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-11 T H EDITION OF- THE SCIENTIFIC DAYS OF THE NATIONAL INSTITUTE OF INFECTIOUS DISEASES “PROF.DR. MATEI BALŞ” - ABSTRACT VOLUME ID in ID or Identity Definition in Infectious Diseases BUCHAREST, 14-16 OCTOBER 2015 ISSN 2457-8525 ISSN–L 2457-8525 PRESIDENT OF THE CONFERENCE Prof. Dr. Adrian Streinu-Cercel SCIENTIFIC COMMITTEE Prof. Dr. Adrian Streinu-Cercel Prof. Dr. Vlad Ratziu Dr. Olivier Patey Prof. Dr. Victoria Aramă Dr. Mona Munteanu Assoc. Prof. Dr. Monica Luminos Assoc. Prof. Dr. Elisabeta Benea Dr. Mariana Mărdărescu Assoc. Prof. Dr. Alexandru Rafila Lect. Dr. Ana Maria Tudor Lect. Dr. Anca Streinu-Cercel Lect. Dr. Mihai Săndulescu Assist. Lect. Dr. Oana Săndulescu ORGANIZING COMMITTEE Dr. Sorin Petrea Dr. Oana Săndulescu Psih. Odette Chirilă Dr. Mihaela Rădulescu Daniela Dobrescu Dr. Cătălin Tilişcan Ec. Daniela Dumitraşcu Dr. Anca Streinu-Cercel Claudiu-Mihai Şchiopu Dr. Mihai Săndulescu Mariana Andreeana Ruxandra Marin Oral presentations Wednesday, 14 October 2015 The unpredictability of influenza viruses - 20142015 flu season in Romania Daniela Pițigoi1*, Carmen Maria Cherciu2, Mihaela Lazar2, Alina Elena Ivanciuc2, Maria Elena Mihai2, Cristina Tecu2, Rodica Popescu3, Odette Popovici3, Emilia Lupulescu2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 Cantacuzino National Institute for Research and Development for Microbiology and Immunology, Bucharest, Romania 3 National Centre for Transmissible Diseases Surveillance and Control (CNSCBT), Romania Background The evolution of flu is very unpredictable because the influenza viruses A and B types undergo antigenic drift of hemagglutinin that plays an important role in virus escape from host immune defense and imposes annual re-evaluation of vaccine composition. We aimed to investigate the characteristics of influenza viruses circulating in Romania during the season 2014-2015 and their match with the vaccine strains. Methods We tested for the presence of influenza viruses or for other respiratory viruses the clinical specimens collected at national level between week 40/2014 and week 20/2015, from patients with influenzalike illness or severe acute respiratory infections. A second rRT-PCR was performed on the HA gene for determination of H1N1 pdm09 or H3N2 subtype. When influenza B viruses were detected, a second rRT-PCR was performed for lineage determination. Antigenic analysis was performed by hemagglutination inhibition assay. Genetic analysis was performed on the full HA gene. Results The first influenza virus (H3N2 subtype) was detected in week 49/2014, the influenza epidemic started in the week 4/2015, reached the peak in week 9 and the last positive detection was registered during week 18/2015. A total of 698 (51.3%) samples were positive from 1360 specimens tested in the National Influenza Centre. A mixed virological aspect was seen all the season, with a slow dominance of type A (55.7%) over type B (44.3%) and a dominance of subtype H3N2 (63.2%) over H1N1 pdm09 (36.8%). A total of 111 strains were isolated, of which 42 (37.8%) from hospitalized patients. A(H1N1)pdm09 viruses were antigenically characterized as A/California/7/2009, vaccine strain. In contrast, A(H3N2) and B/Yamagata-lineage viruses were poorly recognized by homologous antisera against vaccine strains, A/Texas/50/2012 and B/Massachusetts/02/2012 respectively, but relatively well recognized by antisera raised against vaccine strains recommended for South Hemisphere (A/Switzerland/9715293/2013 and B/Phuket/3073/2013). Genetically, all A(H1N1)pdm09 viruses fell in group 6, subgroup B. The strains A(H3N2) belonged to clades 3C.2 and 3C.3, while the vaccine strain A/Texas/50/2012 belonged to genetic subgroup 3C.1. All viruses type B belonged to clade 3 B/Phuket/3073/2013, while the vaccine strain belongs to clade 2. Conclusions This season the influenza activity was higher than in the previous season, characterized by cocirculation of influenza A(H3N2), A(H1N1)pdm09 and B viruses and two drifted strains. The antigenic and genetic data as well as epidemiological surveillance are able to early capture the molecular changes of the circulating influenza viruses and to support vaccination programmes or antiviral treatment conducting in improvement of patient outcomes. Major trends in antibiotic use in Romania (2011-2014): quantity and quality indicators Gabriel Adrian Popescu1,2*, Levente Mathias3 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 3 IMS Health Romania Background The use of antimicrobials had collateral damages as post-antibiotic diseases (i.e. Clostridium difficile infections – CDI) and the development of antimicrobial resistance. Furthermore, data from various regions indicated that up to half of antibiotics prescribed are inappropriate. The information on total national antimicrobial consumption and the quality of antibiotic use can 3 be an important source for planning rational use interventions. Methods We performed an analysis of national antibiotics sales for a four-year interval, 2011-2014. Data were provided by IMSHealth Romania, a marketing research company; the consumption was measured in DDD/1000 inhabitants/day. In order to compare with other European countries and for the analysis of quality of antibiotic consumption in community we used data from ESAC Net, 2013 being the most recent year included in this European database. Results The total consumption of antibacterials was large, exceeding every year 30.5 DDD/1000inh/day, with a maximum of 31.9 DDD/1000inh/day for 2013 (among the top five European countries in analysed years). The most used group of antibiotic was penicillins with 52-56.6% of total consumption; cephalosporins, quinolones and macrolideslincosamides were the next groups in this order. A significant increase registered broad spectrum antibiotics used in community and in hospital: cephalosporins, with a rate of 0.42 DDD/1000inh/day annually increase (R2=0.99) and quinolones, with a rate of 0.112 DDD/1000inh/day annually increase (R2=0.79). For 2013, the quinolones consumption was the second in Europe and the cephalosporin consumption was the third. From hospital used antibiotics, carbapenems (R2=0.69) and colistin (R2=0.94) had increasing trends (explaining the emergence of XDR and PDR strains of Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter). The usage of antibiotics with greatest risk of Clostridium difficile infection (quinolones, cephalosporins, carbapenems and clindamycin) increased from 7.01 DDD/1000inh/day (2011) to 8.84 DDD/1000inh/day (2014), R2=0.98, representing 22.5% to 28.3% from total consumption of antibiotics. Conversely, less colitogenic antibiotics were less used as tetracyclines, 0.08 DDD/1000inh/day (R2=0.91) and aminoglycosides (R2=0.77). The ESAC Net indicator for broader/narrow spectrum antibiotic usage in community increased from 6.45 (2011) to 11.88 (2014), R2=0.97. Conclusions Our analysis indicates a large level of antibiotics’ consumption in Romania. At the same time, the quality of antibiotics usage is low, with an increase of broad spectrum and salvage antibiotic consumption, including high risk CDI inducers; the restricted usage of these antibiotics is a necessary part of strategies to curb antibiotic resistance (especially XDR and PDR bacteria) and to decrease the incidence of CDI. Overview on bacterial pharyngitis in the first 6 months of 2015 in the National Institute for Infectious Diseases “Prof. Dr. Matei Balș” (NIID), Bucharest Daniela Tălăpan1,2*, Olga Mihaela Dorobăț1, George Jugulete1,2, Monica Luminița Luminos1,2, Mădălina Merișescu1, Angelica Vișan1,2, Mariana Mărdărescu1, Emilia Căpraru1, Smaranda Botea1, Alexandru Rafila1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Despite the fact that viral pharyngitis causes most sore throats, streptococcal pharyngitis has similar symptoms and should be rapidly diagnosed and treated. Group A beta-haemolytic streptococci are the most common cause of bacterial pharyngitis and penicillin remains the drug of choice. Methods Between 1 January-30 June 2015, 6.621 pharyngeal swabs were received in the Microbiology Laboratory of NIID for culture and identification, which remains the gold standard to diagnose the streptococcal pharyngitis. These were processed according to the laboratory standard procedures and beta-haemolytic streptococcal colonies were sub-cultured and further identified as A, C, G or F Lancefield groups. Antibiotic susceptibility testing to erythromycin was performed for any isolate; clindamycin was added, if resistant. Results A total of 910 (13.74%) throat cultures were positive for beta-haemolytic streptococci as follows: 85.27% group A, 9.23% group C, 3.62% group G and 1.86% group F Lancefield. The most affected group age was 6-10 (40.87%), followed by children below 6 years old (38.24%); other affected age groups: 5.38% for 11-15 years old; 4.39% for 16-25 years old; 7.91% for 26-40 years old; 1.75% for 41-50 years old and 1.42% for more than 50 years old. Group A streptococci was the most common bacterial etiology except for two age groups: 16-25 and over 40 years old, where nongroup A streptococci (C and G) was dominant (21 vs. 19 and 18 vs. 11). Overall resistance to erythromycin was 17.47%, higher for group G streptococci (21.21%) and lower for group C streptococci (5.95%); group A streptococci were 18.94% resistant to erythromycin with 52.83% inducible resistance to clindamycin. 4 Conclusions Bacterial pharyngitis was diagnosed in 13.74% of the cases. The dominant cause of streptococcal pharyngitis remains group A streptococci (85.27%), with 18.94% resistant strains to erythromycin. Acknowledgement This paper is partially supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/159/1.5/S/137390. The resistance pattern of Gram-positive cocci in Infectious Diseases Hospital Galați Manuela Arbune1,2*, Miruna-Luminița Drăgănescu1,2, Camelia Pintilie2, Alina Iancu1,2 *[email protected] 1 Medicine and Pharmacy Faculty, "Dunărea de Jos" University Galați, Romania 2 Infectious Diseases Hospital Galați, Romania Background Gram-positive cocci (GPC) are usually commensal organisms. Although they are generally susceptible to a broad range of antibiotics, resistance has been developed to many antimicrobial drugs. Methods We analyzed the resistance of GPC isolated in Infectious Diseases Hospital Galați, during 2014. The biological samples of the hospitalized patients were collected according to the clinical data and we performed bacteriological cultures. Antibiotic susceptibility testing was determined using the disk diffusion method, according to the Clinical and Laboratory Standards Institute (CLSI 2014). Interpretation of the results was based on the inhibition of growth; strains are classified as resistant (R), intermediate (I) or susceptible (S). Results From 3553 hospitalized patients, there were 334 GPC isolated: 72.4% Staphylococcus spp., 24.8% Enterococcus spp. and 2.6% Streptococcus spp. The majority of staphylococcal strains were isolated from varicose ulcers (45.9%), pus (10.3%), stool (9.5%), catheter (7.4%), blood cultures (6.6%). The nasal swab is not routinely tested for Staphylococcus spp., but it was requested in 8 patients. Methicillin resistance (MRS) was found in 43.3% isolates and multi-resistance in 35.1%. The highest rate of MRS was found in the catheter culture and the lowest in nasal swab culture. The main antibiotic resistance rates were found for penicillin 91.4%, erythromycin 76.4%, clindamycin 56.8%, gentamycin 40.7%, ciprofloxacin 36.6%. The majority of Enterococcus spp. strains were from urine culture. The resistance rates were: 5% nitrofurantoin, 28% penicillin, 30% ampicillin, 34% gentamicin, 55% ciprofloxacin, 90% tetracycline. Streptococcus pneumoniae was isolated from blood culture (2) and sputum (4). Other Streptococcus spp. were found in varicose ulcer, urine and conjunctiva secretion. Streptococcus spp. were resistant to penicillin (5/9), erythromycin (3/5), clindamycin (3/6), clarithromycin (4/8), while all strains were sensitive to linezolid, levo/moxifloxacin. Frequently, the profile of patient with GPC is over the age of 60, from urban area, obese or diabetic. The bacteriological risks in males with varicose ulcer are for Staphylococcus spp., while Enterococcus spp. are mostly found in women with urinary symptoms. Based on the diagnostic criteria for colonization or infection, an estimated 63% of cases over-used antibiotics in the management of GPC. Conclusions Although GPC are often isolated in Infectious Diseases Hospital Galați, they are rarely found in invasive infections. Antibiotic resistance of GPC is worrisome, especially for Staphylococcus spp. The hospital's strategy for prudent antibiotic use is considering rigorous selection of antibiotic recommendation for GPC isolates. Thursday, 15 October 2015 Coping with chronic HIV – A retrospective study in the North-Eastern part of Romania Alexandra Largu1,2*, Liviu Prisacariu2, Cristina Nicolau2, Andrei Vâță1,2, Carmen Manciuc1,2 *[email protected] 1 “Gr.T.Popa” University of Medicine and Pharmacy, Iași, Romania 2 "Sf. Parascheva" Infectious Diseases Clinical Hospital, Iași, Romania 3 "Sf. Parascheva" Infectious Diseases Clinical Hospital, Iași, Romania Background Society is slowly shifting its perspective on HIV/AIDS, regarding it as a chronic disease. The five stages of accepting a chronic illness are a useful theory in evaluating an HIV-positive 5 patient’s condition and perhaps predicting adherence to antiretroviral therapy. Methods We studied retrospectively psychological evaluation records of patients hospitalized in the HIV/AIDS Regional Centre Iași, between January 2013-June 2015. We selected data for patients receiving at least 6 months of therapy. We identified, from records of clinical interviews, the stage of acceptance patients were in. We searched for a connection between those and patients’ adherence to therapy, as declared by them. Results During the 30 month period, we evaluated 142 files as follows: 61 in 2013, 53 in 2014 and 26 in 2015. Patients were 52.5% men and 46.5% women. Regarding HIV status, 31.03% of patients were in stages A1, A2, B1, B2 of HIV infection, at the time the files were filled in, while the majority (68.96%) was in the AIDS stage (acquired immune deficiency syndrome), with 42.24% of the total in the final stage of the disease (C3). From patients’ interviews at the moment of the psychological evaluation, 30% were oscillating between the stages of denial and anger, 32% were in negotiation, 18% in depression and only 20% had fully accepted their disease. We found that the patients with the most interruptions of therapy were those in the first three stages of acceptance. In some cases, the patients that seemed to be in the stage of depression were also those accusing “therapeutic fatigue” and giving up life. As expected, patients in the stage of acceptance were also the most adherent to therapy. Conclusions Evaluating the stage of acceptance of HIV/AIDS the patient is in has proven to be a useful tool in patient management from a psychological point of view, towards coping with the disease. It is also important in understanding the decisions patients make regarding their adherence to therapy. Further research may also involve statistical correlations between the stages of acceptance and number of interruptions, CD4, viral load or other markers of adherence. Acknowledgement This paper was supported financially by the project: Program de excelenta in cercetare doctorala si postdoctorala multidisciplinara in bolile cronice, contract nr. POSDRU/159/1.5/S/133377, beneficiar U.M.F. "Gr. T. Popa" Iasi, proiect cofinanţat din Fondul Social European prin Programul Operaţional Sectorial Dezvoltarea Resurselor Umane 20072013. Factors associated with HIV stigma in Romania Florin Lazar1*, Adrian Luca1, Iosif Marincu2 *[email protected] 1 University of Bucharest, Romania Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 2 Background In an era of medical advances which turned HIV into a chronic disease, stigma remains a challenge for people living with HIV (PLHIV) in Romania, discouraging them to be more socially active. The aim of the study is to identify factors associated with stigma, understanding the coping strategies PLHIV use to adapt to stigma. Methods A cross-sectional survey using a self-reported questionnaire was carried out between November 2014 and March 2015 among 252 adult PLHIV aware of their status for at least 6 months. A global score from HIV Stigma Scale (with 40 items, scores: 40-160) represented the dependent variable. Validated measures of quality of life (alpha= .934), coping (alpha= .843), resilience (alpha= .943) and depression (alpha= .946) were tested for association with HIV Stigma Scale (alpha=.943). Independent variables were subscales from the above mentioned scales. A linear multivariate regression was performed (adjusted r square of the final model was: .49) to identify factors associated with HIV stigma (mean 109.57, min. 57, max. 154). Results The most important predictors of stigma are: those with a negative association: factor “social resources” from Resilience Scale for Adults (ß CI95%: -.374 [-1.532 - -.515], p<.000), the domain “social relationships” from WHOQOL-HIV BREF (ß CI95%: -.306 [-2.823 - .761], p<.001), followed by those with a positive association, respectively three factors from the Brief COPE Scale: selfblame (ß CI95%: .198 [.795 - 3.574], p<.002), use of instrumental support (ß CI95%: .196 [.740 4.160], p<.005) and religion (ß CI95%: .181 [.451 3.357], p<.011). Conclusions Stigma negatively affects social resources for resilience of PLHIV, hampering the quality of life, but more specifically their social relationships. In order to adjust to stigma, the coping strategies developed are self-blaming for their condition in this way internalizing the attitudes of the others, the use of instrumental support available within their social network (as a social support mechanism) but also by turning towards religion. Professionals need to better tackle the negative consequences of HIV 6 stigma by enhancing personal development of the person which can create the premises for building social resources and relationships, but also supporting PLHIV to develop functional, adapted coping strategies and not only internalize the public blame. Acknowledgement This paper was co-financed from the European Social Fund, through the Sectorial Operational Programme Human Resources Development 20072013, project number POSDRU/159/1.5/S/138907 "Excellence in scientific interdisciplinary research, doctoral and postdoctoral, in the economic, social and medical fields -EXCELIS", coordinator The Bucharest University of Economic Studies. Neurological impairment in HIV-infected children through vertical transmission Rodica Ungurianu1*, Mariana Mardarescu1, Cristina Petre1, Ruxandra Draghicenoiu1, Alina Cibea1, Matei Carina1, Ioana-Alina Anca2, Alexandra Mardarescu1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 The Institute for Mother and Child Protection “Alfred Rusescu”, Bucharest, Romania Background The nervous system is a frequent target of HIV infection. The consequences of the nervous system involvement in HIV infection are serious. The true evidence of the central nervous system involvement is not known, although it is thought to appear in most of HIV infected children and its incidence in children is at least three times higher than in adults. The rates of neurological dysfunction in children with symptomatic HIV infection were estimated at a range of 30 to 50 percent for HIV encephalopathy. Methods Retrospective study over a period of 10 years (2006-2015). The study includes a total of 50 HIV infected children with perinatally-acquired HIV, from the Pediatric and Adolescents Department of Immunodepression in The National Institute for Infectious Diseases “Prof Dr Matei Balș”. The children were evaluated in terms of psychosomatic and neurological development, imagistic (MRI, CT brain, transfontanellar ultrasound), CD4 monitoring and HIV- RNA from blood and CSF. Results 62% of the 50 children have neuropsychiatric impairment of various degrees (HIV encephalopathy). 