradicative but only inhibitive and requires regular daily medication. This increases the risk of the cumulative impact of side effects and drug toxicity. In addition, it is expected that there will be a significant increase in the number of patients with various other non-AIDS comorbidities that will require multiple medication in the coming years. In particular, the higher genetic barrier of the new generation of drugs and an improved safety profile have raised the question of the effectiveness of two-drug combination regimens with the fundamental goal of reducing the burden on the human body by different drugs while maintaining high efficacy fully comparable to the current three-drug combination strategy. However, the question of whether dual combination regimens can sufficiently suppress the persistence of chronic inflammation and immune activation remains unanswered. To answer such a question, robust data from large prospective randomized studies are needed, which are still lacking. This review discusses the principle of systemic immune activation, its regenerative potential in ART, the expected causes leading to systemic immune activation, intervention options to influence it, as well as the limitations of studies to date.

[COVID-19: diagnosis and treatment]

The guidelines provide evidence-based recommendations for the management of COVID-19. The clinical manifestations of the disease are described and indication criteria for hospital admission of patients with COVID-19 are listed. Polymerase chain reaction and antigen testing are used in direct diagnostics. Indirect detection of infection by antibodies is currently of limited value. There are a number of hematological and biochemical laboratory test used to diagnose COVID-19. Pathological values of some laboratory parameters are associated with severity of COVID-19. Of the imaging studies, chest X-ray, chest computer tomography and lung ultrasound are used. COVID-19 therapy includes symptomatic and specific therapy (antivirals, immunotherapeutics and anticoagulants) and intensive care in the severe and critical forms of the disease. Remdesivir and favipiravir are available as antiviral agents. Immunotherapeutics include monoclonal antibodies (casirivimab/imdevimab, bamlanivimab/etesevimab), dexamethas one, baricitinib and tocilizumab. Low-molecular-weight heparin is a dominant form of anticoagulant therapy. The guidelines provide specific therapeutic recommendations for each stage of the disease. Antibiotics are recommended only if bacterial superinfection is suspected or demonstrated, which is not common in the early stages of the disease.

First Autochthonous West Nile Lineage 2 and Usutu Virus Infections in Humans, July to October 2018, Czech Republic

We present epidemiological, clinical and laboratory findings of five Czech patients diagnosed with autochthonous mosquito-borne disease—four patients with confirmed West Nile virus (WNV) and one patient with Usutu virus (USUV) infections, from July to October 2018, including one fatal case due to WNV. This is the first documented human outbreak caused by WNV lineage 2 in the Czech Republic and the first record of a neuroinvasive human disease caused by USUV, which illustrates the simultaneous circulation of WNV and USUV in the country.

Circulating microparticles in patients with chronic hepatitis C and changes during direct-acting antiviral therapy

BACKGROUND

Microparticles (MPs) are heterogeneous vesicles derived from membranes of different cells. Between 70 to 90% of MPs detected in blood originate from platelets. The release of MPs is associated with proinflammatory and procoagulant states. Elevated levels of MPs have been found in different diseases. We investigated MPs levels in patients with chronic hepatitis C (CHC) and changes in level during treatment using direct-acting antivirotics (DAA).

PATIENTS AND METHODS

Thirty-six patients with CHC and forty healthy volunteers were included in the study. Concentrations of MPs were determined indirectly by measuring their procoagulant activity in plasma at baseline, end of therapy (EOT), and 12 weeks after EOT when the sustained virological response was assessed (SVR12).

RESULTS

All patients achieved SVR12, which was associated with rapid improvement of markers of liver damage and function as well as liver stiffness (P=0.002). MPs levels were significantly higher in CHC patients than in healthy volunteers (P<0.001). No statistically significant decrease was found observed between baseline and SVR12 (P=0,330). Analysis of subpopulations with minimal fibrosis F0-1 (P=0.647), advanced fibrosis F2-4 (P=0.370), women(P=0.847), men (P=0.164) and genotype 1 (P=0.077) showed no significant changes during the follow-up period.

CONCLUSIONS

MPs levels are higher in CHC patients and remain elevated shortly after achieving SVR. Higher concentrations of MPs in plasma are probably caused by a chronic uncontrolled exaggerated inflammatory response caused by CHC. Longer observation would probably confirm the significance of MPs levels decrease because normalization of liver function, inflammation, and structure after SVR requires more than 12 weeks.

