Invasive pneumococcal diseases in adults admitted to the Na Bulovce Hospital: Serotype replacement after the implementation of general childhood pneumococcal vaccination.

OBJECTIVE: The aim of this study was to analyse epidemiological and clinical characteristics of invasive pneumococcal disease (IPD) in adults before and after the introduction of the general childhood conjugate pneumococcal vaccination programme in the Czech Republic. MATERIAL AND METHODS: The retrospective observational sentinel study included adults with IPD admitted to the Na Bulovce Hospital in Prague from 1/2000 through 12/2019. A case of IPD was defined as isolation of Streptococcus pneumoniae from a primarily sterile site. RESULTS: A total of 304 IPD cases were diagnosed during the study period, with a male to female ratio of 1.49:1 and age median of 58 years (IQR 43-73). The most prevalent clinical forms were bacteraemic pneumonia (185 cases; 60.9%) and purulent meningitis (90; 29.6%). A total of 157/293 patients (53.6%) required intensive care, and the case fatality rate was 25.3% (n = 77). The serotype was determined in 292 (96.0%) isolates, the most prevalent being serotypes 3 (38; 12.5%), 4 (28; 9.2%), 7F (24; 7.9%), 8 (21; 6.9%), and 1 (18; 5.9%). Both clinical and epidemiological characteristics of IPD caused by the most prevalent serotypes differed considerably. Patients diagnosed with serotype 3 were older, more frequently required intensive care, and showed higher mortality. The proportion of IPD caused by non-PCV13 serotypes increased from 28.8% (19/66) in 2000-2005 to 54.8% (40/70) in 2015-2019 (p = 0.001). CONCLUSION: The study demonstrated that invasive diseases caused by the most prevalent pneumococcal serotypes differ in their epidemiological and clinical characteristics and case fatality rate. During the study period, there was a significant increase in IPD caused by non-PCV 13 serotypes, limiting the effect of vaccination in adults.

[The prevalence, incidence, persistence and transmission ways of human papillomavirus infection (HPV)]. / Prevalence, incidence, perzistence a moznosti prenosu infekce lidským papilomavirem (HPV).

Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide, which may result in the development of benign or malignant tumours. HPV infec-tions cause approximately 5% of all human cancers. Infection at all sites is strongly associated with sexual behaviour, but this association does not appear to explain substantial differences in the prevalence, incidence, persistence, and clearance of HPV infection in the anal, genital, and oral areas. Discussed are the similarities and differences among the natural histories of infection in different anatomical sites of the human body of both genders. Despite the huge advances already achieved, more research is needed to suggest effective prevention strategies (including the screening of high-risk groups and vaccination) for HPV infection and associated diseases.

[Management of care of HIV-positive pregnant women in the period 1996-2014]. / Management péce o HIV pozitivní tehotné v období let 1996-2014.

OBJECTIVE: The evaluation of multidisplinary care about HIV positive pregnant women in the Czech Republic. DESIGN: Review. SETTINGS: Gynekologicko-porodnická klinika 1. LF UK a Nemocnice na Bulovce, Praha. METHODS: The vertical transmission of HIV infection from mother to fetus occurs most often during birth, still 1-2% of HIV-positive pregnant women will transfer the virus transplacenta. Due to careful screening for HIV during pregnancy, counselling, combination antiretroviral (cART) therapy, childbirth planning and its performance by C-section there appears a significant decrease of the virus transmission to the fetus, its occurrence is around 2%. If the HIV infection is detected in the context of screening for sexually transmitted infections (STIs), we begin with combined antiretroviral therapy (cART) depending on the level of viremia and CD4 as soon as possible. All HIV-positive pregnancies are tested for possible coinfection with hepatitis C. Since the first application of the antiretroviral treatment, the therapy is applies throughout the duration of the pregnancy. The labours of the HIV- positive women in the Czech Republic are scheduled. The primary choice is a caesarean section during the 38th week of pregnancy. CONCLUSION: From 1996-2014 the HIV positive status at 18 months of child age was confirmed in 4 cases in the Czech Republic. Three children were born to mothers whose HIV status was unknown at the time of the birth. Thanks to strict adherence to the interdisciplinary care, HIV positive woman have a chance to deliver a HIV-negative newborn and the risk of the transmission of the virus is significantly low.

