A case of imported Middle East Respiratory Syndrome coronavirus infection and public health response, Greece, April 2014

On 18 April 2014, a case of Middle East Respiratory Syndrome coronavirus (MERS-CoV) infection was laboratory confirmed in Athens, Greece in a patient returning from Jeddah, Saudi Arabia. Main symptoms upon initial presentation were protracted fever and diarrhoea, during hospitalisation he developed bilateral pneumonia and his condition worsened. During 14 days prior to onset of illness, he had extensive contact with the healthcare environment in Jeddah. Contact tracing revealed 73 contacts, no secondary cases had occurred by 22 April.

Effect of hepatitis C virus on immunological and virological responses in HIV-infected patients initiating highly active antiretroviral therapy: a meta-analysis

Co-infection of human immunodeficiency virus (HIV) with hepatitis C virus (HCV) is rather common. In the era of highly active antiretroviral therapy (HAART), viral hepatitis could result in adverse outcomes in HIV+ patients. The current meta-analysis aims to evaluate the impact of HCV on immunological and virological responses after HAART initiation in HIV/HCV co-infected individuals by synthesizing the existing scientific evidence. A comprehensive search of electronic databases was performed. Eligible studies were analysed using univariate and multivariate meta-analytic methods. Totally, 21 studies involving 22533 individuals were eligible. The estimated summary difference in CD4 cell counts increase between HIV and HIV/HCV co-infected subjects after 3-12 months on HAART was 34.86 cells/mm(3) [95% confidence interval (CI): 16.82-52.89]. The difference was more prominent in patients with baseline CD4 counts below 350 cells/mm(3) (38.97, 95% CI: 20.00-57.93) and attenuated 2 years later (13.43, 95% CI: 0.83-26.04). The analysis of ratio measures yielded similar findings. The virological control remained unaffected by the presence of HCV (adjusted Hazard Ratio for co-infected patients vs those with HIV alone: 0.99, 95% CI: 0.91-1.07). The bivariate meta-analytic method confirmed the results of the univariate approaches. This meta-analysis supports the adverse effect of HCV on immune recovery of HIV+ patients initiating HAART, especially of those with initially impaired immunologic status. Although this effect diminishes over time, early administration of HAART in the setting of co-infection seems to be justified.

Differential viral kinetics in treated genotype 4 chronic hepatitis C patients according to ethnicity

Data concerning the efficacy of PEG-IFN alpha 2a plus ribavirin treatment in treatment-naive, genotype 4-infected chronic hepatitis C (CHC) patients from Europe are limited. Hence the aim of this study was to investigate the viral kinetics as well as the sustained virological response (SVR) rates and their predictors, in these patients. One hundred and twenty-three patients were retrospectively analysed. Early (EVR) and late virological response (LVR) was confirmed by undetectable (<50 IU/mL) serum HCV-RNA at week 12 and week 24 of treatment, respectively. SVR was confirmed by undetectable serum HCV-RNA at the end of treatment as well as 6 months later. Overall, 43.5% of patients exhibited SVR, 42.6% were nonresponders and 13.9% were relapsers. EVR was observed in 40.74% and LVR in 59.25% of them. The positive predictive values of EVR and LVR were 72.97% and 86.27% whereas their negative predictive values were 64.29% and 92.85%, respectively. EVR independently predicted SVR in Caucasian patients (P < 0.001) but not in Egyptian patients (P = 0.613), in whom the only independent predictor of SVR was the absence of cirrhosis (P = 0.004). LVR seems to be a better predictor of SVR than EVR in the vast majority of genotype 4-infected CHC patients, irrespective of ethnicity and all the other baseline parameters.