[Impact of outreach testing on elimination of hepatitis C]

OBJECTIVES

Analysis of changes in a group of patients with chronic hepatitis C (CHC) treated with direct-acting antivirals (DAAs) with a special focus on risk factors for transmission. Evaluation of cooperation with organizations working with people who inject drugs (PWID) including the impact of outreach testing.

METHODS

A retrospective analysis and interannual comparison of CHC patients treated with DAAs at the Department of Infectious Diseases, University Hospital Brno, Czech Republic between 2018 and 2020.

RESULTS

A total of 291 (101 in the year 2018, 111 in 2019 and 79 in 2020) patients with CHC have been treated. Comparison of results from the years 2018, 2019 and 2020 demonstrated a significant rise in the proportion of PWID (46.5 %, 64.9 % and 65.8 %, respectively). Also the proportion of genotype 3a infection (23.8 %, 30.6 % and 35.4 %) increased at the expense of genotype 1b infection (52.5 %, 46.9 % and 38.0 %). By contrast, the median age (43, 40 and 38 years) and the proportion of patients with liver cirrhosis decreased (20.8 %, 15.3 % and 12.7 %). The percentage of patients started on DAA therapy within one year of diagnosis increased (47.5 %, 53.2 % and 62.0 %). And so did the proportion of patients receiving therapy as a result of cooperation with organizations and facilities working with PWID (5.9 %, 25.2 % and 25.3 %). The downside was high numbers of patients lost to follow-up (19.8 %, 23.4 % and 22.3 %). Those were mostly patients who completed their therapy as planned and were only lost to after receiving the final dose of DAAs.

CONCLUSIONS

The fact that PWID have gradually become the dominant group of CHC patients is accompanied by a younger age of treated patients, a higher proportion of those with genotype 3a and less advanced liver damage. The changing spectrum of CHC patients makes medical professionals change their approach. Outreach testing and cooperation with organizations working with PWID have proved an effective way of improving the diagnosis and treatment of CHC.

The first case of periorbital human dirofilariasis in the Czech Republic

Dirofilaria repens and Dirofilaria immitis are the most common filarial species affecting humans in Europe. Dirofilaria repens causes subcutaneous or ocular infection, whereas D. immitis is responsible mainly for the pulmonary form. In this report, we present the first human case of periorbital dirofilariasis in the Czech Republic. A 58-year-old woman suffered from an eyelid oedema, redness and pain in the left eye. After excising the parasite from her eyelid, all clinical symptoms disappeared. Based on the morphology and cytochrome oxidase I sequencing, the parasite was identified as D. repens. Histology revealed that the excised worm was female with absent microfilariae in uteri. With respect to the length of the incubation period and the sequence identity with a known Czech isolate, we concluded that D. repens was most likely of autochthonous origin.

Acute searching and early diagnosis of HCV infected persons

Hepatitis C virus (HCV) infection is still a major cause of chronic liver diseases, with approximately 71 million chronically infected persons worldwide. People who inject drugs currently or in the past (PWID), mostly intravenously, are the main risk group among HCV chronically infected persons. The efficacy of therapy with direct-acting antivirals (DAA) is almost 100 %. Currently, the main mission is to diagnose HCV infection in the most possible number of infected persons; it is in collision with poor adherence of PWID in particular. Changing the spectrum of chronic hepatitis C patients forces medical professionals to change their approach to diagnosis and treatment of HCV infection. Outreach testing and cooperation with support organizations showed to be an effective way to set a course to eliminate HCV in the PWID population.

Current view on hepatitis B diagnosis and therapy

Hepatitis B virus (HBV) infection remains a global public health problem with changing epidemiology due to several factors predominantly vaccination policy and migration. Chronic hepatitis B is a dynamic process reflecting the interaction between HBV replication and the host immune response and not all patients with chronic HBV infection have chronic hepatitis B. Stopping of nucleotide or nucleoside analogues (NA) therapy is a serious resolution due the danger of reactivation of viral replication associated with increasing HBV DNA level, ALT activity and inflammatory activity in the liver histology. The safest stopping rule for NA therapy is HBsAg loss what is the sign of immune control of HBV infection.

