The Journal of Infection in Developing Countries An open access, peer-reviewed, online scientific research journal focused on global health en-US <p>Authors who publish with this journal agree to the following terms:</p> <ol type="a"> <li>Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a <a title="Creative Commons Attribution License" href="" target="_new">Creative Commons Attribution License</a> that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.</li> <li>Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.</li> <li>Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See <a title="The Effect of Open Access" href="" target="_new">The Effect of Open Access</a>).</li> </ol> (JIDC Central Office) (JIDC Administrator) Fri, 06 Apr 2018 13:26:08 -0700 OJS 60 The role of gender in the prevalence of human leptospirosis in Albania <p>Introduction: Leptospirosis is a zoonotic spirochetal disease with global importance, which continues to have a major impact on public health in developing countries. The prevalence of the disease is much higher in males. The objectives of this study were: to give some data and to share our experience with human leptospirosis in Albania; to describe the prevalence regarding to the role of gender in the prevalence of human leptospirosis; to make a gender specific analysis of the clinical manifestations in patients diagnosed and treated for leptospirosis in our service and to make a review of literature related to this hypothesis.</p> <p>Methodology: We reviewed the epidemiologic data, risk factors and differences in clinical presentation between males and females’ patients with leptospirosis. These data are analysed from hospitalized patients. Diagnosis of leptospirosis was established based on clinical presentation, epidemiological data and subsequently confirmed serologically by Anti-Leptospira IgM antibodies through ELISA test.</p> <p>Results: Between 2005-2016, 233 cases of confirmed leptospirosis were analysed. Males were 208 (89.27%) and 25 of patients (10.72%) were females in ratio 9:1 p &lt; 0.001. The highest prevalence was observed in the 45-64 age groups. Overall mortality was found to be 8.58%, 19 were males and one female p &lt; 0.001.</p> <p>Conclusions: There is a much higher prevalence of leptospirosis in middle aged men. Mortality rate seems to be similar in males and females. While the difference in prevalence may be related to exposure to risk factors, further investigation is necessary to study gender-based genetic and immunological predisposition.</p> Edmond Puca, Pellumb Pipero, Arjan Harxhi, Erjona Abazaj; Arjet Gega; Entela Puca, Ilir Akshija ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Comparison of biofilm formation and efflux pumps in ESBL and carbapenemase producing Klebsiella pneumoniae <p>Introduction: <em>Klebsiella pneumoniae</em> is an opportunistic pathogen that causes a range of diseases. The appearance of extended-spectrum β-lactamase -and carbapenemase-producing strains, in addition to the biofilm-forming phenotype, is a major problem in the clinical environment.</p> <p>Methodology: A total of 33 clinical <em>K. pneumoniae</em> isolates were used in this study. Antimicrobial susceptibilities were assessed by a disc diffusion assay. Biofilm formation was determined by a microtiter plate assay, staining with 1% crystal violet and measuring&nbsp; absorbance after destaining. Moreover, expression of <em>acrA, kdeA, ketM, kpnEF,</em> and <em>kexD</em> efflux associated genes&nbsp; was measured by qRT-PCR.</p> <p>Results: Isolates displayed high resistance to β-lactams such as cefazolin, cefuroxime, ceftriaxone, cefepime, piperacillin-tazobactam, imipenem, and meropenem and decreased resistance to gentamicin, amikacin, ciprofloxacin, and levofloxacin. ESBL-producing isolates formed more biofilm than carbapenemase-producing isolates<em>.</em> The mRNA expression levels in KPC isolates for <em>acrA</em> (2-fold), <em>kdeA</em> (2.7-fold), <em>ketM</em> (2.2-fold), and <em>kpnEF</em> (3.4-fold) were significantly increased compared to ESBL-producing isolates. There was no significant difference in <em>kexD</em> expression level.</p> <p>Conclusions: Under the conditions used here ESBL-producing isolates formed more biofilm than KPC postive isolates; this was associated with virulence determinants which were also transferred by plasmids together with ESBLs enzymes. Moreover, the upregulation of <em>acrA, kdeA, ketM, </em>and <em>kpnEF</em> efflux pumps was seen in carbapenemase-producing isolates demonstrating that high expression of efflux pumps alone could not confer resistance but may act as a physiological determinant such as bacterial pathogenicity and virulence, and cell-to-cell communication for bacteria.