KPC-2-producing Klebsiella pneumoniae infections in Greek hospitals are mainly due to a hyperepidemic clone

To verify the presence of Klebsiella pneumoniae carbapenemase-producing (KPC-producing) Klebsiella pneumoniae in Greece, we asked 40 Greek hospitals participating in the Greek System for the Surveillance of Antimicrobial Resistance (GSSAR) to apply a combination of the modified Hodge test plus EDTA synergy test on all K. pneumoniae clinical isolates obtained from February 2008 which displayed reduced susceptibility to carbapenems (MIC of imipenem > or = 1 mg/L). The presence of the blaKPC gene was confirmed by PCR and sequencing. This procedure revealed the presence of KPC-2 in isolates from 173 patients in 18 hospitals during a period of 11 months. Of these, 166 isolates belonged to a single pulsotype a fact consistent with possible epidemic spread, whereas the remaining seven isolates were further classified into four different pulsotypes. BlaKPC-2 gene was found to be transferable by conjugation in the four pulsotypes other than the prevailing one. The emergence of a new carbapenemase gene in Greece, where high resistance rates to carbapenems in K. pneumoniae due to the spread of the VIM type metalloenzyme have been observed, emphasises the urgent need for the implementation of public health measures in the field of infection control and antibiotic consumption. It also underlines the need to supplement surveillance systems based on susceptibility data with the surveillance of resistance mechanisms.

Clinical significance of hepatitis B surface antigen in cord blood of hepatitis B e-antigen-negative chronic hepatitis B virus-infected mothers

Vertical transmission of hepatitis B virus (HBV) infection during the perinatal period is the major cause of HBV transmission. The aim of our study was to evaluate the serological and virological profiles of HBV infection in cord blood samples obtained from HBeAg-negative chronic HBV-infected women, at delivery, and to investigate their relationship with the clinical outcome (possible transmission of HBV) in neonates receiving the currently approved passive-active immunoprophylaxis schedule. Sixteen women (32%) exhibited HBsAg positivity in the cord blood but HBV-DNA has not been detected in any of the 50 cord blood samples evaluated. We conclude that HBsAg can be transferred through the placental barrier, as with other proteins, in about one third of HBeAg-negative chronic HBV-infected pregnant women, irrespective of the maternal viral load, the mode of delivery or the placenta HBV pathology. The clinical impact of this phenomenon on the intrauterine-transplacental or perinatal transmission of HBV infection and/or passive-active immunoprophylaxis failure does not seem to be important.

Surveillance for hepatitis B virus infection in pregnant women in Greece shows high rates of chronic infection among immigrants and low vaccination-induced protection rates: preliminary results of a single center study

Epidemiological data on the prevalence of serological markers of hepatitis B virus (HBV) infection in pregnant women in Greece are limited. We evaluated the prevalence of HBV serological markers in a multinational population of pregnant women in Athens, Greece. The overall prevalence of hepatitis B surface antigen (HbsAg) was 4.1% with the highest rates among Albanian immigrants (12%). Relatively low vaccination-induced protection rates (32.5%) were observed, a finding suggesting that surveillance and immunisation programmes targeted at pregnant women are necessary.

Surveillance for hepatitis B virus infection in pregnant women in Greece shows high rates of chronic infection among immigrants and low vaccination-induced protection rates: preliminary results of a single center study

Epidemiological data on the prevalence of serological markers of hepatitis B virus (HBV) infection in pregnant women in Greece are limited. We evaluated the prevalence of HBV serological markers in a multinational population of pregnant women in Athens, Greece. The overall prevalence of hepatitis B surface antigen (HbsAg) was 4.1% with the highest rates among Albanian immigrants (12%). Relatively low vaccination-induced protection rates (32.5%) were observed, a finding suggesting that surveillance and immunisation programmes targeted at pregnant women are necessary.

Prospective monitoring of BK virus replication in renal transplant recipients

BACKGROUND

BK virus-associated nephropathy (BKVAN) can be diagnosed only with renal graft biopsy. Definitive diagnosis of BKVAN requires demonstration of BK virus (BKV) replication in renal allograft tissues. Non-invasive analysis of urine and blood is considered essential in screening renal transplant recipients.

PATIENTS AND METHODS

This study evaluated prospectively the replication of BKV in plasma and urine with qualitative and quantitative real-time polymerase chain reaction in 32 de novo (group A) and 34 chronic (group B) renal transplant recipients and the long-term impact on graft function.