[A case of tuberculous meningitis associated with persistently reduced CD4+ T lymphocyte counts]. / Prípad tuberkulózní meningitidy provázené perzistujícím snízením CD4+ T lymfocytu.

A case history is presented of a 35-year-old man admitted to the hospital with tuberculous meningitis complicated by caseous necrosis of cervical lymph nodes and thrombosis of the left jugular vein. Another complication, malignant brain edema, appeared more than one year after discharge from hospital and was managed at the neurosurgery department. The most probable cause was a post-inflammatory obstruction of the cerebrospinal fluid pathways. A challenging finding, observed repeatedly while in hospital and at follow ups after discharge, was medium significant CD4+ T cell lymphopenia, with the lowest CD4+ T cell count of 308 cells/µl of peripheral blood. For this reason, the patient was screened several times for anti-HIV antibodies, but always with a negative result. Active tuberculous infection was considered as another possible reason behind persistent CD4+ T cell lymphopenia. However, imaging and laboratory analyses were not suggestive of tuberculosis. The patient is currently in good condition and his CD4+ T lymphocyte counts returned to normal at seven years of follow-up. It is underlined that patients after tuberculous meningitis need a long-term follow-up.

Incidence, immunological and clinical characteristics of reactivation of latent Toxoplasma gondii infection in HIV-infected patients.

To determine changes in incidence of reactivation of Toxoplasma gondii infection, manifesting as toxoplasmic encephalitis, and to assess the immunological mechanisms controlling reactivation in HIV-infected patients, a Czech cohort of 502 HIV/T. gondii co-infected patients was followed for 2909·3 person-years. The incidence of toxoplasmic encephalitis between the periods before and after the introduction of combination antiretroviral therapy (cART) was compared. Toxoplasmic encephalitis was diagnosed in 21 patients. In those patients the geometric mean value of CD4+ T lymphocytes was 12·6 times lower than in patients with non-reactivated T. gondii infection but an additionally significant decline in CD8+ T lymphocytes (3·3-fold) and natural killer cells (4·3-fold) was observed. This confirms the significance of these parameters. A twelvefold decrease in Toxoplasma reactivation incidence (40·2 vs. 3·4/1000 person-years) between monitored periods was seen. In the cART era, Toxoplasma reactivation was observed only in patients with unrecognized HIV infection or refusing therapy.

[Guidelines for caring for HIV-infected adults and postexposure prophylaxis for HIV infection]. / Doporuceny postup pece o dospele infikovane HIV a postexpozicni profylaxe infekce HIV.

The authors present instructions for providing antiretroviral therapy in the Czech health care system, based partly on recommendations from abroad and partly on their own experiences of caring for HIV /AIDS patients. The structure and content are similar to those in the 2010 edition, with new study outcomes and modern trends in treatment strategy being taken into consideration. The guidelines are based on systematic patient assessment and aimed at making an accurate diagnosis and formulating recommendations according to individual criteria. The document provides specific instructions for decisions on initiating antiretroviral therapy, selection of individual drugs, monitoring of treatment effect and adverse reactions, and reaction to potential therapy failure. Special attention is paid to administration of antiretroviral drugs to pregnant women and patients with comorbidities, especially tuberculosis, hepatitis or renal insufficiency. The new version includes procedures for postexposure prophylaxis for HIV infection. The guidelines are supplemented by a table summary of antiretroviral drugs. The presented document is to be used in negotiations between the association,state authorities and health care payers.

First detection of Chlamydia trachomatis LGV biovar in the Czech Republic, 2010-2011.

We present four cases of proctitis in HIV-infected men having sex with men (MSM) living in the Czech Republic. The causative agent in all cases was the lymphogranuloma venereum (LGV) biovar of Chlamydia trachomatis. The spread of proctitis caused by C. trachomatis serovars L1­3 among MSM has been observed in several European countries, the United States and Canada since 2003. To our knowledge, no LGV cases in eastern Europe have been published to date.

[Infectious complications of biological therapy]. / Infekcní komplikare biologické lécby.

Biological treatment represents a significant progress in the therapy of many serious diseases. Together with the growing knowledge of pathophysiology and subsequent development of new therapeutic agents, this progress will definitely lead to further expansion of biologics. Since biologics interfere with many mechanisms of host defence, which may sometimes be compromised by them, increased risk of infectious complications must be taken into account. Patients treated with biologics are prone to classical virulent infections (e.g. listeriosis, legionellosis and tuberculosis) and opportunistic infections such as progressive multifocal leukoencephalopathy. Furthermore, suppression of the immune response that is caused by biologics may lead to reactivation of latent infections such as tuberculosis or viral hepatitis B. Therefore, the knowledge of basic mechanisms by which biologics modify the immune response is important for a rapid clinical diagnosis of possible aetiology of infectious complications.