</p> Burak Yazgan, Ibrahim Türkel, Rıdvan Güçkan, Kılınç Kılınç, Tuba Yıldırım ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Antimicrobial agents active against carbapenem-resistant Escherichia coli and Klebsiella pneumoniae isolates in Lebanon <p>Introduction<strong>:</strong> It is not yet clear which antimicrobial agents should be used to treat the ominously increasing infections with carbapenem-resistant (CR) bacteria. We therefore investigated the activity of different antimicrobial agents against CR <em>Escherichia coli</em> and<em> Klebsiella pneumoniae</em> in Lebanon.</p> <p>Methodology: This retrospective study assessed the minimum inhibitory concentrations (MICs) of three carbapenems (by Etest), as well as the <em>in</em> <em>vitro</em> activity of eight other antimicrobials (by disk diffusion) against CR <em>E. coli</em> (n = 300) and <em>K. pneumoniae</em> (n = 232) isolates recovered at a major University Medical Center in Lebanon.</p> <p>Results: Higher percentages of isolates showing carbapenem MICs of ≤ 8 µg/mL were noted among the CR <em>E. coli</em> compared to the CR <em>K. pneumoniae</em> for ertapenem (48% vs 27%), imipenem (74 % vs 58%) and meropenem (82% vs 63%). Among the eight other antimicrobials, activity was generally higher when the MICs for the three carbapenems were ≤ 8 µg/mL. Regardless of the MIC level of the three carbapenems, very low susceptibility rates (≤ 33%) were noted for ciprofloxacin, trimethoprim-sulfamethoxazole and aztreonam against both <em>E. coli</em> and <em>K. pneumoniae</em> isolates. With Amikacin, higher susceptibility rates were seen against <em>E. coli</em> isolates (81%-97%) than against <em>K. pneumoniae</em> isolates (55%-86%), also reflecting higher activity than gentamicin (44%-54%). The best activity (66%-100%) was observed for tigecycline, colistin and fosfomycin against both CR species.</p> <p>Conclusions: Based on the in vitro findings in this study, the combination of a carbapenem showing an MIC of ≤ 8 µg/mL together with an active colistin, tigecycline, or fosfomycin, would offer a promising treatment option for patients infected with CR <em>E. coli</em> or <em>K. pneumoniae</em>.</p> George Farah Araj, Aline Z Avedissian, Lina Y Itani, Jowana A Obeid ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 The prevalence and the risk factors for hepatitis C virus infection in Serbia <p>Introduction: The epidemiological characteristics of the hepatitis C virus (HCV) infection in Republic of Serbia have not been studied sufficiently so far. The aim of this study was to estimate the prevalence of anti-HCV positivity in the general population of Serbia and determine the risk factors for this infection.</p> <p>Methodology: Estimation of the prevalence was done using the median ratio method with data from several regional countries to a previously determined prevalence of anti-HCV positivity among volunteer blood donors of 0.19%. In order to determine the risk factors a matched case-control study was conducted of 106 subjects with confirmed HCV infection from the Clinic for Infectious and Tropical Diseases, Clinical Center of Serbia and the same number of hospital controls matched by sex and age.</p> <p>Results: The estimated prevalence of anti-HCV positivity in the general population of Serbia was 1.13% (95% CI: 1.0-1.26%). The most important predictive risk factors of HCV infection were: intravenous drug use (OR = 31.0; 95% CI: 3.7-259.6), blood transfusions (OR = 3.7; 95% CI: 1.6-8.7), invasive dental treatment (OR = 3.1; 95% CI: 1.4-6.8), and low level of education (OR = 2.2; 95% CI:1.1-4.7). A total of 91.5% of the persons with hepatitis C had at least one of the significant risk factors.</p> <p>Conclusion: The prevalence of anti-HCV positivity ranks Serbia in the range of mid-endemic European countries. Preventive measures should be directed at preventing drug use, on education about getting the infection, creating safe conditions for blood transfusions, and strict adherence to adopted practices in dentistry.</p> Nikola Mitrovic, Dragan Delic, Ljiljana Markovic Denic, Natasa Nikolic, Ksenija Bojovic, Jasmina Simonovic Babic, Branko Brmbolic, Ivana Milosevic, Natasa Katanic, Aleksandra Barac ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 FIB-4 and APRI scores for predicting severe fibrosis in chronic hepatitis C - a developing country's perspective in DAA era <p>Introduction: Chronic Hepatitis C Virus (HCV) infection leads to progressive fibrosis making fibrosis staging necessary in the evaluation of such patients. Different fibrosis scores are emerging as possible non-invasive alternatives for liver biopsy. The Fibrosis-4 Index (FIB-4) and AST to Platelet Ratio Index (APRI) scores are the most widely used and the most extensively tested. This study aims to determine if it was possible to accurately use these to identify patients that are unlikely to have severe fibrosis.