RESULTS

In group A, 456 samples (228 plasma, 228 urine) were examined and BKV was detected in 31 (31/228, 14%) samples of plasma and 57 (57/228, 25%) samples of urine in 20 (20/32, 62.5%) and 23 (23/32, 72%) recipients, respectively. Incidence of viremia and viruria increased during the first 6 months presenting a peak the third postoperative month (viremia: 28% and viruria: 31%). Immune suppressive treatment with tacrolimus showed significant relation with viremia. Renal graft function in de novo renal transplant recipients remained stable throughout the follow-up period without influence of BKV replication. In group B, incidence of viremia and viruria were 3% (1/34) and 9% (3/34) correspondingly, indicating that after the first post-transplant year the risk of BKV re-activation is diminished.

CONCLUSION

The highest incidence of BK viremia and viruria is observed the third post-transplantation month, confirming previously published studies in Europe and the United States, and long-term follow up shows that BKV replication decreases significantly after the third post-transplant month and even transient viremia or viruria does not have an impact on renal function.

Coxsackievirus B3 sequences in the myocardium of fatal cases in a cluster of acute myocarditis in Greece

AIM

The investigation of three fatal cases during a nationwide cluster of cases of an upper respiratory tract infection (URTI) associated with myocarditis and/or pericarditis in Greece in 2002.

METHODS

In the three women who died, necropsies were performed and tissue sections were taken for histological examination, antigen detection by immunohistochemistry and indirect immunofluorescence assay (IFA), amplification of viral genomes by nested reverse transcription polymerase chain reaction (RT-PCR), and sequence analysis.

RESULTS

All samples showed histological signs of active myocarditis. Immunohistochemistry revealed the presence of the enterovirus VP1 family of proteins and IFA revealed the presence of coxsackievirus B3 antigen. Nested RT-PCR amplified enteroviral alleles of the 5'-untranslated region which were identical to each other and to the coxsackievirus B3 sequences.

CONCLUSIONS

This study provides pathological evidence of enteroviral infection among fatal myocarditis cases in a nationwide URTI cluster of cases associated with myocarditis and/or pericarditis.

Algorithm for statistical detection of peaks--syndromic surveillance system for the Athens 2004 Olympic Games

INTRODUCTION

No generally accepted procedure exists for detecting outbreaks in syndromic time series used in the surveillance of natural epidemics or biologic attacks.

OBJECTIVES

This report evaluates the usefulness for syndromic surveillance of the Pulsar approach, which is based on removing long-term trends from an observed series and identifying peaks in the residual series of surveillance data with cutoffs determined by using a combination of peak height and width.

METHODS

Simulations were performed to evaluate the Pulsar method and compare it with other approaches. The daily syndromic counts in emergency departments of four major hospitals in the Athens area during August 2002-August 2003 were analyzed for two common syndromes. A standardized residual series was generated by omitting trends and noise in the original data series; this series was examined for the presence of peaks (i.e., points having magnitude higher than at least one of three probabilistically determined cutoffs). The whole process was iterated, and the baseline was recalculated by assigning reduced weight to the identified peaks.

RESULTS

For the specific simulation schema used, the Pulsar method fared well when compared with other approaches in meeting the performance criteria of sensitivity, specificity, and timeliness.

CONCLUSIONS

Although the suggested algorithm needs further validation regarding the correspondence between detected peaks and true biologic alerts, the Pulsar technique appears effective for observing peaks in time series of syndromic events. The simplicity of the algorithm, its ability to detect peaks based not only on height but also on width, and its performance in the simulated data sets make it a promising candidate for further use in syndromic surveillance.