[Diagnostic pitfalls of HIV-associated Kaposi's sarcoma]. / Uskalí diagnostiky Kaposiho sarkomu sdruzeného s HIV infekcí.

Kaposi's sarcoma was one of the very first diseases which indicated the advent of the AIDS pandemic. Despite the marked fall in its occurrence thanks to the introduction of the cART, Kaposi's sarcoma remains the most frequent tumour in HIV-positive patients and still represents a major diagnostic and therapeutic problem. Particularly in the early stages both the macroscopic and histopathological picture of Kaposi's sarcoma may be very atypical, which can cause diagnostic difficulties right at the time when an early therapy may be most successful. In order to improve both the diagnostics and therapy of Kaposi's sarcoma, close collaboration between physicians taking care of HIV-positive patients--mainly infectologists, dermatologists and pathologists, is necessary.

Antibody response of HIV-infected patients to latent, cerebral and recently acquired toxoplasmosis.

The aim of this longitudinal study with 626 HIV-infected patients was to evaluate the capability of serological tests in diagnosing the presence of Toxoplasma gondii infection in HIV-infected patients, as well as the potential impact of various treatment regimes on serological results. Low IgG antibody levels and stable or declining titres predominated. IgM positivity occurred in ten patients (one seroconversion, seven latent, two cerebral toxoplasmosis). Complement fixation test (CFT) titres >or=1:32 imply that the relative risk of cerebral toxoplasmosis is 6.84 (95% confidence interval [CI] 1.44-32.5) but with a predictive value of only 14.0% (95% CI 5.3-27.9). Values of specific antibodies are not biassed by antiretroviral treatment and/or prophylaxis for toxoplasmosis, and the detection of specific antibodies is very useful in the identification of T. gondii infection in the HIV-infected population, but the role of serology in predicting the clinical manifestation of T. gondii infection is limited.

[Treatment of invasive candidiasis--recommendations of professional]. / Lécba invazivní kandidózy--doporucení odborných spolecností.

National working group representing clinicians (hematologists, oncologists, infection diseases and ICU specialists), microbiologists, and different special medical societies and working groups prepared evidence-based guidelines for the treatment established fungal infection--invasive candidiasis in the adult hematology and ICU patients. These guidelines updated those published in the Czech Republic in 2003-2004. Evidence criteria of the Infectious Diseases Society of America (IDSA) were used for assessing the quality of clinical trials, and EORTC/MSG Consensus Group for definitions of invasive fungal disease.

[Treatment for invasiveness aspergillosis--recommendations of professionals]. / Lécba invazivní aspergilózy--doporucení odborných spolecností.

An increasing incidence of invasive aspergillosis is observed in most immunocompromised patients, and especially patients with acute leukemia and after hematopoietic stem cell transplantation. In order to decrease the mortality due to this infection, the clinicians need to optimise their treatment choice. The objective of these guidelines is to summarize the current evidence for treatment of invasive aspergillosis. The recommendations have been developed by an expert panel following an evidence-based search of literature with regard to current recommendation of European Conference in Infections in Leukemia and Infectious Diseases Society of America.

[Analysis of a group of HIV positive women who gave birth in the Czech Republic]. / Analýza souboru HIV pozitivních rodicek v Ceské republice.

OBJECTIVE: An analysis of HIV positive women who gave birth between 1st January 1985 to 31st December 2006 in the Czech Republic. SUBJECT: A retrospective descriptive analysis. SETTING: Teaching Hospital Bulovka, 1st Faculty of Medicine, Charles University, Prague. SUBJECT AND METHODS: The study included HIV positive women that gave birth between 1st January 1985 to 31st December 2006 at Bulovka hospital. The group of 62 HIV positive women (including 7 secundiparae) gave birth to 71 new-borns (twice twins). The deliveries were performed by C-section. We interrupted breast-feeding by all these women. RESULTS: All new-borns were born alive, no one had Apgar score less than 7 at five minutes. No congenital disorders were found. Three new-borns were transfered to Intensive care unit for new-born babies, two due to dysmaturity and one due to abstinence syndrome. 3 new-borns out of total 71 new-borns were HIV positive (4.2%). CONCLUSION: Routine prenatal screening for HIV and high-quality cooperation between obstetricians and infection control doctors are the basic condition of low rate of vertical trasmission HIV infection in the Czech Republic.