75% of children diagnosed with HIV encephalopathy manifest mental retardation, cognitive deficit and impaired language development which add: 15% cerebral palsy with important motor deficit, 15% peripheral neuropathy, 22% hypotonic syndrome. Conclusions Neurological disorders in children with HIV infection include peripheral neuropathies (nerve disorders that affect the limb or feet and hands), myelopathy (disorders of the spinal cords), CNS abnormalities, seizures and encephalopathy. Development delays and regressions are also important CNS–related problems in HIV infected children. HIV encephalopathy is especially common in HIV infected children who present in early infancy and have rapid downhill course. The risk of HIV encephalopathy is correlated directly with the severity of HIV related symptoms and depression of CD4 counts. ARV compliance in families and children is the most important factor in controlling neuropsychiatric manifestations and ensuring proper development. Cardiac abnormalities in children with perinatal exposure to HIV infection Mariana Mardarescu1*, Rodica Ungurianu1, Elena Tanase2, Cristina-Roxana Petre1, Ruxandra NeaguDraghicenoiu1, Alina Cibea1, Ioana-Alina Anca2, Mihai Mitran3, Carina Matei1, Georgiana Ionescu1, Alexandra-Henriette Mardarescu1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Institute for Mother and Child Care "Prof. Dr. Alfred Rusescu" 3 Clinical Hospital for Obstetrics and Gynecology “Prof. Dr. Panait Sarbu” Background A low incidence of HIV infection in children (under 2% in Romania) is countered by a growing incidence among adults, which is reflected on the infant population, the majority of HIV infected persons being at childbearing age. The issue that we raise is based on a growing number of children hospitalized with cardiac disease. Therefore, we supposed that cardiac effects in children with HIV infection or exposed to HIV are frequent. Methods Between January-June 2015, 43 children out of a cumulative total of 93 children perinatally exposed to HIV at national level, were kept under surveillance in the National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, in accordance 7 with the National Protocol enclosed in the National Registry of Pregnant Women-infected with HIV and of perinatally exposed children. They were assessed immunologically and virologically as well as for possible birth defects through ultrasound exploration at the National Institute for Mother and Child Care “Alfred Rusescu”. Six children (13.95%) exposed to HIV presented cardiac pathology. Results All 6 children present both structural abnormalities (heart defects - atrial septal defect, ventricular septal defect, persistent arterial duct, transposition of great arteries, ventricular hypertrophy or valvular abnormalities) and functional (particularly arrhythmias) with cardiac failure. In addition, one child exposed to the mother’s i.v. drugs (heroin and legal highs) associated other malformations, a genetic consultation establishing the diagnosis of gangliosidosis type I. In what concerns mothers’ clinical background: 4 out of 6 newly diagnosed mothers lacked ART treatment while 2 (from the Romanian cohort) discontinued treatment for more than five years. According to the latest statistical data presented by the Compartment for Monitoring and Evaluation of HIV/AIDS Data in Romania, 48% of HIV positive women had CD4<500/cmm and 50% of all new cases are detected at the threshold of CD4<350/cmm. In addition, children born to HIV infected mothers are exposed to HBV, HCV, tuberculosis and i.v. drugs, thus cumulating a suite of risk factors, resulting in multiorganic impairment regardless of the exposed/infected status. Conclusions Despite a low incidence of mother to child transmission (below 2%), currently we have a large number of HIV-positive women in childbearing age, with a risky behavior (drug abuse, promiscuity), some of them with low adherence to ART during pregnancy and reluctance to access specific health care services. Thus, the rate of cardiac abnormalities in children exposed to HIV infection is high with a possible underestimation of these cases. Clinical aspects in tuberculous meningitis compared with cryptococcal meningitis Raluca Elena Jipa1*, Eliza Manea1, Roxana Petre2, Serban Benea1,3, Nicoleta Irimescu1, Diana Tanase1, Andreea Florea3, Adriana Hristea1,3 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 National Institute of Aeronautical and Space Medicine “Gen. Dr. Aviator Victor Anastasiu”, Bucharest, Romania 3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background The aim of the study was to compare tuberculous meningitis (TBM) in HIV infected patients with TBM in HIV non-infected patients and cryptococcal meningitis (CM). Methods Retrospective study between January 2012 - June 2015. We included patients diagnosed with TBM, tested for HIV and HIV infected patients admitted with CM. Patients were defined as having TBM according to a consensus definition published by Marais et al. [1]; CM diagnosis was established upon positive India ink stain, culture and/or cryptococcal antigen assay. Neurological staging was made according to Medical Research Council definitions [2]. We analysed demographic and clinical data, cerebrospinal fluid (CSF) changes, cerebral imaging and outcome. Results We identified 38 patients with TBM (14 HIV infected, 24 HIV non-infected) and 18 patients with CM. The mean age in HIV infected patients with TBM was 31 (23-40) compared to 45 (35-59) in HIV non-infected patients (p=0.004). There were no statistically significant differences between TBM in HIV infected and non-infected patients regarding duration of symptoms before admission, CSF changes and clinical data, except neurological staging. Nineteen (79%) HIV non-infected patients were in neurological stages II and III compared to 9 (64%) HIV infected patients with TBM (p=0.3, OR[95%CI]=0.4[0.1-2.2]). Hydrocephalus was more frequent in HIV infected patients (29%) than in HIV non-infected patients (21%) (p=0.6, OR[95%CI]=1.6[0.3-7.4]). Two (14%) HIV infected patients died compared to one (4%) HIV non-infected patient with TBM (p=0.5, OR[95%CI]=3.8[0.3-46.6]). No statistically significant differences were observed between HIV infected patients with TBM and CM regarding demographic, clinical data and CSF changes, except duration of symptoms before admission, 6 (3-11) days in patients with CM vs. 16 (7-28) in HIV infected patients with TBM (p=0.001) and CSF/blood glucose ratio which was significantly lower (0.302[0.225-0.332]) in HIV infected patients with TBM compared to patients with CM (0.428[0.335-0.530]) (p=0.033). The mean CD4 cell count was 25 (8-33) in patients with CM compared to 100 (19-197) in HIV-infected patients with TBM (p=0.001). Hydrocephalus was more frequent in patients with CM (39%) than in patients with TBM (29%) (p=0.4, OR[95%CI]=2.6[0.513]). Eight (44%) patients with CM died compared 8 to two (14%) HIV-infected patients with TBM (p=0.1, OR[95%CI]=4.8[0.8-27.9]). Conclusions Clinical and laboratory data were similar in TBM regardless HIV status, but the outcome was poorer in HIV infected patients. CM appeared in a more advanced HIV disease and had a poorer outcome. References 1. Marais S, Thwaites G, Schoeman JF. Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis. 2010;10:803-12. 2. Medical Research Council (1948). Streptomycin treatment of tuberculous meningitis. Lancet 1:582596. Prevalence of osteo-renal impairment in the Romanian HIV cohort Anca Streinu-Cercel1,2*, Oana Săndulescu1,2, Gabriela Ceapraga2, Daniela Manolache2, Monica Andreea Stoica2, Liliana Lucia Preoțescu1,2, Adrian Streinu-Cercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background We have performed a study to evaluate the prevalence of kidney disease and the changes in bone mineral density in the Romanian cohort of HIV-infected patients [1,2,3]. Methods We performed dual-energy X-ray absorptiometry (DXA) evaluation of the femur and lumbar vertebrae, as well as laboratory tests including standard serum panels and urinalysis in 72 patients from the Romanian HIV cohort. Results The study included 72 patients, with a male:female ratio of 1.8:1. The median (IQR) age was 38 (18) years. Most of the patients had received one prior antiretroviral (ARV) regimen (23, 31.9%) or over three prior regimens (22, 30.6%), while only 3 subjects were at their first treatment regimen (4.2%). At the time of evaluation, 28 (38.9%) had undetectable HIV viral loads, 5 (6.9%) had viral loads below the lower limit of quantitation, and the rest of the patients had values ranging from 27 to 170,000,000 copies/mL. The median (IQR) CD4 cell count was 508 (380) cells/cmm, with a nadir CD4 count of 387 (290) cells/cmm in the whole group, in a range of 19-1190 cells/cmm. Twentyseven (37.5%) were current smokers, 2 (2.8%) were ex-smokers and 40 (55.6%) were nonsmokers. The median (IQR) creatinine values were 0.9 (0.3) mg/dL, while the mean and standard deviation (SD) for urea were 30±8.5 mg/dL. Proteinuria was absent in 58 of the subjects (80.6%). The mean±SD for 25-hydroxyvitamin D were 18.8±10.8 ng/mL, situated in the insufficient range. Only 6 patients (8.3%) had optimal serum vitamin D levels, above 30 ng/mL. The mean±SD T-score was -0.8±1.0 for L1-L4 vertebrae and 0.4±0.8 for the left femur. Four patients (5.6%) had vertebral osteoporosis, and 11 (15.3%) had vertebral osteopenia. None of the patients had femoral osteoporosis, but 13 (18.1%) of them had femoral osteoporosis. Conclusions We identified a relatively high prevalence of asymptomatic osteopenia in the Romanian HIV cohort, and a fairly low prevalence of kidney involvement. References 1. Streinu-Cercel A. Osteo-renal impairment in HIV infection. Germs 2014;4:29. 2. Streinu-Cercel A, Săndulescu O, Șchiopu CM, et al. Screening for osteo-renal involvement in the Romanian HIV cohort. BMC Infect Dis. 2014;14:P65. 3. Streinu-Cercel A. HIV and bone mineral density. Germs 2015;5:7. Acknowledgements 1) Partially supported by the Osteo Renal Program, AbbVie. 2) Partially supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract numbers POSDRU/159/1.5/S/137390. Risk factors for low bone mineral density in HIV infected males from Romanian cohort Anca-Ruxandra Negru1*, Daniela-Ioana Munteanu1, Raluca-Ioana Mihailescu1, Catalin Tiliscan1,2, Ana-Maria Tudor1,2, Remulus Catana1, Cristina Popescu1,2, Mihaela Radulescu1,2, Raluca Nastase1, Ioan-Alexandru Diaconu1, Alina Orfanu1, Irina Lapadat1, Irina Duport1, Violeta Molagic1, Anca Leustean1, Ligia Ionescu1, Victoria Arama1,2, Stefan-Sorin Arama2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 9 Background Although life expectancy of HIV infected patients has significantly increased in the last years due to the progresses made in the field of antiretroviral treatment (ART), these patients present an accelerated aging process, developing osteopenia and osteoporosis at younger ages compared to the general population. Loss of bone mineral density (BMD) is associated with a higher risk for fractures and important morbidity and medical costs. Chronic inflammation, vitamin D deficiency and ART are just a few causes responsible for bone metabolism disorders in HIV infected patients. Our objective was to investigate risk factors for low BMD in HIV infected male patients from Romanian cohort undergoing ART. Methods We present a cross-sectional study on 33 male HIV infected patients form Romanian cohort, undergoing ART. We analyzed patient data regarding lifestyle, family and personal history and we calculated the body mass index (BMI). Blood samples were collected and analyzed for markers of systemic inflammation: interleukin-6 (IL-6), C reactive protein (CRP), tumor necrosis factor alpha (TNF-alpha). BMD was assessed using whole body dual energy X-ray absorbtiometry (DEXA). For statistic analyses we used SPSS 21. Results Were enrolled 33 patients with a median age of 31 years (20.5, 39) of which 34.5% were smokers. Median BMI was 24.2 kg/sqm (22, 27.4). Median ART length was 44 months (22, 110). Thirty two percent of patients had abnormal BMD: according to T-score 25% had osteopenia and 7% had osteoporosis. Regarding inflammation markers, 59%, 4.5% and 37.5% of patients had abnormal values for TNF-alpha, IL-6 and hsCRP respectively. We found no significant correlations between the T-score and duration of ART or the total number of antiretroviral combinations received since the infection diagnosis. We found a directly proportional correlation between T-score and BMI (Spearman`s rho = 0.484, p-value = 0.004). There was no difference in T-score for patients undergoing ART regimens with or without protease inhibitors (p>0.005), or with or without non-nucleosidic revers-transcriptase inhibitors (p>0.005). Conclusions A significant number of HIV infected patients develop BMD disturbances at young ages, having a high risk for fractures which are associated with important morbidity. This is the reason why we consider screening of BMD using DEXA mandatory in HIV infected patients, especially in those with low BMI. Acknowledgement This paper is supported by the Sectoral Operational Programme Human Resources Development (SOPHRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/187/1.5/S/155420. The prevalence of cardiovascular risk factors in HIV-infected patients under antiretroviral treatment at the National Institute of Infectious Diseases „Prof. Dr. Matei Balș” Elisabeta Otilia Benea1,2*, Liana Gavriliu1,2, Alina Cozma1, Daniela Camburu1, Georgeta Ducu1, Manuela Podani1, Roxana Dumitriu1,2, Șerban Benea1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Patients with HIV infection have an increased risk of cardiovascular disease, caused by increased prevalence of traditional factors of cardiovascular risk, even with factors associated with HIV infection and the effects of antiretroviral therapy. Objectives: to identify the prevalence of major cardiovascular risk factors in our patients. Methods We made a prospective evaluation of our patients on antiretroviral treatment for at least 12 months. We analysed demographic data (age, gender), duration of HIV infection, duration of antiretroviral therapy, BMI, presence of traditional cardiovascular risk factors, current level of CD4 cells and HIV-RNA. Results Preliminary results were obtained in 208 patients. The average age of patients was 39.8 years (19-79 years), with a balanced distribution between the sexes (49% women vs. 51% men). The average duration of HIV is 13.2 years (1-27 years) and the median duration of antiretroviral therapy is 10.6 years 91-23 years). The prevalence of traditional cardiovascular risk factors were: active smokers45.2% (94 patients), physical inactivity-61.5% (128 patients), hypertension-34.6% (72 patients), diabetes-7.7% 96 patients), total cholesterol <200 mg/dL-42.8% (89 patients), HDL-cholesterol <40 mg/dL-60.1% (125 patients), LDL-cholesterol <150 mg/dL-38.5% (80 patients), triglycerides≥250 mg/dL-48.6% (101 patients). In 20.7% of the cases the current value of the CD4 was <350 cells/cmm and 19.2% of the patients had detectable HIV-RNA 10 of last assessment; both factors are associated with increased cardiovascular risk. In 37 patients (17.7%) Framingham score was between 10-20% and in 18 patients (8.7%) was ≥20%. In 106 cases we found the presence of a major cardiovascular risk factor in combination with antiretroviral therapy lasting over 10 years, suggesting that these patients had indication for investigations for subclinical coronary atherosclerosis. Conclusions The prevalence of traditional cardiovascular risk factors is increased to the 208 patients evaluated so far. Complex and intensive measures are required to reduce the risk of coronary heart disease. It also requires adequate cardiological evaluation for assessing the presence of subclinical atherosclerosis in these patients. Cardiovascular risk in HIV-infected patients on ARV treatment Irina Magdalena Dumitru1,2*, Roxana Carmen Cernat1,2, Aurelia Hangan1,2, Valentina Cornenco2, Claudia Fodor1, Eugen Dumitru2, Sorin Rugină1,2 *[email protected] 1 HIV/AIDS Regional Centre Constanța, Romania Faculty of Medicine, “Ovidius” University, Constanța, Romania 2 Background The introduction of HAART has substantially reduced mortality among HIV-infected population, but cardiovascular diseases have become one of the leading causes of morbidity and mortality. The study objectives are to identify of cardiovascular risk factors in HIV infected patients on antiretroviral treatment and to compare the cardiovascular risk in patients from cohort (aged 25-27) with cardiovascular risk in patients older than 30 years. Methods A retrospective study conducted in HIV / AIDS Regional Centre Constanta on a 207 HIV-infected patients, 104 aged 25-27 years (group 1) and 103 older than 30 years (group 2). Results Out of 207 patients infected with HIV, a rate of 51.21% are women and 48.97% are men. In relationship with comorbidities, hypertension, obesity and diabetes are more frequent in group 2 (12 /1 patients, 24 /2 patients, 9 /0 patients) but chronic hepatitis B and C and depression are more frequent in group 1 (21/13 patients, 30/6 patients). Dyslipidemia was more frequent in group 2 (total cholesterol> 200 mg in 70 patients in comparison with 25 patients in group 1 and hypertriglyceridemia in 61 patients in comparison with 40 patients in group 1). We noticed that out of 104 patients (group 1) 24% are smokers, 5% alcohol consumers, and 2% are drug users and out of 103 patients older than 30 years, 40.8% are smokers, 25.2% alcohol consumers, and 2.9% are drug users. In both groups the patients received treatment with protease inhibitors in similar percentages (68%). We calculated Framingham score in all patients; 78 patients (76%) in group 2 had the Framingham score > 1 and only one patient in group 1 (1%). 62.02% of cardiovascular risk patients undergoing treatment with protease inhibitors. Conclusions Of the 207 HIV-infected patients, 79 (38.16%) had cardiovascular risk, more common in patients older than 30 years. Cardiovascular risk was correlated with: age, hypertension, diabetes, obesity, dyslipidemia, smoking and alcohol consumption as in the general population. Patients older than 30 years may be associated cardiovascular risk in case of a long-term treatment with protease inhibitors (over 10 years). Pathological patterns at upper endoscopy screening in HIV infected patients Cristina Olariu1,2*, Magdalena Popa3, Adriana Nurciu1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Elias University Emergency Hospital, Bucharest, Romania Background HIV infected patients experience various symptoms suggestive for upper digestive tract pathology. Moreover, many of these patients have also hepatitic viral infections that require careful endoscopic examination for establishing the degree of portal hypertension. There is an increasing interest regarding the spectrum of upper digestive lesions in the context of HIV, still there are few studies published by now. We tried to establish a pattern of lesions in HIV infected patients that enables us to further investigate the upper endoscopy role in the management of these patients. Methods We analyzed the endoscopic appearance in a total of 86 HIV-infected patients which underwent this 11 investigation between November 2012 and July 2015, disregarding the reason for the endoscopic screening. The age in our cohort varied between 19 and 68 with an average of 34.45 years. Results Only 5 of the 86 patients (5.81%) showed no pathological sign at the EDS (endoscopy). In the rest of the 81 patients in our screening, at least one pathological macroscopic finding was seen. The most frequent lesion encountered in HIV infected patients at the EDS screening is esophagitis (30.23%). The second type of lesion seen in these patients is represented by gastritis. According to our analyses – 27.9% of the subjects had minimal erythematous gastritis, while 17.44% had erosive type gastritis. Regarding the duodenum, only 15.11% of our patients presented anomalies of this segment at the EDS. The most common duodenal pathology is represented by erosive duodenitis (9.3%). Conclusions Upper digestive tract lesions are very common at the EDS screening of the HIV infected patients. The most affected segment seems to be the esophagus, where esophagitis-type lesions are frequently encountered. The second most frequent lesion is represented by erosive gastritis. Also minimal mucosal modifications (erythematous gastritis) are commonly encountered but their importance in the clinical picture remains obscure. The duodenum is rarely involved as a demonstrable source for the upper tract symptoms in HIV infected persons. Metabolic complications in elderly HIV positive patients from South-East region Miruna Draganescu1*, Manuela Arbune1, Camelia Pintilie2, Alina Iancu2, Caterina Dumitru2, Nicoleta Cireașă2 *[email protected] ”Dunărea de Jos” University, Galați, Romania Infectious Diseases Clinical Hospital ”Sf. Cuv. Parascheva” Galați, Romania 1 2 Background The HIV epidemic evolves for more than thirty years and the current trend is the growing number of people aged 50 years and older. UNAIDS reports that 10% of HIV positive adults are aged over 50 years, in low and middle-income countries. Romania has a lower percentage of old patients (6%) due to high proportion of young patients infected between 1988-1992. Objectives: to describe the prevalence and the profile of lipid disorders in HIV positive adults over 50 years old from Galați Clinical Infectious Diseases Hospital. Methods We conducted a cross-sectional study on 173 HIV positive patients nosocomially and sexually infected. Patients were stratified by age in 5 groups (23-24, 25-29, 30-39, 40-49 and over 50 years old). Information about total and HDL-cholesterol, triglycerides, glucose blood levels, CD4-cells, and HIV viral load were obtained from patient files. Statistical analysis: MedCalc. Results 173 patients aged from 20 to 81 years old (mean: 28 years), 45% men, 55% women (ratio 1:1.18) were evaluated. Patients over 50 years old: 8.7%. Mean CD4 684 cells/cmm vs. 518 cells/cmm in patients over 50; mean viral load (VL) 151146 copies/mL vs 46723 copies/mL in patients over 50. 