Clostridium difficile Infection: an update on treatment and prevention

Disruption of the colonic microflora is one of the most significant adverse effects of antibiotic (ATB) therapy. Excessive multiplication of toxigenic Clostridioides difficile strains is responsible for about 20 % of cases of post-antibiotic diarrhoea. The global trend of Clostridium colitis incidence, severity, mortality and in particular therapeutic failure keeps rising. At the Department of Infectious Diseases we work on long-term monitoring of the most important colitis-associated risk factors and evaluation of individual therapeutic and preventive procedures (selective ATB therapy, faecal bacteriotherapy). A diligent analysis of risk factors and knowledge of pathogenesis are a prerequisite to practical implementation of effective and rational precautions to curb spreading of this illness. In the future, we anticipate increased use of fecal microbiota transplant, improvements in faecal transplant administration, wider use of probiotics and selective ATBs and further introduction of passive and active immunization into practice.

Increasing procoagulant activity of circulating microparticles in patients living with HIV

OBJECTIVES

HIV-infected individuals are at higher risk of non-AIDS diseases associated with procoagulant status. Microparticles are elevated in disorders associated with thrombosis (e.g., cardiovascular diseases). We investigated the association between microparticle levels in untreated and treated HIV-infected subjects, and determined the association with immune status, viral replication, and duration of antiretroviral therapy.

PATIENTS AND METHODS

We included 144 HIV-infected subjects, including 123 on antiretroviral therapy (ART) and 21 before treatment initiation. A control group of 40 HIV-negative healthy adults matched for age and sex was used for comparison of microparticle levels. Treated subjects were divided into five groups depending on the period of antiretroviral exposure. Statistically significant differences were determined by Kruskal-Wallis test and Chi² test. The relation between microparticles and other parameters was assessed using Spearman's coefficient of correlation.

RESULTS

Microparticle levels were significantly higher in treated and untreated HIV-infected subjects than in non-HIV-infected controls (P<0.001). The microparticle level was similar between the groups on treatment (P=0.913). No association between the microparticle level and CD4+ count, CD4+/CD8+ ratio, number of HIV-1 RNA copies, or duration of exposure to antiretroviral treatment was observed.

CONCLUSION

Increased levels of microparticles may be due to processes independent of viral replication and CD4+ cell count, and microparticle release might persist even during viral suppression by antiretroviral treatment. Elevated microparticle levels might occur in response to other triggers.

Chronic hepatitis C in the Czech Republic: Forecasting the disease burden

OBJECTIVE

Chronic HCV infection is associated with cirrhosis of the liver, hepatocellular carcinoma (HCC), and liver transplantation. HCV disease burden and the impact of new potent direct acting antivirals (DAAs) in the Czech Republic are unknown.

METHODS

Using a modelling framework, HCV disease progression in the Czech Republic was predicted to 2030 under the current standard of care treatment structure. In addition, two strategies to reduce the future burden of HCV infection were modelled: an incremental increase in treatment annually and WHO targets.

RESULTS

The number of viremic infected individuals in the Czech Republic is estimated to peak in 2026 (n = 55,130) and to decline by 0.5% by 2030 (n = 54,840). The number of individuals with compensated cirrhosis (n = 1,400), decompensated cirrhosis (n = 80), HCC (n = 70), and liver-related deaths (n = 60) is estimated to more than double by 2030. Through aggressive increases in diagnosis and treatment, HCV related mortality may decrease by 70% by 2030.

CONCLUSIONS

Disease burden associated with chronic HCV infection is projected to peak in the Czech Republic in 30-40 years. Assuming that the current portion of DAAs used remains constant, a significant reduction in HCV disease burden is possible through increased diagnosis and treatment through 2030. This analysis provides evidence in order to facilitate the development of national strategies for HCV care and management in the Czech Republic.

Current knowledge of hepatitis E virus related disease

Hepatitis E virus (HEV) infection is one of the most common causes of acute hepatitis worldwide. The Czech Republic is also a region with a natural occurrence of HEV genotype 3. Diseases caused by different genotypes have distinct clinical and epidemiological characteristics. In industrialized countries, numerous local animal reservoirs have been described and infection is considered to be zoonotic disease in these areas. The most significant route of transmission is through ingestion of insufficiently cooked meat of reservoir animals. In addition, numerous extrahepatic manifestations, even without dominant liver disease, and the possibility of chronic hepatitis in immunocompromised patients have been described. The review summarizes the current knowledge of HEV related disease and current approaches to the treatment of acute and chronic hepatitis E.