Infective endocarditis in Greece: a changing profile. Epidemiological, microbiological and therapeutic data

The epidemiology, and clinical and microbiological spectrum, of infective endocarditis (IE) in Greece was analysed in a prospective 4-year study in a tertiary hospital and a heart surgery centre in Athens. In total, 101 cases of IE (71 men, 30 women, aged 54.4 +/- 17.1 years) were studied, with a follow-up period of 3 months. Seventy-seven cases were definite and 24 possible; 59 involved native valves (native valve endocarditis; NVE), 31 prosthetic valves (prosthetic valve endocarditis; PVE), of which nine were early and 22 late, and 11 permanent pacemakers (pacemaker endocarditis; PME). There was a predominant involvement of aortic (48/101) and mitral (40/101) valves. Seven patients had rheumatic valvular disease, two had mitral valve prolapse, and eight had a previous history of IE. Thirteen and six patients had undergone dental and endoscopic procedures, respectively. In 13 patients, intravenous catheters were used within the 3 months before diagnosis of IE. There were three intravenous drug users among the patients. Staphylococcus aureus was the most important pathogen, isolated in 22% of cases, followed by viridans streptococci (19%) and coagulase-negative staphylococci (16%). Enterococcus spp. were responsible for 3%, HACEK group for 2%, and fungi for 6% of cases. Viridans streptococci were the leading cause of NVE (29%), Staphylococcus epidermidis of PVE (16%), and S. aureus of PME (54.5%). Six of 22 S. aureus and ten of 16 S. epidermidis isolates were methicillin-resistant. Surgical intervention, including total pacemaker removal, was performed in 51.5% of patients. Overall mortality was 16%, but was 29% with PVE, and was significantly higher with medical than with combined surgical and medical therapy (24.5% vs. 8%). Compared with previous studies, there were changing trends in the epidemiology, microbiology, treatment and prognosis of IE in Greece.

Detection of enterococcal surface protein gene (esp) and amplified fragment length polymorphism typing of glycopeptide-resistant Enterococcus faecium during its emergence in a Greek intensive care unit

The emergence of glycopeptide-resistant Enterococcus faecium (GREF) in a Greek intensive care unit was studied by amplified fragment length polymorphism analysis and esp gene detection. Three GREF clones harboring the esp gene were recovered from 17 out of 21 patients, indicating the dissemination of genetically homogenous and virulent strains of GREF.

Mutations associated with genotypic resistance to antiretroviral therapy in treatment naïve HIV-1 infected patients in Greece

The widespread use of antiviral drugs against HIV has increased the prevalence of HIV-1 resistant strains among naïve individuals due to transmission of resistant strains. The purpose of this study was to investigate the presence of HIV-1 strains harboring resistance mutations in naïve patients in Greece. Blood samples were collected from 25 individuals. The DNA sequence of protease and partial reverse transcriptase regions (codons 41-223) were obtained by direct sequencing. Our results showed the absence of any primary resistance mutations in the study population. However, we were able to identify high prevalence of sequence polymorphisms at positions in reverse transcriptase region associated mainly with resistance to NNRTIs. Moreover, in protease region several secondary mutations were detected, suggesting the higher genetic variability of this region. The clinical significance of the polymorphisms associated with reduced susceptibility to NNRTIs remains to be clarified.

Remote access to an expert system for infectious diseases

An expert-system antibiotic information database was developed in order to help non-specialist doctors to choose the appropriate treatment for patients with infectious diseases. Fifty doctors conducted a pilot trial of the database, using modern access and the telephone network. During an eight-month study period, 1053 queries were received. The range of duration of the queries was 130-350 s. Of the queries, 473 (45%) were for particular patients with an infectious disease. The response rate to a questionnaire mailed out to the users at the end of the project was 100%. All doctors, even those who had limited experience with computers, found it easy to understand and to use the database.

Enterococcal infections in a Greek intensive care unit: a 5-y study

In this study we determined the incidence, resistance pattern, and mortality rate associated with infection caused by Enterococcus faecalis and Enterococcus faecium among patients in a multidisciplinary intensive care unit (ICU). A total of 111 patients with E. faecalis and 60 with E. faecium infections were identified during a 5-y period (1992-96). We observed an increase in the incidence of enterococcal infections (from 5.46 to 8.46 per 1000 patients-days, p = 0.0112), due mainly to the increased incidence of E. faecium (from 0.45 to 4.06 per 1000 patients-days, p = 0.002). Blood was the most common site of enterococcus isolation. E. faecium was more resistant to antibiotics than E. faecalis, but no vancomycin resistant enterococcus was isolated. Patients with E. faecium infection had a significantly higher mortality than patients with E. faecalis infection (66% vs. 41.5%, p = 0.0035 for infection from any site and 85.7 vs. 47.7%, p = 0.012 for bacteremic patients). r 4n- D I .- .- - .. . .