63% of patients had lipid abnormalities, with different prevalence: women 74%, men 56% (p=0.0476). Low HDL-cholesterol was the most frequent lipid disorder (60%), mean value 43 mg% with different prevalence between age groups: 70% in 25-29 years old vs. 46% in 50 years old. Inversely, triglycerides rose with age from 4% in young patients to 50% in patients over 50. High cholesterol had a 35% prevalence, rising with age from 29% to 93% (p=0.0458). None of HIV patients with high-cholesterol was currently on statin treatment. Mean glucose level was 78 mg%. No correlation between lipid disorder and CD4 or VL levels was found. Conclusions Lipid abnormalities are frequent in HIV patients with higher prevalence in older patients. The lipid disorders profile is different with age: low HDLcholesterol is more frequent in young patients due to old chronic HIV infection while high total cholesterol and triglycerides are more frequent in patients over 50 years old. No patient was currently treated with statin ± fibrates for lipid abnormalities. Increasing age brings new challenges for HIV population and monitoring the lipid profile could prevent further cardiovascular events. The current study could be a starting point for monitoring the evolution of lipid disorders over the time in people ageing with HIV infection. The efficiency of HAART regimens during 3 years treatment in HIV/AIDS infected patients in the Republic of Moldova Ina Bistritchi1*, Tiberiu Holban1, Constantin Spinu2, Pavel Micsanschi1 *[email protected] 12 1 State Medical and Pharmaceutical University “Nicolae Testemiţanu”, Chișinău, Republic of Moldova 2 National Public Health Center, Republic of Moldova HAART regimen was obtained therapeutic success both immunologically and virologically for 118 (79.2%) patients. Out of 118 patients, AIDS was diagnosed for 86 (72.8%) patients. Background HIV/AIDS infection is one of the priority issues of public health in Republic of Moldova. Despite the efficiency of highly active antiretroviral therapy (HAART), HIV/AIDS infection remains an evolving infection for life. Appropriate therapeutic approach allows prolonging and improving the quality of life of HIV infected patients. Methods We assessed 149 naive patients with HIV/AIDS who initiated HAART in 2011-2012 with Zidovudine-Lamivudine-Efavirenz (I group), Zidovudine-Lamivudine-Nevirapine (II group), Tenofovir-Emtricitabine-Efavirenz (III group). The average age of patients included in this study was 36.2±0.8 years and 2/3 of them were young people 30-39 years. All patients started HAART late, when they were diagnosed with AIDS related diseases and/or CD4<350 cells/cmm. The way of transmission of HIV infection in 149 patients of the study group was 87.3% (130) heterosexual and 12.7% (19) by injecting drug use. Results During 3 years on first-line HAART regimen, of the total number patients, 9 patients died, 11 patients abandoned treatment and 11 patients had treatment failure and were transferred to secondline HAART regimen. Patients who remained in first-line regimen had success both immunologically and virologically. Immunological success was determined by the average of CD4=427.7±38.9 cells/cmm (I group – 430.2±31.1 cells/cmm, II group – 427.2±48.9 cells/cmm, III group – 425.8±36.8 cells/cmm). Virological success was due to undetectable viral load for 95 patients (80.5%): I group – 35 (70%) patients, II group – 41 (65.1%) patients, III group - 19 (70.4%) patients. The spectrum of opportunistic infections in the studied group was distributed as follows: oropharyngeal candidiasis – 69 (58.5%) patients, tuberculosis – 27 (22.9%) patients, wasting syndrome – 14 (11.9%), Herpes Zoster, Kaposi's sarcoma, HIV encephalopathy and esophageal candidiasis – 2 (1.7%) patients, cerebral toxoplasmosis – 1 (0.8%) patient. Concomitant 22 (18.6%) patients were detected with viral hepatitis B, C. Conclusions This study showed that more than half (63.09%) of HIV/AIDS – infected patients were detected late, with the number of T-lymphocytes CD4<350 cells/µl, but during 3 years of continued first-line Measurement of adherence to antiretroviral therapy for HIV / AIDS infection Mirandolina Prisca1*, Dana Negru2, Mariana Nagy3 *[email protected] 1 Vasile Goldis West University, Arad, Romania Arad Public Health Department, Romania 3 Aurel Vlaicu University, Arad, Romania 2 Background Lack of adherence to antiretroviral treatment regimens has serious consequences for HIV/AIDS patients, like failure to prevent viral replication and increased risk of developing viral resistance. There are severeal methods available for measuring treatment adherence; these have different strengths and weaknesses; there is no optimal measure of adherence. Methods We have studied adherence to antiretroviral therapy for 57 HIV/AIDS patients, using a single measure of treatment adherence, which was their selfreports by completing a nine questions questionnaire, referring to their confidence in treatment efficiency, life quality and their daily compliance in taking medication. Data were processed using MedCalc, in order to establish if there is any correlation in poor adherence and virus load reduction, CD4 cells number, gender, educational background, clinical stage of infection and the time span between starting regimens and adherence measurements. Results Arithmetic mean for age in our patients was 32, extreme 8 and 74 years old. Gender distribution was 71.4% men, 28.6% women. Clinical stage of infection was: 39.3% C3, 30.4% B3, 10.7% C1, 10.7% B1, 5.4% C2 and 3.6% B2 stage. There was significant negative correlation, p=0.0482, r=0.3363, between viral loads and CD4 values, which means that 11% of the lowest CD4 values are due to an increased viral load. Of the patients 22 described an adherence over 95%, which represents 38.6%. Arithmetic mean for adherence was 86.02%, extreme values of 38% - 96%, p<0.0001. The best adherence was in women, 87.88% compared to men, 85.22%. There was a significant difference in adherence, p=0.0019, for clinical stage, where patients in stage C3 had the best 13 median value of 88.54% in adherence compared to B2 where value was 82%. There was a significant difference for time span, p=0.0439, meaning that the patients which had a poor adherence to treatment could only difficultly exceed 8.125 years of treatment while patients with higher adherence could do that more than 8.778 years. Conclusions Poor adherence in 62.48% of HIV/AIDS patients is a problem for medical staff, families and mainly for the patients. New evidence suggests that adherence interventions should be made in multidisciplinary effort involving health care providers, social support networks, family, and friends. Tuberculosis and HIV infection Simona Erscoiu2*, Ionut Popa1, Olivia Burcos1, Maria Nica2, Emanoil Ceausu2, Gratiela Tardei1, Olimpia Nicolaescu1 *[email protected] 1 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Mycobacterium tuberculosis (TB) and human immune deficiency virus (HIV) infections are major public health problems. In Romania, the number of HIV-TB co-infected patients has increased in recent years, mainly due to IV drug users (IVDU). The overall aims of this study were to analyze awareness of HIV and TB infection. They were also to examine the care of HIV and TB patients and to investigate the relationship between these two infections. Methods We performed an observational descriptive, retrospective, longitudinal study on a group of 86 patients. For this study we enrolled 86 HIVinfected patients between January 2013 to December 2014 diagnosed with primary or secondary tuberculosis, in Clinical Infectious Diseases Section I of the Hospital for Infectious and Tropical Diseases “Dr. Victor Babeș” in Bucharest. Clinical, microbiological, bacteriological and immunological and virological diagnosis for HIV and TB were performed. BK PCR sputum, pleural fluid, lymph node biopsies, CSF, as bacterial cultures were carried. BK PCR sputum, pleural fluid, lymph node biopsies, CSF, as bacterial cultures were performed. After a positive M. tuberculosis cultures, sensitivity tuberculosis was made as Xpert MTB/RIF in patients with MDR TB. Results The male/female ratio was 2.5/1, the median age was 21 years, most patients coming from Bucharest and with a very low educational level. In most cases, mode of transmission was parenteral (51% IVDU), different from previous years when the heterosexual route dominated. All IVDU had HCV co infection. Only 8% of patients had HBV coinfection. TB infection was diagnosed after HIV in 57% of subjects, especially in IVDU. Pulmonary TB dominated (60%), the majority of cases being diagnosed in 2013. Clinical, radiologic, PCR examination and subsequent cultures confirmed TB. Immunologic status was very low, below 50 lymphocytes/mmc especially in IVDU, and higher in most subjects nonIVDU. All patients received first or second line TB treatment. Adherence was not predicted so that the evolution of 29% patients (majority IVDU) was MDR and 8.3% were XDR. The abandonment of TB therapy was noted in 33% of patients, the majority IVDU. ARV therapy was applied in 70% of subjects, 45% registering an increase in CD4 lymphocytes. There were 20 deaths, 85% being IVDU. Conclusions It requires the use of classical and modern methods of the swift diagnosis of TB, HIV testing is absolutely mandatory if TB is diagnosed. Social and psycho assistance is essential in order to increase compliance to both treatments, TB and ARV. Friday, 16 October 2015 Ebola preparedness – an European perspective: training and networks Bogdan Cîrciumaru1*, Steluţa Popovici2, Roxana Matei2, Cătălin Apostolescu2 *[email protected] 1 Central Universitary Emergency Military Hospital Dr Carol Davila, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background The Ebola 2014-2015 West Africa outbreak, produced initially a generalized panic; the international response was delayed but successful, as it contained the disease. Therefore, countries should be prepared for the Highly Infectious Diseases, as the immigration from Africa to Europe boosted the last years. 14 Methods The aim is to prepare the European countries for the impact of Highly Infectious Diseases, by training the medical staff and the general population, providing countries with modern facilities, were the best treatment is offered with maximal safety, by “train the trainer” programs (as ETIDE-European Training in Infectious Diseases Emergencies), recommending the high level biosafety procedures for the entire diagnostic process or sustaining the development of the isolation facilities: barrier, or strict-highly infectious isolation-e.g. the EuroNHID (European Network for Highly Infectious Diseases). Results This includes our experience into the training for highly contagious diseases. The trainers were prepared into the “Lazzaro Spallanzani” Italian National Institute for Infectious Diseases, by a multinational expert team (ETIDE); their task was to organize courses and practical lessons (e.g. the proper use of the Personal Protective EquipmentPPE) in their own countries. The Euro-NHID network organized the high degree isolation facilities in at least 16 European Countries, aiming to achieve an acceptable level of biosecurity in reference facilities all over Europe. Conclusions The West African Ebola outbreak stressed the importance of a well trained staff, high degree biosecurity levels for diagnosis, and appropriate barrier facilities for highly infectious diseases. This could only be achieved by the developing a National Network for highly infectious diseases connected with European and other International ones. Acknowledgements To our colleagues from ETIDE, Euro-NHID, Matei Balş Institute of Infectious Diseases, “Carol Davila” Central Military Hospital from Bucharest, “Lazzaro Spallanzani” National Institute of Infectious Diseases, Rome, Italy. Parvovirus B19: a neglected cause of lifethreatening illnesses in immunosuppressed hosts Ruxandra Moroti1,2*, Simona Stancu1,5, Adina Ilie2, Raluca-Ioana Mihailescu2, Viola Popov3, Camelia Kouris2, Valeriu Gheorghita2,4, Cristian-Mihail Niculae1, Raluca Maria Hrisca2,4, Serban Benea1,2, Dragos Florea1,2, Letitia Toma2,6, Ioan-Alexandru Diaconu1,2, Dan Coriu1,6, Adriana Hristea1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania "Colentina" Clinical Hospital, Bucharest, Romania 4 "Carol Davila" Central Emergency University Military Hospital, Bucharest, Romania 5 "Carol Davila" University Hospital, Bucharest, Romania 6 Fundeni Clinical Institute, Bucharest, Romania 3 Background Parvovirus B19 causes mild, usually self-limited illnesses in immunocompetent host, as erythema infectiosum in children and acute/chronic polyarthritis in adults. By the age of 15, approximately 50% of European and American populations have IgG antibodies. In immunocompromised hosts can produce lifethreatening conditions as transient aplastic crisis (TAC), pure red cell aplasia, virus-associated hemophagocytic syndrome; rarely encephalitis, myocarditis, hepatitis and vasculitis. Methods We performed a retrospective analysis of cases with parvoviral infections in adults (>16 years old) admitted or consulted in a tertiary infectious diseases hospital between January 2010 and July 2015. The diagnosis was based on serology (five patients), viremia (qualitative/quantitative viral DNA) in two patients and bone marrow biopsy (BMB) in six patients. Results There were seven patients, five female and two male, median age of 48 years (16-69) with immunosuppressive conditions represented by HIV infection (two patients), cancer or hematological disease (two patients), autoimmune disease (two patients) and chronic immunosuppressive treatment for renal transplant (one patient). Six of them were diagnosed in 2015. Except one case, all were acute infections. Hematological findings included marked anemia (Hgb~2-3g/dL) and moderate to severe thrombocytopenia: TAC (five cases), pure red cell aplasia (one case) and chronic persistent bicytopenia (one case). One patient developed hemophagocytic syndrome. Clinical manifestations included: encephalitis (3 cases), polyarthritis or arthralgias, ecchymotic severe rash. Diagnosis was suggested by BMB and confirmed by serologies (IgM in acute infections) and/or by blood viral DNA. All patients needed repeated blood transfusions and three of them received IVIG. In one renal transplant recipient, the first clinical manifestations were subacute encephalitis, arthralgias, multiple inexplicable large ecchymosis, followed by moderate anemia and severe thrombocytopenia and in the next several weeks the development of hemophagocytic syndrome. The parvovirus DNA was 86 millions of copies/mL in this case and needed temporary cessation of immunosuppressive agents along with IVIG and 15 repeated blood transfusions. All patients with acute disease had slow favorable evolution with good recovery. The patient with chronic severe bicytopenia received monthly blood transfusions and the hematological improvements were temporary and substitution-dependent. Conclusions Parvoviral infections must be considered in immunosuppressed patients with severe hematological and neurological acute impairments. Despite the lack of a specific antiviral agent, the diagnosis is capital since the management includes controlling of immunosuppressive therapy (up to treatment cessation) and immunoglobulins. By ruling out other potential etiologies, some empirical and possible aggressive treatments can be also avoided. 0.00002). Patients who had received antibiotherapy prior to confirmed infection with Clostridium difficile originated primarily from the departments of Gastroenterology - 17 cases (9%), Surgery - 12 cases (6.4%), Internal Medicine - 10 cases (5.3%), Neurology - 9 patients (4.7%) and Diabetology - 7 patients (3.7%). Of the total number of patients treated 28 (14.9%) presented one relapse, while 6 (3.2%) had at least two relapses. Conclusions Almost 50% of patients diagnosed with diarrhea with Clostridium difficile, originating from the community were more than 65 years old, compared to 20% under 65 years of age. Antibiotherapy was a risk factor in patients over 65 years old, being used in 40,9% of cases, and only in 35.2% of subjects in the age group under 65 years. Clostridium difficile infection in elderly patients The use of a chromatographic immunoassay in the diagnosis of Clostridium difficile infection: is it worth it? Egidia Miftode1*, Codrina Bejan1, Cristina Petrovici1, Laura Ghibu1, Radu Miftode1, Larisa Irimita1, Catalina Bucur1 *[email protected] 1 “Gr.T.Popa” University of Medicine and Pharmacy, Iași, Romania Dragos Florea1,2*, Daniela Talapan1,2, Mihaela Fratila1, Emil Neaga1, Gabriela Bodea1, Mariana Constantin1, Alexandru Rafila1,2, Dan Otelea1, Gabriel Adrian Popescu1,2 *[email protected] 1 Background In recent years the prevalence of infection with Clostridium difficile increased especially in advanced ages, traditionally, surgical interventions and antibiotherapy being the most common factors involved in the development of colitis with Clostridium difficile. Methods Our study aimed to compare the epidemiological, clinical and evolutive aspects of patients with Clostridium difficile colitis hospitalized in the Infectious Diseases Clinic of Iași in 2014 according to age under 65 years old and over. Of the 188 patients studied, 83 (44.2%) were over 65 years of age. The patient data were processed by using EPIINFO version 7. Results Infection with Clostridium difficile occurred after therapy with antibiotics in 71 patients (37.7%), 34 being over 65 years of age (40.9%) and 37 under 65 years (p = 0.42), in surgical context for 19 cases (10.1%) of which 8 (9.6%) were over 65 and 11 under 65 years (p = 0.84), 16 patients required oncological therapy (8.5%), 10 being over 65 years of age and 6 under 65 years old (12%) (p = 0.12). Social origin could be established in 62 cases (32.9%), with 41 cases over 65 years of age (49.4%) and 42 cases under 65 (50.6%) (p = National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background A rapid and accurate diagnosis of Clostridium difficile infection (CDI) is critical for patient management and infection control. The objective of the present study was to evaluate the clinical usefulness of a chromatographic immunoassay that detects C. difficile glutamate dehydrogenase (GDH), toxins A and B as in the diagnosis of CDI. Methods A prospective study was performed in one hundred non-duplicate patients admitted in June and July 2015 in our Institute, a tertiary level infectious diseases hospital. Fecal samples were tested for the presence of GDH, toxins A and B (C. difficile GDH + Toxin A+B CerTest, Biotec), toxin B gene (tcdB) and binary toxin (cdtA, cdtB) genes (CDIF Xpert, Cepheid). A CDI was diagnosed when a sample was positive for tcdB and/or toxin A or B. Results Sixty-five samples were positive, either for tcdB only (34 samples), for GDH and toxin A/B only (3 samples) or for all the markers (28 samples). The rate of detection of toxin A/B was not statistically significant associated with the detection of binary 16 toxin. In the studied group the sensitivity, specificity, positive and negative predictive values for the Xpert assay alone were 95.3% (CI95% 86.2-98.8), 100% (CI95% 87.6-100), 100% (CI95% 92.7-100) and 92.1% (CI95% 77.5-97.9). A two-step algorithm with the chromatographic immunoassay used to exclude from PCR testing both GDH and toxin B positive samples and GDH negative samples would have a sensitivity of 72.3% (CI95% 59.6-82.3). In a two-step algorithm with a more stringent approach, which excludes from PCR testing only GDH and toxin A/B positive samples, the sensitivity would be 100% (CI95% 93.0-100) with a reduction of 11% for reagent costs. The increased sensitivity of this approach compared to Xpert testing alone is the result of detection of GDH and toxin A positive but toxin B and tcdB negative samples in the analysed group. Conclusions In settings with a high prevalence of CDI, like the studied group, the use of a chromatographic immunoassay (GDH + toxin A+B CerTest, Biotec) as a first step before PCR may provide a slight benefit compared to Xpert testing alone in the diagnosis of CDI. Acknowledgements Dragos Florea was supported by a POSDRU/159/1.5/S/135760 CERO grant. Clostridium difficile infection: predicting poor outcome January 2012 - April 2013. We analysed clinical data, blood test changes, treatment and outcome. Results We identified 395 patients admitted with CDAD in our hospital between January 2012 and April 2013. The mortality rate was 8.9% (35 deaths). Almost all deaths (97%) were recorded in patients with age above 60 years. The average age was 76.8 years in these patients compared to 63.1 years for the rest of the group. 77.1% of the patients that died received combination of drugs that included metronidazole, vancomycin and tigecycline and 68,6% received other concomitant systemic antibiotics (carbapenem, cephalosporins, quinolones). Age above 60 years, severe comorbidities, using at least 3 antibiotics before the onset of symptomatology were associated with poor outcome and death. The clinical and paraclinical parameters associated with increased risk of death were: fever at admission in hospital (37.5°C- 38.5°C), leukocytosis (above 16,000 cells/cmm), low serum albumins (below 2.5 g/L), high creatinine levels, positive procalcitonin. Regarding treatment options, concomitant systemic antibiotics usage was associated with poor outcome. High values of ATLAS score (above 6) were recorded for patients that died. Conclusions The ATLAS score with its components can be a useful tool for predicting poor outcome for patients with CDAD. Positive procalcitonin can be a negative factor for the patients, probably reflecting the intra-abdominal source for sepsis. Serban Benea1,2*, Irina Crasmaru2, Dragos Florea1, Eliza Manea1, Raluca Jipa1, Doina Antonica1, Ruxandra Moroti1,2, Diana Tanase1, Gabriel Gaciu1, Gabriel Popescu1,2 *[email protected] The evaluation of the prognostic value of procalcitonin, mean platelet volume and neutrophil/lymphocytes ratio in sepsis 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Treatment of Clostridium difficile infection (CDI) is usually based on the severity of the disease. Guidelines recommend using metronidazole for mild to moderate CDI, vancomycin being the drug of choice for severe and complicated disease. The aim of the study was assess the severity of Clostridium difficile associated diarrhea (CDAD) and identify the factors that can predict and are associated with a high risk of death. Methods We included patients admitted to the National Institute for Infectious Diseases “Prof Dr Matei Balș” with the diagnosis of CDAD between Alina Orfanu1,2*, Cristina Popescu1,2, Anca Leustean1, Catalin Tiliscan1,2, Mihaela Radulescu1,2, Anca Negru1,2, Ioan Diaconu1,2, Ligia Ionescu1, Alina Vornicu1, Angelica Tenita1, Victoria Arama1,2, Stefan Sorin Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Sepsis represents a clinical pathology with high incidence worldwide and is considered the main cause of death in the ICUs. The rapid diagnosis and prognosis of septic patients are extremely important in order to establish an efficient 17 antibiotic therapy. For this purpose, several biomarkers of inflammation were evaluated in the last years, such as procalcitonin (PCT), mean platelet volume (MPV) and neutrophil/lymphocytes ratio (NLR). Objectives: the correlation of these biomarkers with the patients’ outcome appreciated through APACHE and APS (Admission Point Score) scores. Methods This is a retrospective analysis of the septic patients admitted in the 3rd Department of “Matei Bals” Institute between January 2014 – July 2015 and the correlation of the inflammatory biomarkers with elements suggestive for severity - number of systemic inflammatory response syndrome (SIRS) criteria, primary infectious focus, septic metastases, organ failures and the two severity scores. Inclusion criteria: at least 2 SIRS criteria and the infection evidence (septic focus or positive blood cultures). For statistical analysis we used SPSS 21. Results 75 patients with a mean age 60.64 and a sex ratio M:F=1.02:1 were included. The primary septic focus was identified in 88% of cases: urinary (32%), respiratory (24%), digestive (18.7%). The etiology was found in 54.7% of patients: Gram negative rods (65%) and Gram positive cocci (35%). The most frequent germs incriminated were E. coli (including ESBL) – 20% and Staphylococcus (MSSA, MRSA, epidermidis) – 9.2% of cases. 