Current view on hepatitis B diagnosis and therapy

Hepatitis B virus (HBV) infection remains a global public health problem with changing epidemiology due to several factors predominantly vaccination policy and migration. Chronic hepatitis B means the duration of HBV infection for more than 6 months. It is a dynamic process reflecting the interaction between HBV replication and the host immune response and not all patients with chronic HBV infection have chronic hepatitis B. All patients with chronic HBV infection are in increased risk of progression to liver cirrhosis and hepatocellular carcinoma. The long-term administration of potent nucleos(t)ide analogue with high barrier of resistance (tenofovir, entecavir) represents the treatment of choice. Pegylated interferon-&#945; can also be considered in mid to moderate chronic hepatitis B patients.

Progressive multifocal leukoencephalopathy - epidemiology, immune response, clinical differences, treatment

Progressive multifocal leukoencephalopathy (PML) is a severe disease of the central nervous system with very high mortality. It is caused by the JC virus with high seroprevalence, at up to 80%. Development of PML is typically opportunistic, particularly in acquired immunodeficiency syndrome, and usually affects patients with profound immunodeficiency. Furthermore, as a result of highly efficient immunosuppressive and immunomodulatory treatments in recent years, the number of PML cases has increased in the general population. In this article, the authors mention virological and epidemiological relationships and characteristic manifestations of PML. Possible relationships of humoral and cellular immunity are discussed and limited treatment options including prophylaxis are mentioned.

[Guideline for fecal bacteriotherapy to treat recurrent Clostridium difficile colitis]

We present a case of a 17-year-old female with anti-NMDAR encephalitis probably associated with vaccination against yellow fever. Her symptoms occurred 27 days after vaccination against yellow fever. Anti-NMDAR encephalitis manifested as acute psychosis, memory loss and catatonia following fever with complex partial epileptic seizures. Interictal electroencephalogram showed slow-wave delta background activity with "delta brushes". The diagnosis was confirmed by NMDAR antibody positivity in serum and cerebrospinal fluid. Since ovarian teratoma, as the most common cause of anti-NMDAR encephalitis, did not develop within five years from its onset, the association with vaccination against yellow fever seems to be highly probable.

Fecal bacteriotherapy in the treatment of Clostridium difficile infection

AIM

Using a prospective analysis to assess the success of faecal bacteriotherapy (FBT) in antibiotic-associated colitis due to Clostridium difficile. To analyse whether any of the factors according to which the treated patients can be categorized has a statistically significant effect on the therapeutic outcome.

MATERIALS AND METHODS

During the 2-year study period (2015-2016), 71 patients received FBT. After treatment, the patients were followed up by means of clinic visits or by phone. If colitis did not recur within eight weeks of follow-up, the treatment was considered successful.

RESULTS

The overall success rate was 76%, with statistically insignificant decline in recurrences. Subgroup analysis did not show any statistically significant difference in the success rate between the routes of administration, i.e. through a naso-enteral feeding tube and rectal enema. Likewise, there were no statistically significant differences in the success rate between the types of prior antibiotic therapy or between using fresh and cryo-stored stool suspension. No unexpected adverse event or lethality occurred during the study period.

CONCLUSIONS

Faecal bacteriotherapy is a successful and safe therapeutic alternative for recurrent C. difficile infections.

Availability of hepatitis C diagnostics and therapeutics in European and Eurasia countries

BACKGROUND

Treatment with direct acting antiviral agents (DAAs) has provided sustained virological response rates in >95% of patients with chronic hepatitis C virus (HCV) infection. However treatment is costly and market access, reimbursement and governmental restrictions differ among countries. We aimed to analyze these differences among European and Eurasian countries.

METHODS

A survey including 20-item questionnaire was sent to experts in viral hepatitis. Countries were evaluated according to their income categories by the World Bank stratification.