[Rhodococcus equi infection in subjects infected with human immunodeficiencv virus (HIV)]. / Infekce bakterií Rhodococcus equi u osob infikovaných virem lidské imunodeficience (HIV).

Disease caused by Rhodococcus equi is a rare complication in subjects infected with human immunodeficiency virus (HIV) and it is associated with severe cellular immunodeficiency. The agent is gram-positive rod of the group non-diphtheric corynebacteria. The genus Rhodococcus belongs to the family Nocardiaceae and order Actinomycetales. The principle of pathogenicity is the survival inside macrophages. Formation of necrotising granulomas is a characteristic feature. Malacoplakia can be a specific cytological finding. Symptoms of disease include wet cough, fever and pleuritic chest pain. Problems persist many weeks before admission to the hospital. Chest X-ray and CT scan of the lungs show cavitary pulmonary lesions. Agents grow not only from the sputum specimen and also from samples received by bronchoscopy. In 50% of cases it can be revealed in hemoculture. Outcome is poor; mortality rate is reported to be over 30%. Better survival can be found in subjects who managed efficient antiretroviral therapy. Recommended treatment of Rhodococcus equi pneumonia includes particularly vancomycin, amikacin, rifampicin, imipenem, ciprofloxacin and erythromycin. Rhodococcus equi infection in an HIV positive subject is reported in case study of 52-year old man with AIDS with cavitary necrotising pneumonia and induced pericarditis, where the agent grew in hemoculture. This Rhodococcus equi pneumonia is the first case and till now the only one Rhodococcus infection in HIV patients described in the Czech Republic.

[Recommendation for diagnostics and therapy of toxoplasmosis in persons with HIV infection]. / Doporucený postup diagnostiky a terapie toxoplazmózy u osob s HIV infekcí.

Reactivation of latent toxoplasmosis is a serious complication in patients with deep immunodeficiency, but the disease has a good prognosis if early diagnosed and effectively treated. Definitive etiologic proof of the reactivation may be difficult and thus an empiric method (therapeutic trial) is used for confirmation of the diagnosis in clinical practice. The preferred therapy is a combination of pyrimethamine + sulfadiazine.

Neuroborreliosis in an HIV-1 positive patient.

Simultaneous co-infections of Borrelia burgdorferi sensu lato and HIV-1 are rare events, with only six published cases. A case of acute neuroborreliosis with facial palsy, meningoradiculitis (Bannwarth's syndrome) in an HIV-1 positive individual is described. Diagnosis was confirmed by Western immunoblot analysis of serum and CSF and by proof of intrathecal production of antibodies against B. garinii. The patient was successfully treated with cefotaxime. In all published HIV+ cases, the course of borreliosis did not differ from that of the HIV negative population and the prognosis in properly treated patients was good.

[Murine typhus - rare cause of fever return from Egypt]. / Krysí skvrnivka - vzácná prícina horecky po návratu z Egypta.

Authors present a case report of 42-year male who spent 14 days in August of 2003 in Egyptian seaside summer town Hurghada and later he was admitted to the Infectious Disease Department Prague with the fever lasting 4 days. His symptoms were as follows: strong headache and dry cough. On the 7th and 8th day appeared transient maculopapular rash, laboratory test revealed a slightly elevated C reactive protein and elevation of amino transferases up to 5 times higher than range values, chest X-ray showed hypoventilation opacities on the lower lung fields, other findings were non-specifically changed or normal. The fever dropped after 15 days without any response to administered antibiotics-amoxicillin/clavulanate, clarithromycin a ofloxacin. Weil-Felix reaction with antigen Proteus OX19 (1 : 5120) was highly positive and positive antibodies IgG and IgM against Rickettsia typhi were positive. Later doxycycline was given, problems fully subsided, laboratory values were normalised up to six weeks from the beginning of the disease. Diagnosis was completed as murine typhus. The patient excluded arthropode bit. The authors considered the possibility of inhaled contaminated dust during his visit of the port. The above given case was firstly referred in the Czech Republic and still it is the only case.