14.6% of patients presented septic metastases and in 44% of cases was identified at least one organ failure: hematological (24%), renal (13.3%), hepatic (9.3%) and respiratory (8%). 28% of patients had 3 or 4 SIRS criteria. The mean value of PCT at admission was 22.23 ng/ml and it was statistically correlated with the negative prognosis calculated through APS score (p=0.02). MPV mean value was 8.57 fl and higher values were statistically correlated with both APACHE (p=0.02) and APS score (p=003). NLR mean value (20.25) wasn’t correlated with any of the gravity scores. Conclusions The prognostic role of PCT and VPM in sepsis was demonstrated through the statistical correlation with APACHE and APS scores of gravity. A high value of NLR is a sign of bacterial sepsis, but it wasn’t statistically associated with the severity. Acknowledgement: This paper is supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/187/1.5/S/155420. The estimated seroprevalence of hepatitis E virus in Romania based on interim results of the HEP-E study Valeriu Gheorghiță1,2*, Anca Streinu-Cercel1,3, Oana Săndulescu1,3, Alina Elena Barbu1, Mădălina Popa1, Simona Elena Albu4, Florin Alexandru Căruntu1,3, Adrian Streinu-Cercel1,3 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Central Universitary Emergency Military Hospital Dr Carol Davila, Bucharest, Romania 3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 4 University Emergency Hospital of Bucharest, Romania Background The natural history of the hepatitis E virus (HEV) infection has dramatically changed since the description of the chronic hepatitis cases in immunosuppressed patients infected with genotype 3 of the HEV. Besides genotypes 1 and 2, two more genotypes have been described, 3 and 4, restricted to developed geographical areas in the world, including Europe. The seroprevalence of HEV infection in European countries is estimated to be as low as 5% and as high as 52% in South-Western France. However, up to this moment no HEV seroprevalence data are available for Romania. Methods The main objective of the Hepatitis E Seroprevalence (HEP-E) study is to define the prevalence of serum HEV-IgG antibodies (HEVIgG-Ab) in the Romanian population. It is a crosssectional ongoing study, since January 2015, taking place in the National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest. The sample size desired for the study is 1000 people. The enrolment criteria are based on consecutive selection of adult patients (over 18 years old) attending our center for any medical reason. The serum HEV-IgG-Ab determination was performed by ELISA methods. Each blood test sample was accompanied by an epidemiological questionnaire. Results We enrolled 164 patients with a median age of 39.5 years (IQR, 28-59). The male/female ratio was 0.6. The geographical distribution of the selected patients covered 25 counties, 72.5% (n=119) being from urban areas with the highest representation for Bucharest, respectively 39.6% (n=65). The serum HEV-IgG-Ab prevalence in our population was 19.5% (n=32). The median value of the ELISA IgG test results was 4.05 UI/mL (IQR, 1.47-7.35) compared to cut-off value of 0.360 UI/mL. The 18 epidemiological characteristics of patients with positive serum HEV-IgG-Ab were: urban area of origin (71.8%), consumption of undercooked meat or offal (59.3%), non-chlorinated water consumption (31.2%), animal caretakers in the household (28.1%) and history of travel through Europe, especially France and Germany (28.1%). However, we did not find statistically significant differences between HEV-IgG Ab positive and negative patients regarding epidemiological risk factors for HEV infection. Conclusions Our data suggest that Romania is an endemic area for HEV infection, the local seroprevalence ranking as fourth in Europe after South-Western France (52%), Czech Republic (27.8%) and Republic of Moldova (24.7%) according to the existing data published by WHO in 2010. Acknowledgement This study is financially and logistically supported by the National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania. Preliminary study of IgG anti-hepatitis E virus antibodies presence in patients of an infectious diseases hospital from North-Eastern Romania Andrei Vâţă1*, Daniela Porea2, Dragoş Aniţă2, Daniela Leca1, Dănuţ Teodor1, Cătălina Mihaela Luca1, Carmen Manciuc1, Gheorghe Săvuţa2, Carmen Dorobăţ1, Adriana Aniţă2 *[email protected] 1 University of Medicine and Pharmacy “Grigore T. Popa”, Clinical Hospital of Infectious Diseases “Sfanta Parascheva”, Iași, Romania 2 University of Agricultural Sciences and Veterinary Medicine, Faculty of Veterinary Medicine, Iaşi, Romania Background Hepatitis E is an acute self-limiting disease, endemic in developing countries, but reports of the disease from industrialized countries are becoming more frequent. There are few data regarding this type of infection in Romania. Methods We prospectively studied a group of 51 subjects (with or without signs of clinical disease) from the Infectious Diseases Hospital “Sfanta Parascheva” Iași, between February and June 2015. We analyzed epidemiological, clinical data and laboratory test results. For each subject we collected serum and whole blood samples and qualitatively determined the presence of IgG anti-hepatitis E virus (HEV) antibodies using a third generation enzyme immunoassay (Dia.Pro, Italy). Results Eight out of 51 patients (15.7%) were identified as positive for IgG anti-HEV antibodies. The seropositive patients were on average older than the seronegatives (43 vs 33 years, p=0.08). Five of them were males and the sex ratio (M/F) was higher among the seropositives (1.7 vs 0.3, p=0.07). There was no significant difference between the two lots regarding their living conditions (urban or rural), but a more frequent contact to farm animals (pigs) was noted in the seropositives (5/8 vs 21%). Two of the seropositives had symptoms and liver enzymes elevations typical of acute hepatitis (without jaundice or other viral cause identified), one of them being a young pregnant woman. No difference in the average ALT and serum bilirubin levels were noted in the asymptomatic patients, according to their IgG anti HEV status. 2/8 seropositives vs 6/43 seronegatives had prior unexplained, self-limited hepatocytolitic syndromes. Conclusions Our preliminary results show that the human HEV infection in not unusual in our region, its prevalence being probably higher than previously estimated. Most seropositive patients were middleaged men or older, with frequent contact to farm animals. Further analysis will try to identify the presence of IgM anti-HEV antibodies and to determine the genotypes involved in human acute HEV infection. Online psychopathological assessment in chronic hepatitis pathology Ioana-Catrinel Cercel1*, Șerban Polli1, Anca Streinu-Cercel1,2, Oana Săndulescu1,2, Adrian Streinu-Cercel1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Viral hepatitis can be associated with psychiatric and/or personality disorders and therefore a multiaxial clinical assessment, evaluating both psychiatric and personality disorders, is needed. Methods Millon Clinical Multiaxial Inventory- III (MCMIIII) is a psychological tool that provides 19 information on psychopathological elements based on the Diagnostic and Statistical Manual of Mental Disorders, the 4th edition (DSM IV). This inventory can be used in patients over 18 years old and it includes 175 items with true or false answers, to be completed during the course of about 24 to 30 minutes. The novelty consists of providing this psychological tool, acquired under license, to patients in an online format, available on mobile devices. The inventory thus becomes an easy to use self-administered instrument. At the end of the assessment the results are processed automatically and interpreted to generate a psychological profile. This information is extremely important both for the clinical psychologist, in order to have an accurate image on psychopathological matters, and for the doctors, to tailor a personalized treatment approach for each patient. Results We have had 20 patients that received identification codes in order to complete the inventory in an online format. The response rate was 75% so we assessed 15 patients, 6 women and 9 men with hepatitis B or C, with range ages between 26-67, with a median of 46±11.71 years. We identified axis I disorders from DSM-IV, we found 3 subjects with clinical syndromes and 4 subjects with personality issues on axis II disorders. For 14 of them MCMI-III indicated the presence of a personality trait. Conclusions This easy to use mobile tool provides an image of the psychological status, useful for the multidisciplinary team to make the best choices in terms of treatment and counseling. Importantly, this method allows a psychological assessment of a large number of patients in a short period of time as it can be self-administered. Serum visfatin in relation to liver disease in a cohort of chronic hepatitis C patients Mihaela Andreea Radulescu1,2*, Victoria Arama1,2, Sorin Stefan Arama2, Cristina Popescu1,2, Daniela Ioana Munteanu1, Raluca Ioana Mihailescu1, Catalin Tiliscan1,2, Irina Duport1, Viorica Ispas1, Adrian Streinu-Cercel1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Recent studies emphasize the role of several adipokines in chronic hepatitis C (CHC) disease progression. Visfatin is an adipokine correlated to liver fibrosis and portal inflammation in nonalcoholic fatty liver, although only a few studies evaluated visfatin in CHC patients and their results are contradictory. This study aimed to assess serum visfatin in relation to liver disease in a cohort of CHC patients. Methods We performed a non-interventional analysis in a cohort of CHC patients, monitored in a tertiary clinic in Bucharest, compared to 30 uninfected controls. We excluded patients with diabetes mellitus, HBV or HIV co-infections, inflammatory and immuno-suppressive conditions, other chronic liver diseases. We recorded demographic data, body mass index, waist to hip ratio, lipid profile, serum viral load, visfatin. Liver disease was assessed by the non-invasive test Fibromax (Biopredictive, France). Statistical analysis was performed with SPSS (17.0 IBM, USA). Results 117 CHC patients were included, with a median age of 54 years (IQR 45-61) and sex ratio M:F=0.54. Median viral load was 5.80 logUI/mL (5.26-6.33). A high fibrosis score (F3-F4) was found in 47 (41.2%) patients, a high activity index (A2-A3) in 54 (47.3%) while 26 patients (22.8%) had a high steatosis score (S2-S3) and 14 (12.2%) had a high non-alcoholic steatohepatitis (NASH) score (N2). Visfatin median was 546 ng/mL (349798) in CHC patients versus 533 ng/mL (247-711) in the control group, p>0.05. In bivariate analysis visfatin was slightly correlated with fibrosis score (rho=0.162, p=0.05). In logistic regression the risk of fibrosis was not influenced by serum visfatin, although a visfatin value below the median limit lowered the risk for advanced fibrosis (F>3) with OR=0.38 (IC95%=0.16-0.94, p=0.037) and the risk for cirrhosis (F4) with OR=0.36 (IC95%=0.140.92, p=0.034). Visfatin was not correlated to activity and steatosis scores, but it was correlated to NASH score (rho=0.270, p=0.014) in overweight and obese patients (body mass index>25). Its median was higher in those with severe steatohepatitis when we compared patients with extreme Nash scores (N0 vs N2) - 98.8 ng/mL (59.7-117.0) versus 84.9 (0.67-0.103), p=0.014. In logistic regression serum visfatin did not influence NASH score. Conclusions In CHC patients high serum visfatin is correlated to advanced fibrosis and steatohepatitis scores. Further studies are necessary to evaluate if visfatin directly contributes to fibrosis progression. 20 A short argument in favor of combination therapies for chronic hepatitis B Laura Iliescu1*, Letitia Toma1, Monica Berechet1, Bogdana Ioana Pulhac1, Alina Tanase1, Carmen Orban1 *[email protected] 1 Fundeni Clinical Institute, Bucharest, Romania Occult hepatitis B virus reactivation in patients with hematological malignancies under biological therapy Violeta Molagic1*, Cristina Popescu1,2, Catalin Tiliscan1,2, Raluca Mihailescu1, Mihaela Radulescu1,2, Angelica Tenita1, Victoria Arama1,2, Stefan Sorin Arama2 *[email protected] 1 Background At the moment, there are two approved types of treatment for chronic hepatitis B virus (HBV) infection: nucleotide/nucleoside analogues and interferon; they have different action mechanisms but neither monotherapy can obtain satisfying rates of virus clearance (absence of serum HBs antigen and seroconversion in the HBe system). Serum HBs antigen (HBsAg) represents an important serological marker of chronic B virus infection in HBe antigen (HBeAg)-negative patients under treatment. We aim to determine the rate of HBsAg decline under different treatment regimens. Methods We studied a cohort of patients with HBeAgnegative/positive compensated CHB treated with peginterferonum alpha 2a - 15 patients (3 epositive/ 12 e-negative) - group A, tenofovir disoproxil fumarate (TDF) - 12 patients (2 epositive/ 10 e-negative) - group B and entecavir 18 patients (2 e-positive/ 16 e-negative) - group C for at least 12 months. Stored serum samples taken before and at 6 and 12 months of therapy were tested for HBsAg, HBV-DNA and HBeAg. Results Before treatment, group A, B and C patients had a mean value of HBV DNA 40000 IU/mL, 45000 IU/mL and 55000 IU/mL, HBsAg 3.5, 3.4 and 3.2 log10 IU/mL respectively. Virologic remission rates at 12 months (HBV DNA undetectable by PCR) were 6.66% in group A, 8.33% in group B and 5.55% in group C. Compared to before treatment, levels of HBsAg decreased by a median of 0.06, 0.30 in group A, 0.04, 0.20 in group B and 0.035, 0.15 in group C at 6 and 12 months, respectively (p<0.0030). No patient cleared HBsAg at 12 months of therapy Conclusions Although this study included a small number of subjects, the results are not very different from those in literature. The lack of HBV clearance with any of these monotherapies suggests that a possible drug combination may have a higher success rate. National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background HBV reactivation (HBV-R) is life-threatening in patients with hematological malignancies (HM) under biological treatment. HBV-R commonly occurs in patients with HBsAg positive but also in patients with HBsAg negative, HBcAb positive with or without HBsAb (occult HBV infectionOBI). We aimed to evaluate the prevalence, clinical characteristics and outcome of OBI reactivation (OBI-R) in patients undergoing biological therapy for HM. Methods We performed a cross-sectional study that included patients with HM treated with rituximab containing chemotherapy and at least one serological marker of HBV infection. The patients were monitored in 3th department of National Institute of Infectious Diseases between 2007 - 2014. Serum HBsAg, anti HBc, HBsAb, ALT and HBV-DNA (by PCR) was measured at baseline and during reactivation. Results We enrolled 53 HBV-infected patients: 37 (69.8%) males and 16 (30.2%) females, with mean age 57.92±12 years. Forty four (83%) patients were AgHBs positive and 9/53 patients (17%) had OBI: five cases with only anti HBc positive and four cases with HBsAb positive with the level at baseline less than 50 IU/mL. Most of OBI patients were males (6 cases) and older than AgHBs positive patients with mean age 63.33±10.21 years versus 56.82±12.24 years. Liver fibrosis (F) was evaluated by Fibroscan in all OBI patients. They had moderate fibrosis F1/F2. Seven patients had non-Hodgkin lymphoma types (NHL) and 2 cases had chronic lymphocytic leukemia (CLL). OBI-R was recorded in 6/9 (66.7%) cases, all with aggressive subtype of HM and a median of 5 rituximab cycles. Five patients developed HBVrelated hepatitis with ALT median value 1235 IU/L (259-2897). The median HBV-DNA level at reactivation was 100.00 IU/mL (IQR= 50,552,198 IU/mL). Entecavir therapy was started once OBI-R was observed. None of the patients experienced 21 liver-related death. In two cases HBV-DNA level was undetectable but anti HDV-IgG was positive and HDV-RNA detectable at very high level. They were treated with Peginterferon alpha 2 A. Two patients died for HM complications, 2 had HM remission and 2 had HM relapse. Conclusions HM patients with rituximab containing chemotherapy have increased risk of OBI -R. HBV screening, including anti-HBc is mandatory and prophylactic antiviral therapy is recommended for anti-HBc positive patients before biological therapy. Patients with positive anti-HBc must be screened for HDV infection before immunosuppressive therapy in order to promptly diagnosed and treat HDV reactivation. Acknowledgement Study supported by SOP HRD financed from ESF and RG under contract number POSDRU/187/1.5/S/155420. The efficacy of entecavir in chronic HBV hepatitis – a lifelong therapy Cristina Popescu1,2*, Alina Orfanu1,2, Anca Leustean1,2, Raluca Dulama3, Catalin Tiliscan1,2, Violeta Molagic1,2, Mihaela Radulescu1,2, Raluca Mihailescu1, Daniela Munteanu1, Raluca Nastase1, Anca Negru1,2, Remulus Catana1, Viorica Ispas1, Liliana Ion1, Ligia Ionescu1, Victoria Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Infectious Diseases Hospital of Ploiești, Romania Background The treatment of HBV hepatitis can use both nucleoside/nucleotide analogues with high genetic barrier (NNA) and pegylated interferon. Virological control during lifelong therapy is the main advantage of NNA. Objectives: To estimate the level of virological control and also the rate of HBsAg loss and HBeAg seroconversion during NNA therapy. Methods We performed a retrospective analysis of HBV infected patients treated with entecavir in Third Department of Matei Balș Institute, between 2008 and 2014. The main inclusion criterion was at least 12 months of entecavir therapy. Results In our Department were monitored more than 1500 HBV infected patients; 213 patients received antiviral therapy and 149 patients received NNA. 129 patients met the inclusion criteria. The demographic characteristics were: mean age47.32, sex ratio M:F=2.2:1, mean duration of entecavir therapy – 32 months (between 12 and 60 months). Nineteen patients had positive HBeAg (14.84%). The rate of virological control (defined as undetectable viral load) was 77.34%. In 3 cases virological failure was recorded and entecavir therapy was stopped. Of 29 patients without virological control, 21 had viral load around low limit of quantification (LLQ) and 5 patients had viral load > LLQ (the maximum value was 26000IU/mL). Of 19 patients with HBe Ag positive, in 5 cases (26.31%) anti-HBe seroconversion was obtained, after a mean period of 36.4 months. The mean duration until viral load was undetectable was 10.9 months. Of 29 patients with detectable viral load, 12 received 12 months of entecavir, 3 received 18 months of entecavir and 14 received more than 18 months of entecavir (one patient had positive viral load after 60 months of therapy). The value of initial viral load ranged between 2400 IU/mL and 4 billion IU/mL, with a mean value of 143862320 IU/mL. Only one patient registered HBsAg loss, without anti-HBs seroconversion (0.77%). Conclusions Entecavir had a good efficacy in patients with chronic HBV hepatitis, even in patients with very high viral load. The rate of virological control during NNA therapy is almost 80% but lifelong therapy is necessary. The need for interferon-free treatments in chronic hepatitis C Laura Iliescu1*, Letitia Toma1, Bogdana Ioana Pulhac1, Monica Berechet1, Alina Tanase1, Carmen Orban1 *[email protected] 1 Fundeni Clinical Institute, Bucharest, Romania Background Chronic HCV infection is a major health issue worldwide, with a severe impact both on patients and national healthcare funds. Recent treatments have shown excellent sustained virologic response (SVR) rates; in a limited resources setting, however, access to new therapies is almost impossible and patients treated with standard double therapy (peg- interferonum and ribavirin) who do not achieve SVR are left with no alternative. We aim to study the characteristics of patients with genotype 1 chronic HVC hepatitis in 22 whom double therapy did not prove to be curative and who should have access to newer treatments. Methods This is a retrospective observational study including 620 patients with chronic HCV hepatitis undergoing treatment with peg-interferonum and ribavirin, admitted to our clinic from April 2013 to October 2014. Patients are classified as responders, relapsers and non responders according to the guidelines. We present the characteristics of the relapsers and nonresponders at the end of the antiviral therapy. Results Out of the 620 patients, 56.46% were nonresponders, 33.87% were relapsers and 9.67% achieved SVR (the control group). Out of the nonresponders, 75.36% stopped treatment after 12 weeks. The mean age in the cohort was 51.20 years. 