RESULTS

Experts from 26 countries responded to the survey. As of May 2016, HCV prevalence was reported as low (≤1%) in Croatia, Czech Republic, Denmark, France, Germany, Hungary, the Netherlands, Portugal, Slovenia, Spain, Sweden, UK; intermediate (1-4%) in Azerbaijan, Bosnia and Herzegovina, Italy, Kosovo, Greece, Kazakhstan, Romania, Russia, Serbia and high in Georgia (6.7%). All countries had national guidelines except Albania, Kosovo, Serbia, Tunisia, and UK. Transient elastography was available in all countries, but reimbursed in 61%. HCV-RNA was reimbursed in 81%. PegIFN/RBV was reimbursed in 54% of the countries. No DAAs were available in four countries: Kazakhstan, Kosovo, Serbia, and Tunisia. In others, at least one DAA combination with either PegIFN/RBV or another DAA was available. In Germany and the Netherlands all DAAs were reimbursed without restrictions: Sofosbuvir and sofosbuvir/ledipasvir were free of charge in Georgia.

CONCLUSION

Prevalence of HCV is relatively higher in lower-middle and upper-middle income countries. DAAs are not available or reimbursed in many Eurasia and European countries. Effective screening and access to care are essential for reducing liver-related morbidity and mortality.

[First experience with elbasvir/grazoprevir fixed-dose combination in real-life practice in the Czech Republic]

Hepatitis C virus infection (HCV) is one of the leading causes of chronic liver disease worldwide. The new fixed-dose combination of the highly potent second wave first generation NS5A inhibitor elbasvir (50 mg) and the second generation protease inhibitor grazoprevir (100 mg) is contained in the drug Zepatier. This combination is indicated for the treatment of patients chronically infected with HCV genotypes 1 or 4. Between June and August 2017, the treatment was initiated in 22 patients with chronic viral hepatitis C, with 17 patients being treated in the Department of Infectious Diseases University Hospital Brno and five patients in the Center of Cardiovascular and Transplant Surgery in Brno. All patients were infected with HCV subtype 1b. In all cases, the duration of Zepatier monotherapy (without simultaneous ribavirin administration) was 12 weeks. At the moment, only preliminary results are available. All 22 patients achieved end-of-treatment virologic response. In nine patients, it was already possible to evaluate the virologic response at four weeks after the end of treatment, with sustained virological response (SVR12) was observed in all these patients. The most common complaints were fatigue (3 patients, 14 %) and headache (2.9 %). These problems were not serious and did not interfere with normal daily activities of treated persons.

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

The new recommendations reflect the increase in knowledge that has been reported since the release of previous Czech guidelines in September 2014. The basis for these guidelines were the European Association for the Study of the Liver guidelines from April 2017. According to qualified estimates, there are 240 million people with chronic hepatitis B (HBV) infection worldwide. The Czech Republic is among the countries with a low prevalence of HBV infection. According to the latest seroprevalence study, 0.56 % of the Czech citizens were chronically infected with HBV in 2001. A similar study conducted in only two regions of the Czech Republic in 2013 showed a prevalence of only 0.064 %. HBV infection can lead to serious life-threatening liver damage - fulminant hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC). The main goals of treatment are to prolong the length of life and improve its quality by preventing the progression of chronic hepatitis to cirrhosis, cirrhosis decompensation and development of HCC. The goals may be achieved if HBV replication is suppressed in a sustained manner. Additional goals are prevention of vertical transmission from mother to newborn, inhibition of HBV reactivation and therapy of HBV-related extrahepatic manifestations. Generally, there are two different strategies of chronic hepatitis B therapy available - treatment with nucleoside or nucleotide inhibitors (NIs) or with pegylated interferon alfa. Currently, the vast majority of Czech and European patients are treated with NIs. The NIs that have been approved for HBV treatment in the European Union include lamivudine, adefovir dipivoxil, entecavir (ETV), telbivudin (TBV), tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF). TAF and TBV have not yet been marketed in the Czech Republic. The main advantages of treatment with potent NIs with a high barrier to resistance (ETV, TDF, TAF) are their predictable high long-term antiviral efficacy leading to undetectable HBV DNA levels in the vast majority of compliant patients as well as their favorable safety profiles. These drugs can be used in any HBV infected patient and represent the only treatment option for patients with decompensated liver cirrhosis, liver transplants, extrahepatic HBV-related manifestations, severe acute hepatitis B or chronic HBV reactivation.