Efficacy of amikacin, ofloxacin, pefloxacin, ciprofloxacin, enoxacin and fleroxacin in experimental left-sided Pseudomonas aeruginosa endocarditis

The efficacies of amikacin, ofloxacin, pefloxacin, ciprofloxacin, enoxacin and fleroxacin, each as monotherapy, were evaluated in a rabbit model of induced left-sided Pseudomonas aeruginosa endocarditis. Therapy started 48 h after infection and lasted 5 days. All agents were given intramuscularly; amikacin at 7 mg/kg/12 h, and each quinolone at 35 mg/kg/12 h. All animals survived except for 1 of the group that received amikacin, and 2 of the untreated control group. No sterile vegetations were found in the untreated group and the group of fleroxacin, while 3 animals from the amikacin, ofloxacin, and enoxacin groups, and 2 from the ciprofloxacin and pefloxacin groups had sterile vegetations. All agents used significantly reduced the number of CFU per gram of vegetation versus untreated controls. Enoxacin and ciprofloxacin were equipotent and more effective than pefloxacin, ofloxacin and amikacin. Fleroxacin had a weaker activity.

Comparative in vitro and in vivo efficacy of roxithromycin and erythromycin against a strain of methicillin-susceptible Staphylococcus epidermidis

The in vitro and in vivo efficacy of roxithromycin was compared with that of erythromycin, against a methicillin-susceptible strain of Staphylococcus epidermidis. We performed standard in vitro testing (MIC, MBC, and time-kill kinetics) for roxithromycin, erythromycin, and rifampin. Both macrolides were bacteriostatic in vitro. There was no significant difference in microbial survival between erythromycin and roxithromycin groups in the time-kill kinetics (p = 0.3). For the in vivo experiments, using the rabbit experimental endocarditis model, roxithromycin was found to be inferior to erythromycin in decreasing the microbial burden of the endocardial vegetations (p < 0.05). Rifampin was highly effective, both in vitro and in vivo. In conclusion, the efficacy of roxithromycin was poor and inferior to erythromycin against a strain of methicillin-susceptible S. epidermidis.

Efficacy and tolerance of roxithromycin versus clarithromycin in the treatment of lower respiratory tract infections

In an open, randomized, parallel group study, the efficacy and tolerance of roxithromycin 300 mg po od was compared with clarithromycin 500 mg po bd in the treatment of 60 patients with lower respiratory tract infections (LRTI). The two groups were well-matched demographically. Fifty patients (25 per group) were clinically evaluable at the end of the study and a satisfactory response was found in 88% of those given roxithromycin and 80% of those given clarithromycin. All had received treatment for a minimum of 3 days. Only one (3.3%) of 30 patients in the roxithromycin group reported adverse events compared with seven (23.3%) of 30 in the clarithromycin group. Thus both roxithromycin and clarithromycin are effective in the treatment of LRTI but roxithromycin is better tolerated (P < 0.05) with the advantage of a once-daily dose.

Itraconazole for the treatment of pulmonary aspergillosis in heart transplant recipients