</p> <p>Methodology: One hundred and forty-two patients with chronic hepatitis C infection who underwent liver biopsy since January 1st 2014 until May 31st 2017 at the Hospital for Infectious and Tropical Diseases in Belgrade were analyzed. The FIB-4 and APRI scores were calculated for each patient and compared to histologically determined fibrosis stage.</p> <p>Results: A comprehensive statistical analysis was conducted in order to compare patients with and without severe fibrosis and to evaluate the accuracy of the fibrosis scores. Patients with non-severe fibrosis were younger, had higher platelet counts and lower transaminase levels. FIB-4 had an AUC of 0.875 and the APRI score had an AUC of 0.861. No patients with severe fibrosis or cirrhosis had a FIB-4 lower than 1.08. FIB-4 was superior to APRI in identifying patients with severe fibrosis in the study cohort.</p> <p>Conclusion: FIB-4 was superior to APRI in the recognition of severe fibrosis. FIB-4 may prove very useful in identifying patients without advanced liver disease, especially if other non-invasive methods are inaccessible.</p> Uros Karic, Ivana Pesic-Pavlovic, Goran Stevanovic, Milos Korac, Natasa Nikolic, Aleksandra Radovanovic-Spurnic, Aleksandra Barac, Nikola Mitrovic, Aleksandar Markovic, Marko Markovic, Anita Petkovic, Ivana Ostojic, Sanja Perunicic, Natalija Kekic, Martina Glidzic, Miljana Djonin-Nenezic, Branko Brmbolic, Ivana Milosevic ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Repercussions of chronic hepatitis C treatment <p>Introduction: Individuals living with hepatitis C experience a series of changes in their lives, caused by either the disease itself or its treatment or both. In this sense, living with a chronic disease such as hepatitis C implies that patients must change their lifestyles, which requires that they rethink their habits in light of the new reality. To comprehend chronic hepatitis C patients’ perceptions, meanings, and quality-of-life effects. Methodology: Qualitative research; interviews with 12 patients at a specialized outpatient clinic from February to July 2012. The cohort size was determined by theoretical saturation and the interviews were analyzed by means of content analysis. Results: Data were organized into four categories: on medication, referenced fears, impact on sexuality, and coping with the new reality. The categorized data were discussed around the following themes: “Becoming sick” due to treatment and perceived aspects and Undergoing treatment and how to cope with it. Conclusion: Patients’ everyday lives and quality of life in general are affected especially by adverse side effects of hepatitis C medication and an assortment of feelings and uncertainties about the disease prognosis. Notwithstanding, most patients manage to find ways to cope with the treatment and complete it expecting a satisfactory outcome.</p> Daniela Maria Falcão Oliveira, Juliano Souza Caliari, Ana Angélica Lima Dias, Rosely Moralez Figueiredo ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Mycobacterium paratuberculosis sheep type strain in Uruguay: Evidence for a wider geographic distribution in South America <p>Johne’s disease (JD) is an economically important disease of ruminants caused by <em>Mycobacterium avium</em> <em>paratuberculosis</em> (MAP), which also infects other species including humans. Two major MAP strain types are currently recognized: sheep (S) and cattle (C) types. Information on JD prevalence and MAP types infecting small ruminants in South America is limited, and all but one of the MAP types reported from this region are of the C type. This study describes clinicopathological, molecular and microbiological findings in 11 cases of JD caused by a type S MAP strain, and estimated true within-flock prevalence in a ~735-sheep operation in Uruguay. Postmortem examination and histology (hematoxylin-eosin and Ziehl-Neelsen stains) of samples from 41 selected sheep revealed lymphohistiocytic/granulomatous enteritis and mesenteric lymphadenitis in 11 animals, with moderate/severe multibacillary lesions in 6 clinical cases, and minimal/mild paucibacillary lesions in 5 sub-clinical cases. Immunohistochemistry using