Intravenous zanamivir or oral oseltamivir for hospitalised patients with influenza: an international, randomised, double-blind, double-dummy, phase 3 trial

BACKGROUND

Neuraminidase inhibitors are effective for the treatment of acute uncomplicated influenza. However, there is an unmet need for intravenous treatment for patients admitted to hospital with severe influenza. We studied whether intravenous zanamivir was a suitable treatment in this setting.

METHODS

In this international, randomised, double-blind, double-dummy, phase 3 trial, we recruited patients aged 16 years or older with severe influenza admitted to 97 hospitals from 26 countries. We randomly assigned patients (1:1:1 stratified by symptom onset ≤4 days or 5-6 days) to receive 300 mg or 600 mg intravenous zanamivir, or standard-of-care (75 mg oral oseltamivir) twice a day for 5-10 days; patients were followed up for 28 days. The randomisation schedule, including stratification, was generated using GlaxoSmithKline's RandAll software. Patients, site study staff, and sponsor were masked to study treatment. The primary endpoint was time to clinical response-a composite of vital sign stabilisation and hospital discharge-in the influenza-positive population. The trial was powered to show an improvement of 1·5 days or greater with 600 mg intravenous zanamivir. Pharmacokinetic, safety, and virology endpoints were also assessed. This trial is registered with ClinicalTrials.gov, number NCT01231620.

FINDINGS

Between Jan 15, 2011, and Feb 12, 2015, 626 patients were randomly assigned to receive 300 mg intravenous zanamivir (n=201), 600 mg intravenous zanamivir (n=209), or 75 mg oral oseltamivir (n=205) twice a day; 11 patients discontinued the study before receiving any study treatment. 488 (78%) of 626 patients had laboratory-confirmed influenza. Compared with a median time to clinical response of 5·14 days in the 600 mg intravenous zanamivir group, the median time to clinical response was 5·87 days (difference of -0·73 days, 95% CI -1·79 to 0·75; p=0·25) in the 300 mg intravenous zanamivir group and 5·63 days (difference of -0·48 days, 95% CI -2·11 to 0·97; p=0·39) in the oseltamivir group. Four patients with influenza A/H1N1pdm09 in the oseltamivir group developed H275Y resistance mutations. Adverse events were reported in 373 (61%) of treated patients and were similar across treatment groups; the most common adverse events (300 mg intravenous zanamivir, 600 mg intravenous zanamivir, oseltamivir) were diarrhoea (10 [5%], 15 [7%], 14 [7%]), respiratory failure (11 [5%], 14 [7%], 11 [5%]), and constipation (7 [3%], 13 [6%], 10 [5%]). 41 (7%) treated patients died during the study (15 [7%], 15 [7%], 11 [5%]); the most common causes of death were respiratory failure and septic shock.

INTERPRETATION

Time to clinical response to intravenous zanamivir dosed at 600 mg was not superior to oseltamivir or 300 mg intravenous zanamivir. All treatments had a similar safety profile in hospitalised patients with severe influenza.

FUNDING

GlaxoSmithKline.

[Treatment of HCV genotype 2 infection]

INTRODUCTION

Hepatitis C virus (HCV) infection is one of the main causes of chronic liver disease worldwide.

AIMS

Retrospectively evaluate the results of therapy of patients with genotype 2 HCV treated during last 15 years at the Department of Infectious Diseases University Hospital Brno and Faculty of Medicine Masaryk University Brno, Czech Republic.

PATIENTS AND METHODS

15 patients (9 men, 6 women, mean age 54.73 ± 13.83 years, median 54 years) with chronic genotype 2 infection were treated at in our department during last 15 years. It is the biggest group of patients with this diagnosis treated in the Czech Republic. Proportion of genotype 2 subtypes was following: 1 times subtype 2a, 2 times subtype 2a/2c, 5 times subtype 2b, in the rest 7 cases only genotype 2 was determined without possibility to determinate subtype.