56.45% of the patients were women. The mean age of patients with SVR, nonresponse and relapse was 41.66, 51.62 and 53.23 years, respectively; the patients with SVR were statistically younger than patients without SVR. Mean ALT levels were significantly higher in patients with relapse (102.52 IU/mL) compared to nonresponders (62.4 IU/mL) and responders (38.41 IU/mL). Liver stiffness measured by Fibroscan also differs between groups: nonresponders had a higher degree of fibrosis (85.71% patients with F3-F4) compared to relapsers (66.66% with F3-F4); only 33.33% of the patients with SVR had F3 fibrosis; none had F4. There was no significant difference between HCV-RNA levels after the treatment in patients with relapse versus nonresponders. Conclusions The need for interferon free regimens does not apply only to patients with F4 liver fibrosis, but also to patients who fail to obtain SVR with the current double therapy. In the end, we must remember that cost reduction involves stopping the progression of this disease to cirrhosis and liver cancer and not limiting access to effective treatments. Tolerability and efficacy of 3-DAA regimens with and without ribavirin in the treatment of chronic hepatitis C in real-life settings Anca Streinu-Cercel1,2*, Oana Săndulescu1,2, Daniela Manolache2, Monica Andreea Stoica2, Gabriela Ceapraga2, Liliana Lucia Preoțescu1,2, Cătălina Udroiu2, Adrian Streinu-Cercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background The advent of highly-effective interferon-free treatment options for chronic hepatitis C virus (HCV) infection has redesigned the way we manage hepatitis C. Given that data from randomized-controlled trials are representative for ‘ideal’ settings and subjects, it is increasingly important to transfer this information in the clinic and to compare it with data from real-life settings. Methods Since September 2014 we have screened 41 subjects with chronic hepatitis C. We have treated treated 40 of them with the 3-DAA regimen (AbbVie, North Chicago, IL, USA) with and without ribavirin in a compassionate study approved by the Romanian National Agency for Medicines and Medical Devices. Results The study group included 23 male (56.1%) and 18 female subjects. The distribution of IL28B genotype was 25.9% CC, and equal proportions (37%) CT and TT. Most (70.3%) of the subjects had been nonresponders to prior therapy. The median (IQR) baseline HCV viral load was 1134683 (2789067) IU/mL. At the end of treatment, of the 16 subjects who completed treatment to date, 12 had undetectable viral loads, and 4 had viral loads below the lower limit of quantitation (<12 IU/mL). However, at 12 weeks post-treatment follow-up, all 16 subjects had undetectable HCV viral load and were considered cured. The mean and standard deviation of liver stiffness as determined by shear waves elastography were 11.6±5.3 kPa at baseline, 11.3±4.6 kPa at the end of 12 weeks of treatment, and 10.2±4.3 kPa at 12 weeks of post-treatment follow-up. The decrease in liver stiffness from end of treatment to 12 weeks post-treatment was statistically significant (p=0.030) with a small-tomoderate effect size (d=0.4337). Treatment tolerability was good, with mild lymphopenia (16 cases, 40%), mild ribavirin-associated anemia (1 case), insomnia (2 cases), hyperglycemia (7 cases), acute angiocholitis (1 case), pruritic rash (1 case), intermittent headache (1 case), asymptomatic overdose (1 case), attention issues (1 case). Conclusions The 3-DAA regimen displayed high effectiveness and good tolerability in real-life settings. Acknowledgement AbbVie provided the 3-DAA regimen in a compassionate study approved by the Romanian National Agency for Medicines and Medical Devices. 23 Characteristics of children respiratory viral infections Community-acquired sepsis – etiological, therapeutical and outcome features Constanta Angelica Visan1*, Anca Cristina Draganescu1, Camelia Kouris1, Anuta Bilasco1, Cristina Negulescu1, Magdalena Vasile1, Madalina Merisescu1,2, Sabina Schiopu1, Endis Osman1, Daniela Pitigoi1,2, Monica Luminos1,2 Brindusa Tilea1,2*, Nina Sincu1,2, Simona Teches1,2, Ioan Tilea1,3 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Identifying the etiology of respiratory infections in children is a priority in the National Institute for Infectious Diseases “Prof. Dr. Matei Balș”. For achieving this objective, we use Mari POC rapid tests, that allow testing of eight types of respiratory viruses (Influenza A and B, Parainfluenza 1, 2 and 3, Adenovirus, Metapneumovirus, Respiratory Syncytial Virus) and the presence of Streptococcus pneumoniae. Objectives: Establishing the etiology of viral infections in children, in order to achieve an adequate management and superior clinical outcomes. Methods We tested children aged 0-14 years admitted in our clinic with a diagnosis of acute respiratory infection. Nasal exudates were collected and immediately processed by the method MariPOC; the results are available after 2 hours. Results Comparative analysis of the incidence of respiratory viruses in the past two years has shown predominance of influenza A in the 2013-2014 season, unlike the 2014-2015 season, when influenza B was found in greater proportion. In significant proportion were present respiratory syncytial virus and metapneumovirus, which made it possible to identify specific particularities. We performed analysis of viral co-infections cases and highlighted the importance of the presence of S. pneumoniae. Conclusions MariPOC method represents a particularly useful tool for the management of respiratory viral infections in children, as it allows: etiological diagnosis established within 2 hours, triage and isolation of patients based on epidemiological criteria, timely administration of antiviral therapy, the study of the incidence and clinical characteristics of the various respiratory viruses affecting children in winter. *[email protected] 1 University of Medicine and Pharmacy Tîrgu Mureș, Romania 2 Clinical County Hospital Mureș, Romania 3 Emergency Clinical County Hospital Tîrgu Mureș, Romania Background Systemic bacterial infections are major causes of morbidity and mortality worldwide and of admission to infectious disease and intensive care units. This study evaluates the prevalence, etiology, therapy and outcome of community-acquired sepsis in a tertiary care Romanian hospital. Methods A retrospective observational study on 40 patients with sepsis admitted in an infectious disease department over a period of one year was conducted. The incidence of sepsis, severe forms, the etiological agent, its sensibility and evolution of cases were evaluated. Vital signs (temperature, heart rate, respiratory rate) and laboratory values including white blood cell (WBC) count measured at admission were registered to define systemic inflammatory response syndrome and organ dysfunction. The diagnosis of sepsis was confirmed by the clinical and biological data: systemic inflammatory response syndrome (SIRS), Creactive protein (CRP), procalcitonin (PCT), dysfunctions of coagulation. In order to identify the causative organism(s) at least two sets of blood cultures were obtained and an automated microbial detection system BacT/ALERT® system (BioMerieux, USA) was used. Antibiotic susceptibility testing was performed by disc diffusion method. Empiric antimicrobial regimen was initially initiated, afterwards adjusted according to the stain’s susceptibility profile and was reassessed daily. Other specific actions (intravenous fluids, vasopressors, steroids, respiratory support), were also performed. Results Majority of the cases were over 50 years old (85%) compared with the rest of them less than 50 years old (15%). Most of the patients were represented by men (85%) compared with women (15%). The underlying disease was: respiratory (47% of cases), urinary (19% of cases), vascular (9% of cases), and cutaneous (8% of cases), digestive and dental (3% of cases) and unknown (8% of cases). The pathogens agents were: Gram positive cocci (52.5%), Gram negative bacilli (20%), Gram 24 negative cocci (5%), fungus (2.05%). 11 patients (27.5% of all cases) with multiple co-morbidities had an unfavorable evolution of sepsis, which developed septic shock and multiple organ dysfunction syndrome (MODS) and then multiple system failure syndrome (MSOF). Conclusions Sepsis and septic shock were more frequent in patients over 50 years old. In the sepsis etiology a higher incidence of Gram positive cocci compared with Gram negative bacilli was noticed. Several independent factors (advanced age, infection with a resistant organism and impaired host immune status) were associated with both higher mortality and resource utilization. Pseudomonas aeruginosa strains collected from a Romanian infectious diseases ward – susceptibility profile and impact of bacteriophages on adherence and biofilm formation Alina Cristina Neguț1,2*, Oana Săndulescu1,2, Anca Streinu-Cercel1,2, Ioana Berciu1,2, Olga Dorobăț2, Magdalena Lorena Andrei2, Veronica Ilie2, Dana Mărculescu2, Mircea Ioan Popa1, Adrian StreinuCercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Evaluated by the Centers for Disease Control and Prevention (CDC) as SERIOUS on the threat level, Pseudomonas aeruginosa infections become more difficult to treat because of multidrug-resistance [1]. CDC reports that 13% of healthcare-associated P. aeruginosa infections are caused by multidrugresistant strains [2]. Methods Between February 2014 and February 2015, we collected data from 21 patients with P. aeruginosa infections from the Adults II ward of the National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Romania. Following the protocol presented in Neguț et al., GERMS 2014 [3], we assessed the impact of Georgian phages in terms of susceptibility and influence of binary phage dilutions on adherence and biofilm formation. Results The study group had a 2:1 male:female ratio; the most frequent sites of infections were urine and skin (9/21 each). Antibiotic susceptibility was low, 33.3% for piperacillin, 35.3% piperacillintazobactam, 41.2% ceftazidime and 18.8% meropenem, but 100% for colistin. Susceptibility to phages was 57.1% for PYO and 52.4% for INTESTI, with non-susceptibility to PHAGYO and PHAGESTI. For 9 strains we performed the PYO and INTESTI assays. All strains formed biofilm. Surprisingly, only three of the strains displayed higher biofilm optical densities compared to ATCC 27853 (Schroeter) Migula, while the other 6 strains recorded lower optical densities. The highest concentration of phages (1/2 dilution) inhibited biofilm formation for 6 strains in the INTESTI experiment (p=0.110) and 3 strains in the PYO experiment (p=0.050). The lowest concentration of phages had no statistically significant influence in both experiments (p=0.110, p=0.326). Conclusions PYO and INTESTI phages appeared to influence bacterial adherence to a certain extent but because of the small sample number the results were not statistically significant. To address this issue, we will increase the number of strains tested. The pilot data reported here show that P. aeruginosa has a capacity for developing strong biofilm and that susceptibility to phages is higher compared to most antibiotics, suggesting the role of potential synergic co-administration in hard to treat infections. Acknowledgements 1. POSDRU/159/1.5/S/141531 2. Carol Davila University of Medicine and Pharmacy, Young Researchers Grant, no 28341/2013 References 1. Streinu-Cercel A. Colistin in the management of severe infections with multidrug resistant Gramnegative bacilli. Germs 2014,4:7-8. 2. CDC. Pseudomonas aeruginosa in Healthcare Settings. Available at: http://www.cdc.gov/hai/organisms/pseudomonas.ht ml Accessed: 25 Jul 2015. 3. Neguț AC, Săndulescu O, Popa M, et al. Experimental approach for bacteriophage susceptibility testing of planktonic and sessile bacterial populations - Study protocol. Germs 2014.4:92-6. Evidence-based management of staphylococcal infections Oana Săndulescu1,2*, Coralia Bleotu3,4, Ioana Mădălina Aldea3, Anca Streinu-Cercel1,2, Mariana Carmen Chifiriuc4,5, Alexandru Rafila1,2, Daniela Tălăpan1,2, Olga Dorobăț2, Alina Cristina Neguț1,2, Ioana Berciu1,2, Adrian Streinu-Cercel1,2 *[email protected] 25 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 3 Ștefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania 4 Faculty of Biology, University of Bucharest, Romania 5 Research Institute of the University of BucharestICUB, Life, Environment and Earth Sciences, Bucharest, Romania Background Staphylococcal infections are responsible for important morbidity and disability, particularly when associated with chronic wounds or implantation of medical prostheses. We have performed a study to determine the key characteristics of staphylococcal species that drive cyto-adherence and biofilm formation. Methods We have created a mathematical matrix for predicting cyto-adherence and biofilm formation in Staphylococcus spp. Cyto-adherence on HEp-2 cell lines was assessed through Cravioto's adapted method, and biofilm formation through Christensen’s plate method. The results were correlated with microbiological characteristics and microscopic findings. Results Staphylococcal strains with high cyto-adherence index (above 80%) have a 17-fold higher chance of internalization (p=0.001), a 5-fold higher chance of tetrad assembly (p=0.001) and of being resistant to methicillin (p=0.010), and an 18-fold higher chance of being susceptible to fosfomycin (p=0.004). We have identified 3 key characteristics of staphylococcal species that drive cyto-adherence (p=0.000) and are inversely correlated with biofilm formation (p=0.000): tetrad assembly, aggregative adherence pattern and methicillin resistance. By computing these parameters into a mathematical matrix, we have generated an aggressiveness score useful in the clinical management of staphylococcal infections. A score of 0 indicates a methicillin-susceptible strain. A score of 1 indicates low cyto-adherence (57%) but high biofilm formation (96%), a score of 2 is intermediate for both parameters, and a score of 3 indicates high cyto-adherence (90%) coupled with low biofilm formation (65%). Conclusions The evidence-based management of staphylococcal infections is facilitated by the clinical implementation of this bench-to-bedside algorithm that can predict cyto-adherence, biofilm and internalization by computing easily-determined strain characteristics such as tetrad assembly, adherence pattern and methicillin susceptibility. Acknowledgement This paper is partially supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/159/1.5/S/137390. Antimicrobial susceptibility of E.coli isolated from urinary tract and blood stream infections and predictive factors for multidrug resistance Roxana Petre1, Adriana Hristea2,3*, Raluca Elena Jipa2, Andreea Serbu3, Anca F. Mocanu3, Alexandru Rafila2,3, Daniela Talapan2, Oana Săndulescu2,3 *[email protected] 1 National Institute of Aeronautical and Space Medicine “Gen. Dr. Aviator Victor Anastasiu”, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Bloodstream infections (BSI) and urinary tract infections (UTI) are important causes of morbidity and mortality in patients with healthcare-associated infections (HCA), but also in patients with community-acquired (CA) infections. Objectives: (1) To describe the resistance patterns of E.coli isolated from UTI and BSI and (2) to identify characteristics associated with multidrug-resistance (MDR). Methods We performed a study on E.coli strains isolated from urine and blood from patients admitted to our facility between July 2014 - June 2015. We included patients for which clinical and epidemiological data were available. MDR was defined as resistance to three or more classes of antimicrobial agents. We divided infections in CA and HCA, where HCA infections included significant recent (three months) healthcare contact/procedures. Results We identified 91 patients with UTI (30% with complicated UTI) and 54 with BSI. Patients with UTI had a median age of 61 (IQR 45-73) years and 69 (76%) were female. Resistance to one, two, and three classes of drugs was identified in 11 (12%), 19 (21%) and 32 (35%) cases, respectively. MDR strains were isolated from HCA vs. CA infections in 47% vs. 53% of cases (p=0.015). ESBL 26 production was identified in 20 (22%) strains. Resistance to beta-lactams, fluoroquinolones, aminoglycosides and sulfamethoxazole was 67%, 24%, 48% and 48% respectively. Patients with BSI had a median age of 62 (IQR 52-77) years and 29 (54%) were female. The source of BSI included the urinary tract in 31 (57%), gastrointestinal tract 6 (11%), respiratory tract 6 (11%), skin and soft tissue 1 (2%) and unknown 10 (19%) patients. Resistance to one, two, and three classes of drugs was identified in 11 (20%), 11 (20%) and 16 (30%) cases, respectively. MDR strains were isolated from HCA vs. CA infections in 75% vs. 25% of cases. (p=0.006) ESBL production was identified in 14 (26%) strains. Resistance to beta-lactams, fluoroquinolones, aminoglycosides and sulfamethoxazole was 67% 28%, 19% and 46% respectively. We did not identify carbapenem resistance. Prior hospitalization, recent urinary tract infection and antimicrobials use were associated with MDR both from UTI and BSI (p<0.005 for all variables). Conclusions Antimicrobial susceptibility was similar for UTI and BSI, except for aminoglycosides resistance, which was higher in UTI. MDR was more frequent in HCA than in CA BSI infections. Acknowledgement Carol Davila University of Medicine and Pharmacy Young Researchers Grant 28.336/04.11.2013. The diagnostic role of procalcitonin in acute Q fever Cristina Popescu1,2*, Alina Lobodan1,2, Anca Leustean1, Raluca Dulama3, Anca Negru1,2, Mihaela Radulescu1,2, Catalin Tiliscan1,2, Violeta Molagic1, Irina Duport1, Alina Vornicu1, Cristina Covaliov1, Roxana Gnaticov1, Ioan Diaconu1, Gabriel-Adrian Popescu1, Stefan-Sorin Arama1,2, Victoria Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Ploiești Infectious Diseases Hospital, Romania Background Procalcitonin (PCT) is a marker which can differentiate between infectious and non-infectious SIRS. In sepsis caused by atypical bacteria, PCT is often negative. In many cases of Q fever the only sign is fever and sometimes the diagnosis is difficult. Objectives: 1. to analyze the sensitivity (Sn), specificity (Sp), negative predictive value (NPV) and positive predictive value (PPV) of PCT in Coxiella burnetii sepsis; 2. to establish which conditions are associated with positive PCT in Q fever. Methods Retrospective analysis of patients diagnosed with Q fever between 2011 and 2014 in Matei Bals Institute. The patients were divided into two groups: group 1 with positive PCT and group 2 with negative PCT. We compared the two groups for several clinical and biological parameters. Results From 89 patients with Q fever, PCT was measured in 75 patients: in 14 patients PCT was positive and in 61 was negative. The mean age was 50.05 years (55.6 years in group 1 and 48.7 in group 2) and sex ratio was M:F=1.58:1 (1.8:1 in group 1 and 1.54:1 in group 2). Sepsis criteria were met in 49 patients (65.3%) - 27 with two SIRS criteria, 27 with 3 SIRS criteria and 5 with 4 SIRS criteria. SIRS criteria were: fever – all the patients, tachycardia – 56 patients, polypnea -11 patients and leukocytosis – 27 patients. Q fever involved one organ in 25 patients, 2 organs in 49 patients and 3 organs in one patient. Q fever was manifested as: pneumonia in 63 patients, hepatitis in 56 patients and carditis in 6 patients. Statistical parameters of PCT for Coxiella sepsis were calculated: Sp – 93.8%, Sb-26.5%, NPV-29.4% and PPV-92.9%. The comparative analysis between PCT positive and PCT negative groups of patients showed which data are associated with positive PCT: leukocytosis >12000/cmm – p=0.0003, heart rate >90/min – p=0.08, more than 3 SIRS criteria – p=0.0003 and liver involvement in Q fever – p=0.036. Conclusions 1. Although PCT is very specific for Q fever sepsis, the sensitivity is very low (around 25%). 