an antibody against <em>Mycobacterium bovis</em> that cross-reacts with MAP (2 cases), and transmission electron microscopy (1 case), revealed myriads of intrahistiocytic mycobacteria. MAP was isolated in one case and detected by PCR in 6 cases. The S type of MAP was identified using a multiplex PCR that distinguishes between S and C types, and PCR-REA. The estimated true within-flock prevalence was ≤ 2.3%. This represents the first communication on within-flock prevalence of JD associated with a type S MAP strain in South America and the second documentation of this strain in the subcontinent. Additional studies are required to better understand the molecular epidemiology of the different MAP types in the region.</p> Federico Giannitti, Martin Fraga, Ruben Dario Caffarena, Carlos Omar Schild, Georgget Banchero, Aníbal Guillermo Armién, Gabriel Travería, Douglas Marthaler, Scott Joseph Wells, Franklin Riet-Correa ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Genome analysis of a MDR Streptococcus pneumoniae 23F serotype causing meningoencephalitis in a 10-months refugee infant <p>Purpose: <em>Streptococcus pneumoniae</em> is an important human pathogen causing invasive pneumococcal diseases (IPD). The re-emergence of eradicated <em>S. pneumoniae</em>-associated meningoencephalitis in Lebanon is a major point of concern.</p> <p>Methods: We aimed at conducting a comparative genome analysis of a multi-drug resistant <em>S. pneumoniae</em>, LAU-23F, linked to meningoencephalitis and fatality in a 10-months Syrian refugee infant in Lebanon, and 24 related publically available genome sequences. Serotype, capsular genes, MLST, SNPs, phylogenetic relatedness and repertoire of resistance genes were investigated. Genes encoding penicillin binding proteins (PBPs) were examined for mosaicity. Virulence factors were screened for SNPs as compared to reference strains.</p> <p>Results: The isolate belonged to ST-277 and was of serotype 23F. It showed an intermediate resistance to ciprofloxacin, cefuroxime and penicillin and carried multiple components of different efflux pumps. Gene mosaicity was observed in <em>pbp2x</em>, it was also distinct from other penicillin-resistant strains; <em>pbp1a</em> and <em>pbp2b </em>appeared to be conserved between LAU-23F and the reference strain SP49. The arrangement of capsular gene loci was similar to ATCC 700669 though polymorphism was detected in the <em>cpsABCD</em> region, believed to be conserved among different <em>Streptococcus</em> species. Amplitude of virulence factors was detected showing varying degrees of conservation compared to reference strains. Observed zones of high heterogeneity were associated with phage encoded regions.</p> <p>Conclusions: The fine levels of diversity throughout the genome could account for the pronounced invasiveness of this isolate. The genomics-based methods used support the importance of implementing WGS in routine clinical diagnostics and surveillance of streptococcal diseases.</p> Tamara Salloum, Elie Tannous, Samar Merheb-Ghoussoub, Elie Ghoussoub, Sima Tokajian ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Refractory Giardiasis in an Immunosuppressed Patient in Turkey <p>Giardiasis is an infection of the small intestine caused by the protozoan parasite <em>Giardia duodenalis</em>. In immunocompetent patients the infection is usually self-limited and no treatment may be needed. Immunodeficiency, however, is a predisposing factor for the development of severe <em>Giardia</em> infection. In this report, a case of recurrent giardiasis refractory to nitroimidazoles and nitazoxanides presented. A 28-year-old male patient with hypogammaglobulinemia admitted to our hospital because of chronic diarrhoea. Microscopic examination of stool revealed a high number of <em>Giardia </em>trophozoites and cysts. Treatment with higher doses and a longer course of metronidazole, trimethoprim-sulfamethoxazole, ornidazole and albendazole failed. Administration of nitazoxanide, which has been reported to be effective against <em>Giardia duodenalis </em>refractory to nitroimidazoles, was commenced, but his symptoms persisted and stool samples demonstrated <em>Giardia </em>trophozoites and cysts again.</p> Filiz Kaya, Ahmet Çağkan İnkaya, Salih Maçin, Yakut Akyön, Sibel Ergüven ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700 Who should be screened for Chlamydia trachomatis infection? Three years' experience at a University Hospital in Switzerland Rosa Catarino, Abdessalam Cherkaoui, Laurence Toutous Trellu, Michal Yaron ##submission.copyrightStatement## Sat, 31 Mar 2018 00:00:00 -0700