RESULTS

9 patients were treated with the combination of peginterferon α-2a (180 µg once weekly subcutaneously) and ribavirin (1 000 or 1 200 mg daily according to the weight) for 24 weeks in the years 2002-2015, sustained virological response (SVR) achieved 6 of them (67 %). Two relapses and one breakthrough were recorded. 7 patients were treated with combination of sofosbuvir (400 mg daily) and ribavirin (1 000 or 1 200 mg daily according to the weight) for 12 weeks in the years 2015-2016 - 6 of them were treatment naïve, one after breakthrough in previous therapy. All of these 7 patients achieved SVR (100 %).

CONCLUSIONS

Genotype 2 therapy still not represents serious therapeutic problem. The number of difficultly treatable patients is gradually increasing in many well-developed countries during last several years. However the therapeutic possibilities are quickly developing.Key words: chronic hepatitis C - genotype 2 - pegylated interferon - ribavirin - sofosbuvir.

[Viral hepatitis A - possible diagnostic and therapeutic problems]

Viral hepatitis A (VHA) is the disease which has an ancient history. Reports of epidemic jaundice were described by Hippocrates in Greece during the 5th century B.C. Incidence of VHA in developed countries is dropping in last decades. What was once common disease is now very rare, usually emerging in local epidemies. With decreasing incidence of hepatitis A clinicians losing practical experiences with disease. Authors present possible diagnostic and therapeutic problems based on their experience with large epidemic of hepatitis A, which occurred in 2016-2017 in Brno area.Key words: hepatitis A (VHA) - hepatitis A virus (HAV).

[History and presence of hepatitis B and C therapy]

Infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) are the worlds major causes of chronic liver disease. Care of patients infected with HBV and HCV and/or over the last 20 years has significantly improved thanks to the better understanding of the pathophysiology of disease, improvement of diagnostic, therapeutic and preventive options. The goal of treatment of chronic hepatitis B is to extend the length of life and improve its quality through the barriers of the progression of chronic hepatitis to cirrhosis, decompensation cirrhosis and hepatocellular carcinoma (HCC). Chronic HBV infection can by currently treated either with tenofovir or entecavir orally (absolute majority of cases), and that in the long-term (years), or even for life-long therapy, or with pegylated interferon α-2a, which is given by injection once a week for 48 weeks (limited possibility of use). The primary goal of chronic hepatitis C treatment is to cure the infection, by achieving a sustained virological response defined as undetectable virus nucleic acid (HCV RNA) in peripheral blood 12 or 24 weeks after the end of therapy. At present, IFN-free regimens become the standard of chronic HCV therapy with the efficiency of 95-100 % and with minimum of side effects and contraindications.Key words: chronic hepatitis B - chronic hepatitis C - IFN-free therapy.

[Is it necessary to revaccinate against hepatitis B virus when the titer of anti-HBs drops below 10 IU/L?]

Viral hepatitis B still represents a major epidemiological issue worldwide. After recombinant vaccine administration, a titer of anti-HBs antibodies ≥ 10 IU/L has long been considered to be seroprotective. Persons without this antibody level after complete vaccination are referred to as non-responders. A progressive decline in anti-HBs levels over years is also commonly seen in responders. Recently, there has been increasing evidence that the titer of anti-HBs ≥ 10 IU/L does not provide 100 % protection against infection and clinically manifest illness. Additionally, an important role of cellular immune memory has been demonstrated - without any correlation with anti-HBs titer. Based on current knowledge, there is no need for regular anti-HBs titer testing or booster vaccination in immunocompetent individuals with anti-HBs ≤ 10 IU/L. At present, regular serological testing and, if need be, revaccination to maintain anti-HBs ≥ 10 IU/L are recommended in immunocompromised persons and after liver transplantation.

[Tenofovir alafenamide fumarate - a new generation of tenofovir]