2. PCT might be positive in Coxiella sepsis if the patient has leukocytosis, hepatitis, tachycardia and more than 3 SIRS criteria. Acknowledgement This paper is supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/187/1.5/S/155420. Retrospective validation of two scoring systems for tuberculous meningitis in adults Adriana Hristea1,2*, Roxana Petre3, Eliza Manea1, Serban Benea1,2, Ruxandra Moroti1,2, Irina Panait1, Gabriel Gaciu1, Raluca Elena Jipa1 *[email protected] 27 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 National Institute of Aeronautical and Space Medicine “Gen. Dr. Aviator Victor Anastasiu”, Bucharest, Romania Background The delay in diagnosis and treatment is associated with increased mortality in tuberculous meningitis (TBM) Objective: retrospective validation of a diagnostic score previously published (Hristea et al Int J Tuberc Lung Dis, 2012), based on four variables: duration of symptoms before admission of ⩾5 days, presence of neurological impairment (altered consciousness, seizures, mild focal signs, multiple cranial nerve palsies, dense hemiplegia or paraparesis), CSF /blood glucose ratio <0.5 and CSF protein level >100 mg/dl against a consensus definition and a scoring system comprising six clinical criteria, five CSF criteria, five cerebral imaging criteria and evidence of tuberculosis elsewhere (Marais et al. Lancet Infect Dis 2010). Methods We retrospectively studied patients admitted to our hospital between January 2012 and June 2015 with TBM. Patients were classified according to the consensus definition and scoring system published by Marais, with points given for variables that were present on admission. Patients were classified as having probable TBM if they scored at least 10/12 points with/without cerebral imaging results, and possible TBM if they had a diagnostic score of 6–9 when cerebral imaging is available, or 6–11 points without cerebral imaging. According to the simplified diagnostic score the probability of TBM in a given patient ranged from 98% (95%CI 94– 100) when all four variables were present to 0% when all variables were absent, ruling out TBM. The cut-off for TMB was ≥ 6 points. Results Thirty-eight patients with TBM were identified, median age of 29 years (24–39 years); 14 (37%) were HIV-infected. Twenty-four (63%) patients had microbiologically confirmed TBM with a positive CSF culture for M. tuberculosis (11 patients), positive commercial nucleic acid amplification test (5 patients), or both tests positive (8 patients). Thirty-six (95%) patients had CNS imaging investigation. Hydrocephalus was present in 9/36 (25%), tuberculoma in 7/36 (19%) and vasculitis in 6/36 (17%) patients. Duration of symptoms before admission of ⩾5 days was noted in 37 (97%); presence of neurological impairment in 28 (74%); CSF /blood glucose ratio <0.5 in 31 (82%); CSF protein level >100 mg/dL in 32 (84%) patients. Twenty (52.6%) patients with TBM would have been classified as having probable and 18 (47.4%) possible TBM according to the Marais scoring system. The simplified diagnostic score based on the four variables confirmed 35/38 (92%) cases, 95.8% of microbiologically documented and 85.7% of probable/possible TBM cases. Conclusions A diagnostic score suitable for resource-limited and high tuberculosis prevalence settings is a valuable tool in clinical practice. Assessing the fibrosis stage is still a crucial step in the era of powerful drugs for HCV and HBV Mona Munteanu1* 1 Noninvasive Diagnosis Unit, BioPredictive, PitiéSalpêtrière Hospital, Paris, France *[email protected] Thanks to non-invasive blood diagnosis panels such as FibroMax and elastography, the entire perception of the disease has been transformed in such a way that the patient will get within 20 minutes the exact status of the illness, prognostic information and predictability of treatment response. Despite efficient drugs with high rates of viral cure (HCV) or viral suppression (HBV) lead to the improvement of long-term prognosis of patients, non-invasive evaluation of fibrosis remains important for staging fibrosis and cirrhosis is still an independent negative predictor for the response rates. HCV chronically infected patients with cirrhosis had lower response rates to some second and even third generation DAA containing therapy [1]. Sensitive biomarkers such as FibroTest-FibroMax are extremely useful in cured HCV patients for tracking the remaining risk of primary liver cancer estimated to be about 5% at 10 years after HCV sustained viral response, patients that are supposed to not regress fibrosis. [2]. The presence of two or more metabolic factors is a strong risk predictor of non-regression of fibrosis after SVR. Biomarkers such as FibroMax demonstrated to be an efficient strategy for screening and prognosis in NAFLD – risk subjects [3] and some of the HCV cured patients have a metabolic profile continuing to present an important risk of development of fibrosis despite viral cure. In HBV carriers, despite effective virus suppression under NUC, the overall incidence of cirrhosis increased, with a remaining 5.8% risk of HCC. Predetermined cutoffs of FibroTest-ActiTest are 28 used to rank the severity of chronic hepatitis B from inactive carrier status to three stages in cirrhotics (F4.1-not decompensated, F4.2 –varices not decompensated and F4.3-decompensated) but also to follow-up fibrosis under analogues. 93% of HBV carriers that developed HCC under efficient viral suppression had fibrosis-progression during repeated evaluation using FibroTest. [4] Overall, clinicians have to continue to estimate fibrosis dynamic despite viral cure (HCV) or viral control (HBV), as fibrosis can progress in more than 10% of patients. References 1. JAMA 2014; 2. J Hepatol 2014; 3. Aliment Pharm Ther 2014; 4. J Hepatol 2014. 29 Poster presentations Epidemiological considerations on HIV in Constanţa county. Aspects of geographical distribution on HIV AIDS cases in territory. Elements of the HIV AIDS infections management with impact on environment Iulia Gabriela Şerban1*, Sorin Rugină1,2 *[email protected] Clinical Infectious Diseases Hospital of Constanța, Romania 2 Faculty of Medicine, “Ovidius” University, Constanța, Romania 1 Background The theme chosen is representative of current progress, expressing general public health services in Romania, especially regarding HIV-AIDS healthcare insurance, the specific elements of management epidemiological HIV AIDS impact on the environment. The main objective - We have proposed organizing an existing case law database, to elucidate the epidemiological process. Methods I followed the period 1987-30 June 2013, highlighting some aspects of the geographical distribution of HIV AIDS cases in the county of Constanta. Results A database recorded in the period 1987 - 1993 was analyzed. There were studied early 1728 AIDS HIV cases detected in Constanta. The vast majority of the population cohort came from public care and pediatric wards, dystrophy centers, premature infant surgery ward of Constanta County Hospital. To these were added detected and diagnosed children in other parts of the country (especially in the west), sent to be supervised in various international partnership programs. In 1990 a total of 406 AIDS patients were reported, of which 73.153% of urban (N = 297) and 26.847% of rural (N = 109). Of these, 35.961% from Constanta (N = 146 - urban hospital). Conclusions It has been required the role of epidemiologist - the clinician community! Epidemiologic and environmental management of Blood Transfusion Unit. It has been required the environmental specialist role (biology, engineering) in a hospital for infectious diseases (fundamental role of environmental science). The role of the multidisciplinary team (biochemist, biologist, epidemiology, infectious disease specialist, hygienist, and psychologist, specialist in environmental ethics and medical ethics, engineer) is relevant. It highlighted the importance of computer science, environmental ethics, Artificial Intelligence, Engineering, Electrical and Electronic Environmental Sciences, Epidemiological Intelligence, Developmental Biology. The importance of epidemiological monitoring RIS (International Health Regulations) and GIS (Geographic Information Systems) is fundamental. Is fundamental the Environmental bioethics education (fundamental civilizing factor, located at the intersection of realistic sciences and humanities), in compliance with best practice, guides Bioethics Environmental, procedures, ethical clinical principles and is important to continue the education on environmental thematic, ethical training, according with special literature. Establishment of databases: valuable epidemiological data on the environmental impact (transmission, non healthy behaviors, iatrogenic) The need to develop ethical behavior in contemporary modern “transition” society (sexual behavior – men having sex with men, heterosexual, drug users, the MTCT - maternal fetal transmission, environmental hygiene: beaches, road and rail station transportation, social activities, ethological changes). Epidemiological elements on management of nosocomial infections and hand hygiene in Infectious Diseases Hospital from Constanta, Romania. The nosocomial infections reported in HIV AIDS department. Iulia Gabriela Serban1*, Mărioara Neacşu1 *[email protected] Clinical Infectious Diseases Hospital of Constanța, Romania 1 Background Nosocomial infections (NI) remain a cause of disease worldwide. Motivation - The need to monitor the emergence, development and evolution of NI in the hospital environment. Raising the psychological impact of NI in HIV AIDS Compartment. Originality of the study - a descriptive presentation made in the registers and studied observation sheets was ordered into a valuable loco-regional data base. The general period is 2003 - 2015, focusing on the interval 2011 30 – July 2015. This paper aims to present some epidemiological considerations on NI, based on a complex retrospective epidemiological investigations. Objectives - Reporting the NI from Infectious Diseases Hospital, Constanţa Epidemiological elements on General Management of the Hand Hygiene. Methods We performed an epidemiological analysis in the reports on period 2003 – July 2015. We studied the patient observation charts and NI from registries. We analyzed the use of soap and water-alcohol solution. Results Graphical presentation of risk areas in hospital High-turnover of patients - graphics focused on discharges of the patients, period 2011 - 2014 Graphical Communication, period 2003 - 2015 The duration of hospitalization and treatment, period 2003 - 2015 - Analysis of nosocomial infections by type of germs and frequency, period 2011 - 2015 - Examples - Nosocomial infections in HIV AIDS Department - Epidemiological elements on hand hygiene in Infectious Diseases Hospital, Constanţa - Number of communications, internal notes on the NI theme, addressed to hospital departments, 2011 - 2014 - The number of epidemiological surveys performed between 2012 – 2014. The low incidence of NI, compared to international studies, means possible underreporting in hospital, but best practical care and close monitoring. Conclusions NI are an important cause of morbidity and mortality and increase the cost of medical care. The Plan for preventing the NI and for medical staff training is designed to stimulate awareness of the importance and timeliness of the topic, supervision, monitoring and evaluation of the NI. The SPCIN Nucleus – fundamental role in surveillance, prevention and control of nosocomial infections. Through the development of the complex epidemiological system, active surveillance and control of the NI, through infectious therapy, psycho-sociological counseling and motivation of the adherence, focused on HIV-AIDS, Romania in general and Constanţa in particularly, is an European model and beyond. Elements of epidemiological surveillance focused on Clostridium difficile infections in the Infectious Diseases Clinical Hospital, Constanta, period 25 June 2014 – 25 March 2015 Iulia Gabriela Serban1*, Roxana Carmen Cernat1 *[email protected] Clinical Infectious Diseases Hospital of Constanța, Romania 1 Background International, national and local importance of Clostridium difficile infection (CDI). Theme chosen is approaching a current difficulties of clinical epidemiology Objectives - CDI reporting in Hospital, for a period of 9 months. Methods We conducted an epidemiological analysis of the CDI reported in period June 2014- March 2015. We studied observation charts of each patient and CDI books of SPCIN (Surveillance, prevention, control of nosocomial infections). Results We are presenting graphics of the: - Suspected CDI hospitalized. Distribution according to age groups, gender (F/M), calendar month of hospitalizations, place of origin. Seasonal and quarterly variations CDI confirmed, complicated, relapse. Contact with another CDI case. - Previous administration of antibiotics. Combinations of antibiotics. Number of cures of antibiotic therapy. - History of Immunosuppression, IPP therapy, Surgery in the last 2 weeks Conclusions 1. Of the total of 60 suspected CDI, there are CDI confirmed 47 (78.33%): F(30)>B(17), U(34)>R(13). 2. Of the total of 47 CDI confirmed (100%) there are: - 3 (6.38%) CDI confirmed complicated: F(2)>M(1), U(2)>R(1), with diagnosis Septic toxic condition (3), from which 1 case with “Toxic Megacolon. Ascites” - 10 (21.27%) are CDI with relapse: M(7)>F(3), U(7)>R(3). - 46 (97.87%) are cases CDI hospitalized in the last year: F(30)>M(16), U(33)>R(13). - 18 (38.30%) are CDI confirmed who performed treatment with IPP. - 4 (8.51%) are CDI confirmed by colonoscopy with pseudomembranous colitic aspects: F(2)=M(2), U(3)>R(1) – accessibility of urban! 3. Of the total of 46 CDI confirmed hospitalized in the last year, according to the criterion “Last discharge”: under 4 weeks (40 - 86.95%)> 4 – 12 weeks (4 - 8.69%) > over 12 weeks (2 - 4.05%) 4. CDI confirmed – history of: Surgery in the last 2 weeks (2) Contact with another CDI case (3). Immunosuppression - 1 case: M – U, HIV.Total – 6 cases - 12.76% of the total of 47 CDI confirmed. 5. Hospitals where patients CDI confirmed were hospitalized are different (County Hospital - 19 F – 63%, 11 M – 37%). 6. Previous antibiotic therapy: 1 antibiotic was used in 11 (23.40%) cases and combination of antibiotics in 36 (76.60%) cases. In 30 (63.82%) cases there have been multiple courses. The necessity of monitoring the risk factors in the case of CDI. 31 Epidemiological elements focused on management of Clostridium difficile infections in Clinical Hospital of Infectious Diseases, Constanța, period 25 June 2014 – 25 June 2015 Iulia Gabriela Serban1*, Andra Elena Petcu1 *[email protected] Clinical Infectious Diseases Hospital of Constanța, Romania 1 Background Approached theme is important for accurate epidemiological management elements of the Clostridium difficile infections (CDI), within health service in Romania, is relevant to the organization, operation and development of health services systems Argument - Mode of knowledge selforganization, opportunity to build new understanding, analysis and epidemiological interpretation Methodological training opportunity, argument, issuing suggestions, practical proposals, elaboration developing strategies of perspective now is a professional context of personal interest. Epidemiological measures to limit local epidemic evolution. Objectives - Reporting the CDI from 1 year period (25 June 2014 - 25 June 2015) in the Infectious Diseases Clinical Hospital, Constanta. Updating database. Methods We reviewed the CDI documentation of one year. Results There are 88 cases suspected CDI hospitalized distribution according to gender (50F – 56,81%/38M – 43,18%), from which 66 (75%) CDI confirmed. There are 3 CDI confirmed with complications, 14 CDI relapses, 60 cases with admission in hospital in the last year. Previous administration of antibiotics in the last 3 months in 64 situations. 1 case with just one antibiotic, 46 cases with combinations of antibiotics. Number of cures of antibiotic therapy was different (1 cure / 26 cases, 2 cures / 14 cases, 3 cures / 16 cases, 4 cures / 8 cases). History of cytostatin therapy in 3 situations, Proton pump inhibitors treatment in 20 cases. CDI confirmed by colonoscopy with pseudomembranous colitis aspect in 5 cases. Conclusions Considered the model of care in every hospital. We do not move the patient, we move us around. Prevention - restriction of antibiotic use. Wash hands (no alcoholic gel) with liquid soap and water, gloves, probiotics (Bifidolactobacillus, Saccharomyces) Limiting the development of CDI - national guide, public education, limitation the interpersonal transmission. Multi Interventional Strategy - Epidemiological measures of hospital control - individual room, patients group, dedicated staff, contact isolation, disinfection – continuous, terminal, rescue vehicles - request buttons, linens, beds, tables, telephones, walls. Disinfection, with correct dilution: detergent disinfectant - quaternary ammonium salts, chlorine disinfection - sodium hypochlorite 10% surfaces, and terminal disinfection - peracetic acid, hydrogen peroxide. Perioperative prophylaxis 24 hours (one dose 30-60 minutes before) Programs of good practice in the field of antibiotics use in the hospital. Antibiotic Guide updated with data from Romania. Isolation stops after 3 days of normal stool. Microbiome fecal transplant. A case of tularemia glandular form in Republic of Moldova Ina Bistritchi1*, Liviu Iarovoi1, Tiberiu Holban1, Lilia Cojuhari2 *[email protected] 1 Department of Infectious Diseases, Parasitology and Tropical Medicine Nicolae Testemițanu State University of Medicine and Pharmacy, Chișinău, Republic of Moldova 2 Department of Infectious Diseases, Faculty for Continuing Medical Education, Nicolae Testemițanu State University of Medicine and Pharmacy, Chișinău, Republic of Moldova Background Tularemia is a rare infectious pathology caused by the bacterium Francisella tularensis, which is nonmotile. It can present different clinical forms, with involvement of lymph nodes, lungs and other internal organs. Glandular tularemia is also rare, and it is clinically similar to the ulceroglandular form, except without the development of a skin ulcer. It is acquired through the skin, and may not require a scratch or abrasion. In the Republic of Moldova, cases of tularemia are rarely reported. Thus, since 1991, only six human tularemia cases were registered. Out of which, 4 cases were registered in 1994, 1 case in 2009 and the 6th is described here. Case report We present a case of a 48 years man hospitalized to Clinical Infectious Disease Hospital "Toma Ciorbă" with a diagnosis of respiratory infection. The patient was admitted with asthenia, fever, pain on swallowing, dry cough, myalgia, pain in the eyeballs, left axillar lymphadenopathy. After 2 days without fever, on antibiotic treatment with ceftriaxone and metronidazole, the temperature increased to 37.9°C; objective data: hyperemia of 32 throat, dry cough, persistent painless left axillar lymphadenopathy and epidemiological data infected wound left thumb, in his household has cattle, pigs, rabbits and sometimes he observed rats. Local axillary bubonic description - size approximately 1 cm x 2 cm, painless, non-stick, soft, unilaterally on the left. Combination of this two antibiotics was continued 7 days and concomitant was positive ELISA test for tularemia: IgM – 3.488 U/mL (N˂0.41 U/mL), IgG – 1.877 U/mL (N˂0.47 U/mL); blood culture was negative and we confirmed patient with tularemia glandular form. Patient was hospitalized for 21 days, out of which he was treated for 7 days with ceftriaxone and metronidazole without improving the general condition, with persistent fever and after positive tularemia test; treatment was continued 14 days with ciprofloxacin and gentamicin. On the second antibiotic combination ciprofloxacin and gentamicin fever gradually normalized, affected lymph node decreased in size being about 0.5 cm x 0.5 cm, other clinical signs remitted. Prolonged evolution of the disease and prolonged hospitalization was due to the difficulty of diagnosis. Conclusions Considering that currently tularemia is a rare disease, it is difficult to establish the diagnosis and thus causing difficulty in determining treatment regimens. Severe Anemia in AIDS. Case report. Mihai Olariu1*, Adina Ilie1, Cristina Olariu1,2, Camelia Dobrea2,3, Didona Vasilache3, Adriana Nurciu4 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Fundeni Clinical Institute, Bucharest, Romania 4 University Emergency Hospital of Bucharest, Romania Background Many times, HIV-infected patients are anemic. Anemia is seen in 80 percent of patients at some point in their course. Causes range from ineffective hematopoiesis to significant hemolysis. Case report We present a case of a 28 year old, occasional drug user, who was diagnosed in November 2014 with HIV and coinfection with HBV and HCV. At that time the patient had a normal blood count, CD4 14 cells/cmm, without inflammatory syndrome and the viral load was 19675 copies/mL. From November to May 2015 the patient was treated with Lamivudine/Zidovudine and Lopinavir/r. In May 2015 blood count showed severe anemia with macrocytosis (hemoglobin 4.8g/dL) and leukopenia (1.4x103/µL) with neutropenia (0.864x103/µL), CD4 11 cells/cmm, and we considered that all these changes were due to antiviral therapy. We administered two units of packed red blood cells and changed antiviral therapy with Abacavir/Lamivudine and Raltegravir. After one month, on June 30, the patient came back with arthralgia, tachycardia, dyspnea, pallor, with hemoglobin 2.9g/dL, leukopenia and the marker for hemolytic anemia was negative. We administered three units of packed red blood cells and performed a bone marrow biopsy. Histopathological exams show many erythroblasts with prominent nuclear inclusions, which are characteristic of parvovirus B19 infection. We performed serology for parvovirus B19. Patient was treated initially with cortisone and then with intravenous immune globulin and hemoglobin increased to 7.3g/dL. Conclusions Pure red cell aplasia in human parvovirus B19 infection have occurred in HIV-infected patients with advanced immunosuppression. Most cases of pure red cell aplasia have occurred prior to the availability of potent antiretroviral therapy. We must always search for a human parvovirus B19 infection in patients with immunodeficiency and severe anemia. Epidemiological management in Clinical Infectious Diseases Hospital of Constanţa, Romania Iulia Gabriela Serban1*, Stela Halichidis2, Claudia Cambrea2 *[email protected] Clinical Infectious Diseases Hospital of Constanța, Romania 2 Faculty of Medicine, “Ovidius” University, Constanța, Romania 1 Background Constanta is an important town from Romania and “Clinical Hospital for Infectious Diseases” is one of the most famous in S-E Europe, a reference hospital in our region, with