The objective of this study was to evaluate the effects of itraconazole as a first choice drug in the treatment of pulmonary aspergillosis in heart transplant recipients. Heart transplant recipients suffering from invasive pulmonary aspergillosis were included in this study. Group 1 included 4 patients treated with i.v. itraconazole (Janssen Pharmaceutica) 400 mg daily, as a first choice drug for 28 d. Itraconazole was discontinued and amphotericin-B was started before the 28th day if clinical or radiographic worsening was observed. Group 2 included 3 patients treated with amphotericin-B as a first choice drug. Itraconazole was discontinued in all patients of Group 1 after 12-26 d of treatment because of radiographic worsening (n = 3) or combined clinical and radiographic worsening (n = 1). Subsequent treatment with amphotericin-B resulted in improvement of all patients. On a 5-yr follow-up period no relapse of aspergillosis was observed in 3 of them. The fourth patient expired from cerebral hemorrhage. The 3 patients of Group 2 treated with amphotericin-B showed a gradual improvement, and all were doing well on a 2-yr follow-up. In conclusion, in our study population consisted of heart transplant recipients amphotericin-B was superior to itraconazole in the treatment of invasive pulmonary aspergillosis.

Efficacy of deoxycholate amphotericin B and unilamellar liposomal amphotericin B in prophylaxis of experimental Aspergillus fumigatus endocarditis

OBJECTIVE

To evaluate and compare in vivo the protective efficacy of unilamellar liposomal amphotericin B (L-AmB) with that of deoxycholate amphotericin B (D-AmB) in experimental endocarditis.

MATERIAL AND METHODS

In the rabbit model of experimental Aspergillus fumigatus endocarditis, two doses of each antifungal agent (1.5 mg/kg each) were administered intravenously at 4 hours and at 30 minutes before challenge with an inoculum of A. fumigatus. Three days later, the animals were sacrificed, and the aortic vegetations were analyzed.

RESULTS

All 19 animals that did not receive chemoprophylaxis acquired endocarditis. In contrast, endocarditis developed in 2 of 10 animals pretreated with D-AmB (P < 0.01) and 3 of 8 animals pretreated with L-AmB (P < 0.01). Both D-AmB and L-AmB prevented the development of endocarditis due to A. fumigatus and decreased the concentration of fungi in the aortic vegetations by more than 1 log10.

CONCLUSION

In the rabbit experimental model of Aspergillus endocarditis, D-AmB and L-AmB were equally effective in reducing the incidence of the infection and the tissue burden of fungi.

Methicillin-resistant Staphylococcus aureus: interstate spread of nosocomial infections with emergence of gentamicin-methicillin resistant strains

A methicillin-resistant strain of Staphylococcus aureus (MRSA, phage type 84/85) was introduced into City of Memphis Hospital by a burn patient who had recently been treated for MRSA bacteremia in another institution 500 miles distant. Despite prompt recognition of the problem and institution of isolation procedures, six other patients developed secondary colonization during the ensuing six months, and five of these experienced clinically significant infections with MRSA. Three of the patients originally infected with MRSA, as well as two additional patients, subsequently developed colonization with staphylococcal strains of phage type 84/85 that were resistant to both methicillin and gentamicin (MRGRSA). Spread of the staphylococcal strains was most likely accomplished primarily via passive transfer from person to person. The hydrotherapy unit, which became contaminated with both MRSA and MRGRSA, may have played a secondary role. As illustrated by this outbreak, patients carrying potentially dangerous bacterial strains should be identified and informed of the problems posed by such carriage. It may be imprudent to admit such patients to hospitals that are free of the potential pathogen. The outbreak described here exemplifies a number of potential problems associated with control of nosocomial staphylococcal infections: (a) interhospital spread of methicillin-resistant strains; (b) secondary patient-to-patient intrahospital spread; and (c) emergence of even more resistant strains, possibly associated with selective pressures exerted by widespread use of broad-spectrum antimicrobial agents.

Susceptibility of skin and throat strains of group A streptococci to rosamicin and erythromycin

The minimal inhibitory concentrations of rosamicin and erythromycin were compared for 210 strains of group A streptococcus isolated from a diverse spectrum of streptococcal diseases. Of these strains, 97.6% were inhibited by 0.1 to 0.2 mug of rosamicin per ml, whereas 90.9% were inhibited by 0.025 to 0.05 mug of erythromycin per ml. The minimal inhibitory concentration of rosamicin for 154 strains exceeded that of erythromycin by at least fourfold. Five group A strains of streptococcus that were highly resistant to erythromycin were even more resistant to rosamicin.