Antiretroviral therapy as a life-long treatment has to meet the criteria of maximum efficiency while maintaining the highest possible level of safety and tolerance. Tenofovir disoproxil fumarate (TDF) is an antiretroviral drug with an excellent effect of virological suppression. However, some patients can over time develop clinically significant nephrotoxicity or bone loss. Tenofovir alafenamide fumarate (TAF) is a novel prodrug of tenofovir (TFV) that is more stable in human plasma and more efficiently penetrates into target cells than TFV. Tenofovir converted from TAF reaches plasma concentration which is 90% lower than that of TFV converted from TDF. Conversely, the active metabolite converted from TAF reaches a higher intracellular level in target cells than TFV from TDF. This allows a substantial reduction of its oral dose, decreasing the risk for renal and bone toxicity. It is even possible to reduce the dose of TAF in case it is administered concurrently with cobicistat further improving its absorption and optimizing its pharmacokinetic profile. Pharmacokinetic properties are another factor substantially influencing its safety profile. TAF is not a substrate for renal organic anion transporters and thus shows no cytotoxicity related to their expression. Based on clinical trials, a fixed-dose combination tablet (single-tablet regimen) containing elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide fumarate was approved by the FDA in November 2015. This regimen showed higher efficacy, better safety profile and tolerance than TDF-based regiments. Recently, it has been approved in European Union countries.

[Severe osteoporosis - the story of chronic medication-related hyponatremia]

The authors present a case-report of a 73 years old woman treated for arterial hypertension within past 15 years with diuretics (thiazides, amiloride and indapamide) and concomitantly with antidepressive trazodone. The patient developed severe osteoporosis after 6 years of such a treatment with multiple fractures even after minor trauma; during whole this period severe hyponatremia without adequate supplementation was documented. Most probably, there exists tight relationship of osteoporosis and hyponatremia in this patient - the authors discuss possible pathophysiological mechanisms at the level of renal tubules, osteoblasts and osteoclasts, hypopituitary-skeletal axis, syndrome of inadequate adiuretin secretion (SIADH) and possible influence of acid-base balance disturbances.

[Extrahepatic manifestations of HCV infection]

Extrahepatic manifestations of hepatitis C virus infection (HCV) are very common. The most common of these is mixed cryoglobulinaemia. Anti-HCV antibodies and viral ribonucleic acid, HCV RNA, can be found in the cryoprecipitates, together with the rheumatoid factor. Cryoglobulins consist of a complex of immunoglobulins that in vitro precipitate upon the cooling bellow the human body temperature. Vasculitis is caused by the deposition of such immune complexes in the small blood vessels. A link with the HCV infection is considered to be established with membranoproliferative glomerulonephritis, leukocytoclastic vasculitis, lymphoproliferative disorders (in particular B cell lymphoma), Sjögren and sicca syndrome, lichen planus, porfyria cutanea tarda and diabetes mellitus. Very probable is the relationship of chronic HCV infection and thyroid disease, arthralgias, otherwise unexplained fatigue and autoimmune hepatitis.Key words: direct acting antivirals - extrahepatic manifestations - chronic hepatitis C - mixed cryoglobulinaemia.

[Possibilities of IFN-free therapy of hepatitis C]

Chronic hepatitis C therapy using Directly Acting Antivirals (DAA) has high efficacy (till 100 %), minimum contra-indications and extraordinarily favorable safety profile. Primarily, it is necessary to pay attention to drug-drug interactions. However they are well documented and successfully resolvable already in general clinical practice. Current possibilities of interferon-free therapy represent combinations of sofosbuvir with other DAA or with ribavirin and combination of paritaprevir boosted by ritonavir+ombitasvir±dasabuvir (3D combination).

[Fecal bacteriotherapy for the treatment of recurrent Clostridium difficile colitis used in the Clinic of Infectious Diseases of the University Hospital Brno in 2010-2014 - a prospective study]

INTRODUCTION

The aim of the study is to assess the efficacy of fecal bacteriotherapy in the treatment of Clostridium difficile colitis.

MATERIALS AND METHODS

A prospective study of fecal bacteriotherapy in 80 adult patients hospitalized in the Clinic of Infectious Diseases, University Hospital Brno between 1 January 2010 and 31 December 2014.

RESULTS

During the study period, 80 patients were treated with fecal bacteriotherapy. The majority of the study group received fecal bacteriotherapy via a nasojejunal tube (n=78) and two patients via a rectal enema. Six patients were instilled with 20 g of feces, with a success rate of 50 %. The outcomes of nine patients were unevaluable. In the rest of 65 patients, the success rate with 40 g of feces was 83.1 %. There were no severe adverse events or mortality associated with fecal bacteriotherapy.

CONCLUSIONS

Fecal bacteriotherapy is a safe and effective treatment modality in Clostridium difficile colitis.