recent renovations and facilities financed by the Ministry of Health, Local Council and World Bank, which allowed assisting patients at high standards; specialist care are made, with a focus on epidemics, food poisoning, for the 33 tourists, especially during the summer, rabies prophylaxis, infectious diseases treatment, tropical imported diseases for the travelers and sailors, Center of Excellence for HIV patients - currently: cooperation with Baylor on HIV – AIDS, Travel Medicine– Summer School: medical subjects about pilgrimages, tourism, cruising and camps, general epidemiological surveillance - influenza, digestive diseases, West Nile... It is a certified hospital according to Quality Management System ISO 9001 / 2008 and the epidemiologist was responsible for quality management. It is the only accredited hospital in the city, according to the Standards of the National Commission for the Accreditation of Hospitals. Laboratory quality meets national standards. High patient turnover in the clinic. Methods We presented: - risk areas of the hospital, calculated according to the scale of national surveillance Guide on nosocomial infections. chronologically the nosocomial infections reported, length of stay and duration of treatment. We quantified the number of communications, internal notes on nosocomial infections, hospital departments addressed, in the period 2011-2014. We showed the number of patient satisfaction questionnaires completed between 2011 - 2013, the number of epidemiological surveys carried out in 2012 - 2014 and epidemiological investigation with conclusions and recommendations. Results There were 676 epidemiological internal communications addressed to hospital departments in 2012, 665 in 2013, 486 in 2014, 392 in the first 6 months of 2015. During 2014 - the mortality rate was 0,3%, we registered one respiratory viral nosocomial infection, were 35258 consultations and 6919 hospitalized patients. In the first 6 months of 2015 were 3782 hospitalized patients, 16318 consultations and 25051 days of hospitalization. Conclusions All insured hospitalized patients benefit of free of charge medical investigations and treatment, according to the hospital’s own procedures, protocols - that respect medical standards, the national and international practice guidelines, improving the patient assistance for a better evolution of the health condition. Nephrotic syndrome in a patient with HBV chronic hepatitis 1 Fundeni Clinical Institute, Bucharest, Romania Background Chronic HBV hepatitis is known to be associated to different types of nephropathies, including membranoproliferative glomerulopathy and IgA nephropathy. Also, antiviral treatment (entecavir) increases the risk of renal affections. However, a clear diagnosis in case of renal disease associated with chronic HBV hepatitis can be established only by kidney biopsy. Case report We describe a rare case of nephrotic syndrome caused by an association of IgA nephropathy and Alport syndrome in a 37 years old woman with chronic HBV infection. We underline the importance of histopathological analysis of kidney biopsy, crucial not only for diagnosis but for attentive screening of family members. The patient presented for persistent proteinuria (over 4000mg/24 hours). She had been diagnosed with chronic HBV hepatitis in 2003, with nephrotic syndrome at diagnosis. She had been treated with lamivudine for 2 years, then entecavir, and azathioprine. The nephrotic syndrome persisted, therefore she was referred to our clinic for further evaluation and treatment. Laboratory tests showed no signs of liver cytolysis, DNA-HBV undetectable, HBeAg negative, normal renal function, proteinuria 4.2g/24 hours. Liver biopsy performed before initiating treatment with lamivudine revealed a Knodell score of 10moderate inflammation. We performed kidney biopsy. Optical microscopy revealed numerous lipid-laden foam cells (marker of Alport syndrome) in the interstitium. Ultrastructural studies by electron microscopy showed important changes in the glomerular basement membrane (GMB): alternation between increased and reduced thickness of GMB with splitting of the lamina densa, electrondense deposits in the mesangium. Podocytes showed diffuse effacement of foot processes. Immunofluorescence microscopy showed deposits of IgA in the glomeruli. We started pulse therapy with methylprednisolone and after the first administration urinary protein levels decreased to 3.9g/24 hours. Conclusions To our knowledge there has been no other case report of associated HBV infection, Alport syndrome and IgA nephropathy. Choosing the right therapeutic approach to combine immunosuppression and antiviral treatment is the key of good outcome of the patient. Letitia Toma1*, Bogdana Ioana Pulhac1, Monica Berechet1, Laura Iliescu1 *[email protected] 34 Clinical and biochemical manifestation of the acute C viral hepatitis in Republic of Moldova Lilia Cojuhari1*, Victor Pantea1, Gheorghe Placinta1, Valentin Cebotarescu1, Liviu Iarovoi2, Viorica Cotos3 *[email protected] cm in all patients (100%) and splenomegaly – 2.0±0.2 cm in 27 patients (45.8%). Conclusion Acute hepatitis C virus affects both sexes, being more frequent in men, and is manifested through acute onset in the icteric form, moderate form being characterized clinically by the dyspeptic, asthenic, and biochemical syndrome through the ALT activity increase and bilirubin. 1 Department of Infectious Diseases, Faculty for Continuing Medical Education, Nicolae Testemițanu State University of Medicine and Pharmacy, Chișinău, Republic of Moldova 2 Department of Infectious Diseases, Parasitology and Tropical Medicine Nicolae Testemițanu State University of Medicine and Pharmacy, Chișinău, Republic of Moldova 3 Clinical Infectious Diseases Hospital ”Toma Ciorbă”, Chișinău, Republic of Moldova Background The World Health Organization reports that 3% of the globe’s population has had HCV infection and that there are more than 170 million chronic carriers at risk of liver cirrhosis and/or liver cancer. Methods In this study were included 59 patients with acute C viral hepatitis who were hospitalized in the Toma Ciorbă Clinical Infectious Diseases Hospital aged from 45.3±0.6 years. The analysis parameters: age, sex, clinical manifestation, liver size, disease level, total bilirubin, ALT, prothrombin. Results The largest share of damage can be seen in the 3039 age range - 22 (37.3±6.3%) cases, followed by the 40-49 age group - 19 (32.2±6.1%) cases. Transmission pathways: after various medical interventions (dentistry, surgery) were infected 27 (45.8±6.5%) patients, intravenous drug - 13 (22.0±5.4%) patients, about habitual - 6 (10.2±3.9%) patients, after transfusion of blood derivatives - 3 (5.1±2.9%) patients, after tattoos - 2 (3.4±2.4%) patients. 8 (13.6±4.5%) patients of infection pathway has not been determined. Acute C viral hepatitis in the both sex has been observed: women – 25 (42.4±6.4%), men – 34 (57.6±6.4%). The disease more frequently is manifested in icteric form in 39 (66.1%) patients, anicteric form in 20 patients (33.9%). Depending on the severity of the disease most commonly has been average form 83.1% cases, severe form – 6.8% and mild form – in 10.1% cases. Acute C viral hepatitis includes asthenic, dyspeptic and althralgic syndrome. Biochemical investigations: increased level of bilirubin 132.1±16.01 mkmol/L, ALT constitutes 10.80±0.61 mmol/h/L and thrombinic index – 77.10±1.26%. Hepatomegaly constitutes 3.5±0.16 Varicella complicated by thrombocytopenia case report Oana Obretin1*, Augustin Cupsa2, Maria Marinescu1, Lucian Giubelan2 *[email protected] “Victor Babeș” Clinical Hospital of Infectious Diseases and Pneumology, Craiova, Romania 2 University of Medicine and Pharmacy Craiova, Romania 1 Background Chickenpox may be complicated by thrombocytopenia, more common in adults than in children; platelet count is usually above 25,000/cmm, bleeding events are rare in these cases. The literature discusses both about immunologic mechanisms and non-immune mechanisms responsible for the low platelet count. Case report We present a male patient, 5 years old, hospitalized in Craiova in May 21, 2015 in Infectious Diseases Victor Babeș Hospital for fever associated with a polymorphic exanthema elements (patches, papules, vesicles), disseminated evolving “in waves” 6 days before the admission. He was diagnosed with varicella and acyclovir antiviral treatment was started, 200mg, 4 times daily. At 3 days of treatment he developed small hematomas in right tibia, right iliac crest and retroauricular. The complete blood count performed revealed severe thrombocytopenia (2000 / mm3). We decided to transfer the patient to the Institute for Infectious diseases “Matei Balș” in Bucharest to address the platelet deficit. There positive IgM anti VZV were detected, HIV ELISA test was negative and immunoelectrophoresis and levels of complement C3, C4 were normal. During hospitalization he received platelet concentrate izogrup, izoRh150mL - 2 administrations, corticosteroids and acyclovir antiviral treatment continued 800mg/day, 3 days, with favorable outcome of platelet count and gradual remission of purpuric lesions, the patient is discharged on 31 May. 35 As mechanisms of occurrence of thrombocytopenia, are immune causes (chronic autoimmune thrombocytopenia, autoimmune thrombocytopenia associated with collagen disease, certain drugs, post-transfusion purpura) and non immune causes (bacterial and viral infections). In the case of our patient immunoelectrophoresis and levels of C3, C4 were within normal limits, which does not tilt to an immune cause. Rapid administration of thrombocyte, prevent the onset of complications of thrombocytopenia (gastrointestinal bleeding or cerebral), described in the literature. Conclusions Severe thrombocytopenia associated with varicella in children is a rare complication, but can be lifethreatening, through the possible bleeding as cerebral bleeding, which is the most severe complication in children. Effective collaboration between doctors led to favorable resolution of the case described. A rare case of ocular filariasis with recurrent episodes of acute anterior uveitis Alexandra Elena Sarbu1, Sanda Popa1,2, Cristian Bengus1, Emanuela Dumea1, Andrei Anghelie1, Clara Matei3, Maria Isabela Sarbu4*, Mircea Tampa3,4, Simona-Roxana Georgescu3,4 *[email protected] 1 Department of Ophthalmology, "I Care Clinic", Bucharest, Romania 2 Department of Ophthalmology, Emergency Eye Hospital, Bucharest, Romania 3 Department of Dermatology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania 4 Department of Dermatology, "Victor Babeș" Hospital of Infectious Diseases, Bucharest, Romania Background Intraocular filariasis is rare in humans but frequent in animals. Zoonotic filarias are nematodes belonging to the Filarioidea superfamily. Dirofilaria are the most frequent nematodes affecting humans and are transmitted by bloodfeeding arthropods. It usually manifests as larva migrans or subcutaneous nodules and only rarely affects the eye. Case report We report the case of a 56 year old female, Caucasian patient from the urban area who addressed our clinic for blurred vision and conjunctival hyperemia. Her family history was unremarkable. The disease had occurred approximately 37 years before when the patient presented urticarial lesions with intensely positive patch tests for all tested antigens. After several months she presented with blurred vision, conjunctival hyperemia and pain in her right eye and was diagnosed with acute anterior uveitis and treated with antibiotics, anti-inflammatories and mydriatic agents. She presented recurrent episodes of uveitis in both eyes ever since. The patient permanently moved to Costa Rica four years later where she was diagnosed with ocular filariasis.. Peripheral blood smear examination was performed in Costa Rica and was positive for Dirofilaria, Strongyloides stercoralis and Toxocara canis. Ocular examination of the right eye showed pupillary seclusion occlusion and keratic precipitates. Visual acuity was hand movement perception for the right eye and 60/60 for the left eye. Ocular ultrasound revealed no involvement of the posterior pole. She was treated with diethylcarbamazine, ivermectin and albendazole as well as corticosteroids. Despite the treatment, the patient presented yearly re-occurrences of the disease which required high doses of prednisolone and anti-parasitic agents. Conclusions Even though the disease was diagnosed in Costa Rica, the affliction was probably acquired in Romania as the symptoms occurred four years before the patient departed. While very few cases of filariasis were documented in our country so far, the incidence of the disease is increasing in other European countries. We therefore suggest that ocular filariasis should be suspected in cases of recurrent anterior uveitis of unknown etiology. Acknowledgement This paper is partly supported by the Sectorial Operational Programme Human Resources Development (SOPHRD), financed by the European Social Fund and the Romanian Government under the contract number POSDRU 141531. Acute hepatic failure. Comatose chronic viral hepatitis B. Acute viral hepatitis E. Case presentation. Adelina-Raluca Marinescu1*, Alexandru Crișan2, Narcisa Nicolescu2, Virgil Musta2, Voichița Lăzureanu2, Luci-Cecilia Rotar1, Ruxandra Laza2 *[email protected] Dr. Victor Babeş Clinical Hospital of Infectious Diseases and Pneumology, Timişoara, Romania 1 36 Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 2 Background Acute hepatic failure is a rare condition representing the quick deterioration of the hepatic function with the alteration of the mental status and the emergence of hemorrhagiparous syndrome in individuals previously considered healthy. This pathology remains topical because of its high risk of morbidity and mortality. Case report We present the clinical case of a male 56 year-old patient, from the rural area, a shepherd, with multiple comorbidities, admitted into Clinic II of the Infectious Diseases and Pneumophtisiology “Victor Babeș”, Timișoara, with the diagnosis of chronic viral hepatitis B. Acute infection with hepatic virus E has stimulated the emergence of acute hepatic failure in a patient with chronic infection with virus B. Afterwards, the members of the patient’s family (wife and 2 children) have also been found out to be asymptomatic carriers of B virus. Conclusions The concomitant infection with hepatic virus B and E (rare in our days) proves the uniqueness of the case, with an unfavorable response to the treatment, despite the complex paraclinical investigations. It is notable the fact that, even though there is the possibility of performing the serologic investigation in the case of hepatic virus E infection, it is currently underestimated in our country, because in many of these situations, this pathology does not fit into the diagnosis algorithm of hepatic conditions. diversity of the etiologic agents and the seriousness of the clinical manifestations. In infants and small children the symptomatology is more severe, therefore imposing a quick diagnosis and, implicitly, an appropriate therapy. Methods The work contains a cross-observational retrospective study, performed on 458 children admitted in Clinic II of the Hospital for Infectious Diseases and Pneumophtisiology “Victor Babeş”, Timișoara, during May 2014 – April 2015. Results Acute diarrhea represented 30% of the total of admitted children (1569 children). The highest acute diarrhea morbidity has been registered in children aged 0-2. From the multitude of pathogen agents, a significant part (61%) has remained undiagnosed. The distribution of the identified etiologies has been in decreasing order: Rotavirus (120), Salmonella (42), E. coli (6), Giardia lamblia (6), Shigella (2), Candida (1). Average seriousness clinical forms predominated. Conclusions Within the last years the number of Rotavirus diarrheic diseases has increased, whereas the number of bacterial etiology diarrheic diseases, such as Shigella and E. coli, has certainly decreased. Because of the large number of uncertain etiologies, an improvement of the bacteriologic results’ accuracy is necessary. Stand to be discussed the diagnosis possibilities of other viral infections, as well as those of some bacteria that cannot be diagnosed routinely at the moment. Acute bacterial meningoencephalitis. Subdural collections. Case presentation. Clinico-aethiologic considerations in acute diarrhea at children Narcisa Nicolescu1*, Alexandru Crișan1, Voichița Lăzureanu1, Virgil Musta1, Adelina-Raluca Marinescu2, Mihaela Stanca Pleș3, Ruxandra Laza1 Ruxandra Laza1*, Alexandru Crișan1, Narcisa Nicolescu1, Voichița Lăzureanu1, Virgil Musta1, Amelia Blescun2, Adelina-Raluca Marinescu3 *[email protected] Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 2 Dr. Victor Babeş Clinical Hospital of Infectious Diseases and Pneumology, Timişoara, Romania 3 Emergency Clinic Hospital County "Pius Brînzeu" Timişoara, Romania 1 *[email protected] Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 2 “Dr. Teodor Andrei” Lugoj County Hospital, Lugoj, Romania 3 Dr. Victor Babeş Clinical Hospital of Infectious Diseases and Pneumology, Timişoara, Romania 1 Background Acute diarrhea is one of the important public health problems because of its high incidence, the Background Bacterial meningites represent another infectious pathology current problem despite the progress made, especially within the last years. At sucklings and small children the diagnosis is even more difficult, especially if there are other associated pathologies as well. 37 Case report We present to you the case of a male 3 year-old suckling, admitted between 27.05-19.06.2015, into the Hospital for Infectious Diseases and Pneumophtisiology “Victor Babeş”, Timisoara, with the following diagnosis: 1. Acute bacterial meningoencephalitis; 2. Bilateral fronto-parietotemporal subdural collections; 3. Cranial post traumatic status; 4. Mixed anemia; 5. Thrombocytosis; 6. Minor tricuspid regurgitation; 7. minimal pulmonary regurgitation. The suckling has been transferred to the Neurology clinic for the draining of the subdural collections. The suckling’s evolution was slowly favorable, with ulterior NPI dispensation and Pediatric Cardiology. Conclusions At sucklings and small children, the symptomatology is more atypical, which represents a hindrance in establishing the diagnosis of meningitis. The bulginess of the fontanelle represented an essential alarm signal in the presented case. Cranial trauma, even if minor, combined with other factors can sometimes generate complications in this small age group. The imagistic intake, respectively the cerebral MRI, has been essential in establishing the diagnosis, with a benefic collaboration of various specialty branches of medicine. Key words: meningoencephalitis, fontanelle’s bulginess, subdural collections. Recurrent bacterial meningitis in a patient with transethmoidal nasal meningoencephalocele Liana-Catalina Gavriliu1,2*, Otilia-Elisabeta Benea1,2, Loredana Lazar1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Recurrent bacterial meningitis is a less common clinical entity, but it poses more serious diagnostic challenges and it often requires extensive tests in order to determine any underlying pathology. Case report We present the case of a 27 year-old patient with a history of Waldeyer’s ring non-Hodgkin lymphoma, for which he was treated, cured and dismissed from hematological follow-up for 10 years and a history of 3 episodes of bacterial meningitis: 13, 9 and 7 years previously, who presented to the emergency room in march 2015 with symptoms compatible with meningitis. Cerebrospinal fluid (CSF) exam established the diagnosis of bacterial meningitis. CFS Gram staining showed gram-positive diplococci. The CSF cultures were negative. The patient was started on Ceftriaxone and Vancomycin, Dexamethasone 0.5 mg/kg and symptomatic treatment. Serologic test for HIV was negative. Immunoglobulin A,G, M and complement levels were normal. Chest and sinus X-ray exams were unremarkable. Ear-nose-throat exam didn’t reveal abnormal structures, rhinorrhea or otorrhea. The brain magnetic resonance revealed a bony defect at the right cribriform plate, continued with a small sac into the right nostril, between the nasal septum and the right nasal cornet. The patient was treated for 14 days. He was discharged in the 16th day and he was referred to a neurosurgical clinic for the treatment of the anatomical defect. One of the anatomical abnormalities leading to recurrent bacterial meningitis is encephalomeningocele. According to the literature data, it is usually present in pediatric patients and the correct diagnosis of the predisposing condition of the recurrent meningitis is often delayed for many years. Our patient had the first episode of meningitis at the age of 14 and the gap between the first episode of bacterial meningitis and the diagnosis of the predisposing condition was 13 years. Another issue that we took into consideration in our patient was the vaccination against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae. This approach is recommended in some cases of recurrent bacterial meningitis, although it is questionable in the cases secondary to anatomical abnormalities. Due to the fact that the patient was going to be subjected to the surgical repair of the anatomical defect, we decided not to proceed with the vaccination. Conclusions This case emphasizes the fact that anatomical abnormality should also be carefully assessed in adult patients with recurrent meningitis, its closure being essential in order to prevent further episodes of bacterial meningitis. Antimicrobial resistance of Staphylococcus aureus strains isolated from blood in INBI “Prof. Dr. Matei Balș” in 2014 Liana-Catalina Gavriliu1,2*, Otilia-Elisabeta Benea1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 38 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Increasing antimicrobial resistance of Staphylococcus aureus (SA) is a concerning problem all over the world. According to the latest European Antimicrobial Resistance Network (EARS-Net) report, Romania reports an increasing number of methicillin-resistant Staphylococcus aureus (MRSA) strains isolated from invasive infections. We analyzed the antimicrobial resistance of SA strains isolated from blood in 2014 in the National Institute for Infectious Diseases (INBI) “Prof. Dr. Matei Bals”. Methods We analyzed the antimicrobial susceptibility tests of SA strains isolated from blood between January 1st-december 31st 2014 and between January 1stdecember 31st 2010, in INBI “Prof. Dr. Matei Bals”. We compared the evolution of the resistance between these two periods. The statistical analysis was performed using the Fisher exact test. p<0.05 was considered statistically significant. Results We identified 51 strains of SA isolated from blood in 2014: 92.15% penicillin-resistant, 64.7% MRSA, 68.62% resistant to macrolides, 64.7% resistant to tetracycline, 5.88% resistant to ciprofloxacin, 1.96% resistant to rifampicin, 9.8% resistant to gentamicin, 0% resistant to trimethoprimsulfamethoxazole. From the 33 strains of MRSA, 87.87% were resistant to macrolides, 84.84% resistant to clindamycin, 87% resistant to tetracycline, 9.09% resistant to ciprofloxacin and gentamicin, 3.03% resistant to rifampicin. We found no resistant strains to trimethoprimsulfamethoxazole, vancomycin or linezolid. We identified 58 strains of SA isolated from blood in 2010: 91.37% penicillin-resistant, 56.89% MRSA, 47.36% resistant to macrolides, 42.30% resistant to tetracycline, 15.51% resistant to ciprofloxacin, 12.96% resistant to rifampicin and to gentamicin. From the 33 strains of MRSA, 53.12% were resistant to macrolides, 15.62% resistant to clindamycin, 53.57% resistant to tetracycline, 21.21% resistant to ciprofloxacin and 20.69% resistant to gentamicin, 20.69% resistant to rifampicin. We found no resistant strains to trimethoprim-sulfamethoxazole, vancomycin, linezolid. Comparing these two periods we found: statistically insignificant increase in MRSA (p=0.43). Among the MRSA we found increasing resistance to macrolides (p=0.02), clindamycin (p=0), tetracycline (p=0.008) and a decreasing resistance to trimethoprim-sulfamethoxazole (p=0.08), rifampicin (p=0.05), gentamicin (p=0.28). Conclusions 1. The number of SA strains isolated from blood were similar: 58 in 2010, 51 in 2014 2. The percentage of MRSA strains increased statistically insignificant between 2010-2014, from 56.89% to 64.7%. Our data are similar to those reported to EARS-Net by our country (64.5% in 2013) 3. Between 2010-2014 we found a statistically significant increase of the resistance to macrolides, clindamycin, tetracycline and a statistically insignificant decrease of the resistance to trimethoprim-sulfamethoxazole, rifampicin and gentamicin. 4. We didn’t find any strains resistant to vancomycin and linezolid. Milker's nodules: differential diagnosis challenges Mircea Tampa1,2, Maria Isabela Sarbu2*, Madalina Mitran2, Cristina Mitran2, Clara Matei1, Monica Costescu1,2, Ilinca Nicolae2, Vasile Benea2, Simona-Roxana Georgescu1,2 *[email protected] 1 Department of Dermatology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Dermatology, "Victor Babes" Hospital of Infectious Diseases, Bucharest, Romania Background Milker's nodule is a skin infection caused by a Parapoxvirus. It is a common zoonosis affecting cattle worldwide. Humans are infected through direct contact with infected cattle or contaminated meat. It is an occupational disease affecting milkers, veterinarians and butchers. Case report We report the case of a 54 year old male, Caucasian patient from the urban area who addressed to our hospital for multiple, bluish, tender nodules located on both hands. The lesions had occurred approximately two weeks before, initially as erythematous macules which then turned into papules and nodules. The patient worked as an engineer in the urban area. A thorough anamnesis revealed that he had spent his vacation at a farm but the patient denies having had direct contact with any of the animals. However, he does admit having had contact with fresh cow meat that he had personally prepared. The patient was otherwise healthy. The local examination revealed multiple, bluish, tender nodules, some of them covered by crusts, located on the palms and lateral aspect of the fingers. One of the lesions was ulcerated. A total blood count was performed and was within 39 normal range. Syphilis tests were negative, as was the tuberculin skin test. The differential diagnosis included pyogenic granuloma, pyoderma, giant molluscum contagiosum, keratoacanthoma. However, all these lesions tend to be solitary. Orf was also excluded as the patient denied having had any contact with sheep, goats or their meat. A biopsy was taken from one of the lesions and showed irregular acanthosis, papillary dermal edema and mixed inflammatory infiltrate. Based on the clinical features, anamnesis and histopathological examination the patient was diagnosed with milker's nodules. Since the disease is self-limited he only received symptomatic treatment and the lesions resolved after approximately one month. Conclusions Milker's nodule is an occupational disease which usually occurs in milkers, veterinarians or butchers after direct contact with the infected animals or fresh meat. It rarely affects people outside these professional categories. Therefore, a thorough anamnesis is required in establishing the correct diagnosis. Acknowledgement This paper is partly supported by the Sectorial Operational Programme Human Resources Development (SOPHRD), financed by the European Social Fund and the Romanian Government under the contract number POSDRU 141531. Prevalence of MRSA and their genetic characterization among microbial strains isolated from leg ulcers in dermatological patients Mihaela Georgescu1,2,3*, Irina Gheorghe2,3, Marcela Popa2,3, Florin Constantin Ghiaţău1, Mariana Carmen Chifiriuc2,3 *[email protected] 1 Central Universitary Emergency Military Hospital Dr Carol Davila, Bucharest, Romania 2 University of Bucharest, Faculty of Biology, Microbiology Department, Romania 3 Research Institute of the University of Bucharest ICUB, Romania Background Infections play an important role in the delayed healing of leg ulcers. The majority of chronic leg wounds presents signs of infections and are one of the main reasons for admission in the hospital. Various reports in the literature suggest that most of the isolated bacterial strains belong to Staphylococcus spp., with the predominance of Staphylococcus aureus. SCCmec (staphylococcal cassette chromosome mec) is a mobile genetic element characterized by the presence of two complexes, i.e. mec, containing the mecA gene and ccr, responsible for the mobility of mecA and of other resistance or virulence genes. Methods A total number of 83 bacterial strains were isolated from 63 patients with leg ulcers, admitted in the period December 2014 – June 2015 in the Dermatology Department of SUUMC Dr Carol Davila, Bucharest. The isolates were identified by using the conventional biochemical tests. We used PCR to determine the presence of the following genes responsible for antibiotic resistance profiles: mecA, SCC mec V1J, ccr, type IVa. Results From the total of bacterial isolates, 28 were Staphylococcus spp. strains, out of which 10 were methicillin-resistant Staphylococcus aureus (MRSA), 11 methicillin-susceptible Staphylococcus aureus and 7 were coagulase-negative staphylococci. PCR was further used to detect the essential genetic components of SCCmec. The molecular analysis of the MRSA isolates revealed the following SCCmec elements: 6 of the 10 MRSA isolates were positive for mecA gene, correlated with the presence of cif2 gene; 4 strains exhibited the SSC mec typeIVa, which is the signature of the community acquired MRSA isolates (the rest of the MRSA isolates could not be subtyped) and 1 isolate harbored the ccr gene. Conclusions The obtained results have shown that the MRSA strains isolated from chronic leg ulcers belong to the SCCmec type IVa. The phenotypic methicillin resistance is not always correlated with the presence of mecA gene, but some of the SCCmec cassette elements are always present in the resistant strains. Tuberculosis in a patient with psoriasis vulgaris on anti TNF α therapy – a case report Mihaela Georgescu1*, Anton Mihai Ţilea1, Marcela Poenaru1 *[email protected] 1 Central Universitary Emergency Military Hospital Dr Carol Davila, Bucharest, Romania Background Anti tumor necrosis factor (TNF) α therapy for psoriasis vulgaris implies an increased risk of infection. The 3 anti TNF α drugs approved in 40 Romania have different degrees of safety regarding tuberculosis. Case report A 46 years old patient known with psoriasis vulgaris from 1998 which had different systemic treatment and without other comorbidities was eligible for biological therapy. The patient began therapy with Infliximab in September 2009, (5mg/kg – 4fl [400mg] 0, 2, 6 weeks followed by 4fl/8 weeks). In February 2011 the patient received the last intravenous perfusion with Infliximab. In April 2011, coming for the regular Infliximab perfusion, the patient complained of dyspnea, fatigability, weight loss, 37-37.9 degrees Celsius. The pulmonary X-ray revealed pleurisy. The echocardiography showed pericarditis. The direct examination of the sputum demonstrated acidalcohol resistant bacilli (BAAR). The diagnosis of tuberculosis with pericarditis and pleurisy was established. The patient received the following treatment: hydrazide and ethambutol (for 6 months) and Prednisone 0.5 mg/kg. In June 2011 the diagnosis of tuberculosis was confirmed by growth on Löwenstein selective medium. In October 2011 the patient presented to our department in psoriatic erythrodermia. She was given Acitretin 30 mg per day and underwent ultraviolet light therapy with a maximum dose of 6 j/cm². The patient failed to sustain a remission. In May 2012 the patient began therapy with Etanercept 50mg x2/weeks sc for 4 months, then 50mg/week sc. So far the patient has not shown any signs of tuberculosis. Conclusions Etanercept shows a better safety profile compared with Infliximab regarding infection with Mycobacterium tuberculosis. Case report Female patient, age 26, from urban area, pet shop employee, no significant personal pathologic antecedents, was admitted in Clinic II of the Hospital for Infectious Diseases and Pneumophtisiology “Victor Babeş” Timisoara, between 02.07.2015-09.07.2015, with high fever, chills, predominant nocturnal sweat, dry cough, headache, myalgia, nausea and vomiting, symptomatology which appeared 2 weeks before coming to the clinic. The positive diagnosis of psittacosis was established through positive serology and radiologic investigation, corroborated with the patient’s job; in the diagnosis algorithm of the fever syndrome have been included atypical pneumonias as well. Conclusions A well-led anamnestic examination, joined with careful succession of high utility paraclinical investigations allowed stating a diagnosis of infectious pathology atypical for the geographic area we live in. Having a scarce and non-specific symptomatology, psittacosis remains an alert respiratory pathology, especially through the endemo-epidemic character it can have.. Acute atypical pneumonia. Case presentation. Objectives: To emphasize the importance of preventing Mycobacterium tuberculosis infection in general population, due to the outcome of the disease by itself and its complications. Case report A 63-year-old man was referred for audiovestibular investigations form an infectious disease hospital for hearing loss and severe walking problems after previous tuberculosis meningitis one year ago. Bed-side neuro-otological evaluation and audiometry revealed bilateral lesion of the inner ear, with secondary hearing impairment and disequilibrium. Bacterial meningitis with associated cranial nerve involvement is a severe complication of the primary infection and after the initial acute phase, patients still have important functional impairments. This is true also in this patient since tuberculosis meningitis and VIIIth nerve bilateral lesion has severe negative effects even after one year from the acute episode. Cochlear nerve lesions determined permanent Luci-Cecilia Rotar1*, Alexandru Crișan2, Narcisa Nicolescu2, Adelina-Raluca Marinescu1, Ruxandra Laza2 *[email protected] Dr. Victor Babeş Clinical Hospital of Infectious Diseases and Pneumology, Timişoara, Romania 2 Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 1 Background Pneumonia can most frequently emerge aerogenically, by sepsis hematogenic dissemination, but also by aspiration of secretions (neurologic conditions, comas, elder people) and by iatrogenic maneuvers (oro-tracheal intubation, bronchoscopy). Non-infectious sequelae of the tuberculous meningitis Madalina Georgescu1* *[email protected] 1 Institute of Phono-Audiology and ENT Functional Surgery, Bucharest, Romania 41 bilateral severe hearing loss. Even though the patient is wearing a hearing aid, the verbal benefit is limited due to the cerebral lesions provoked by the meningitis. Bilateral vestibular nerve lesions cannot be centrally compensated so the physical and functional consequences of this bilateral deficit are very difficult to overcome. After one year from the onset of the vestibular lesions, the patient still has severe walking problems since he did not have appropriate treatment from the onset of the lesion, enhanced now by the fact that he had a tibia fracture in one leg. We included the patient in a complex rehabilitation program, with specific vestibular rehabilitation exercises, in order to improve his static and dynamic equilibrium. The aim is to increase the patient quality of life, to regain his independence for walking and daily activities. Conclusions Mycobacterium tuberculosis infection is, unfortunately, very frequent in Romania nowadays. Meningeal involvement, with or without pulmonary tuberculosis lesions is common for the Infectious Disease units, so a thorough evaluation of patients with Mycobacterium tuberculosis infection is mandatory in order to define the lesions and to recommend the appropriate management protocol as soon as possible and benefit of the best neuroplasticity period. Evolutional morbidity particularities of viral infections preventable by vaccination in Dolj County Livia Dragonu1,2*, Dan Dumitru Hurezeanu1,2, Ludmila Prunariu3, Irina Niculescu1,2, Florentina Dumitrescu1,2, Andreea Cristina Stoian1, Lucian Giubelan1,2 *[email protected] 1 University of Medicine and Pharmacy Craiova, Romania 2 “Victor Babeș” Clinical Hospital of Infectious Diseases and Pneumology, Craiova, Romania 3 County Public Health Department Dolj, Romania Background Prophylactic vaccination is a health protection measure which has considerably altered the morbidity of some infections faced by humanity in previous centuries. The national vaccinations calendar in Romania includes prophylactic immunization against the following viral infections: hepatitis B, poliomyelitis, measles, rubella, mumps. The specific prevention through vaccination against varicella-zoster virus is not part of the routine immunization program. The study’s objectives target the morbidity evolution of these viral infections in Dolj County in relation to the application of specific prophylaxis. Methods A retrospective analysis (range 1994-2014) of morbidity by acute viral hepatitis B, poliomyelitis, measles, rubella, mumps and chickenpox was performed. The data from the Department of Statistics and County Public Health Department was used. The morbidity was expressed by the number of new cases of the disease reported annually at 100,000 inhabitants. Results The incidence of morbidity by measles has fallen to an average of 1.62 0/0000 endemic level with increases of epidemic caused by the accumulation of receptive mass during the 1997-1998 period (120 0/0000). The incidence of rubella has presented multiannual variations (between 0.27 and 192 0/0000) with a maximum level in 2012. The introduction of vaccination has led to a significant decrease of mumps infection morbidity (from 161.1 0/0000 to 1.12 0/0000) after 2006. Poliomyelitis has not registered any cases. Regarding acute viral hepatitis type B, after the introduction of vaccination, morbidity has registered a steady evolutionary downward trend from 36.8 0/0000 (1995) to 2.8 0/0000 (2014). In the absence of prophylactic immunization, chickenpox has presented an ascending morbidity trend that ranged between 82 0/0000 and 405 0/0000. Conclusions The specific prophylaxis has resulted in significant decreases of morbidity and even eradication of viral infection can be achieved under the circumstances of optimum vaccination coverage. The clinical surveillance and the seroprevalence studies identify in time the dangers of the restoring transmission of infectious agents among the receptive population. Cytomegalovirus acute viral hepatitis in an immunocompetent host Andreea Stefania Asiminoaei1*, Corina Itu1 *[email protected] 1 Clinical Hospital of Infectious Diseases, ClujNapoca, Romania Background Cases of viral hepatitis have been rarely incriminated to β-herpetoviridae. In acute viral hepatitis the main viruses that cause liver disorders are HAV, HBV and HCV. When the tests are all 42 negative, apart from autoimmune and toxic hepatitis there are those caused by the β/herpetoviridae families. We present a middleaged woman with acute cytomegalovirus hepatitis. Case report We reviewed all medical data regarding this case. A 57 year old woman from a rural area, is examined by the general practitioner for fatigue and sore legs. She noticed darker urine and pale stools. The routine tests shows a high level of liver enzymes and the patient is sent to Cluj-Napoca for further investigations. It must be mentioned that she had no underline disease but her son underwent treatment for viral hepatitis B. The patient complained of upper abdominal pain and was referred to the Gastroenterology and Hepatology Institute, where after performing blood tests and an ultrasound to exclude a gallbladder stone blockage the patient was transferred to our hospital. The test results revealed acute hepatitis with high level of TGP and TGO, cholestasis and mild hyperbilirubinaemia. The immunologic tests were negative for IgM HAV, IgM HBc, Ag HBs, antiHCV, HIV. The IgG CMV was nonreactive and the IgM CMV was reactive. During the hospitalization period she accused only fatigue and sore legs, without dyspeptic syndrome. The patient received Ampicillin 5 days and supportive therapy, liver protectors, amino acids, antacids, and antispastic therapy. After 2 weeks the clinical and laboratory examinations were good, with the decrease of the liver enzymes. Upon discharge the IgG CMV was reactive with a count of antibodies of 52UA/mL. Conclusions Cytomegalovirus hepatitis is rare in an immunocompetent host and the infection is usually subclinical. The diagnosis was sustained by seroconversion. The case had a good outcome without antiviral therapy. Contraceptive behavior among long survivors, nosocomially HIV-infected women in Galati County 1 1 Miruna Draganescu *, Manuela Arbune , Mirela Modrigan2 determined a long survival. Girls from this cohort are now young women thinking to make a family of their own. Although they received over the time contraceptive counselling and free condoms, little is known about the result of these actions. The objective of this study was to describe the sexual and contraceptive behavior. Methods Eligible participants from Day Care Clinic, currently on HAART were consenting interviewed about sexual and contraceptive behavior. Clinical and biological stage of HIV infection, HAART adherence were provided from patient file. For statistical analysis we used MedCalc. Results 83 (60.5%) nosocomially HIV-infected women of 137 at reproductive age were selected; the mean age 23.8 years, median CD4=598cells/cmm, median number of life-time partners 2 (2-11). 24% are rrhoma ethnic, 42% have minimal instruction level, 12% have no instruction at all, 46% have medium and high level of instruction, 13% are legally married, 34% have children. Among contraceptive methods 53% use condoms, 2.5% use other methods, 25.5% use no contraceptive method, 19% have no sexual activity. Almost a quarter (24%) had at least one abortion for an unwanted pregnancy; abortion was more frequent among women with more than 2 partners (p=0.047) and minimal instruction level. Conclusions For the majority of women counselling and free condoms induced a safe sexual practice. Almost a quarter of nosocomially HIV-infected women did not use any contraceptive method, despite counselling and condoms available at no cost and had at least one abortion. Low level of instruction correlates to an increasing number of children and lack of contraceptive method use. Intensive counselling is a challenge that we have to take for a safe sexual behavior and eradication of abortion among these women. Aspects of Clostridium difficile colitis in patients hospitalized within the surgical wards (a prospective study) *[email protected] Victoria Birlutiu1,2*, Alina Lidia Stan2, Rares Mircea Birlutiu3, Maria Igna2 ”Dunărea de Jos” University, Galați, Romania Infectious Diseases Clinical Hospital ”Sf. Cuv. Parascheva” Galați, Romania *[email protected] 1 2 1 Background Universal access to highly active antiretroviral therapy (HAART) of nosocomially HIV-infected children born between 1988-1992 in Romania, has “Lucian Blaga” University Sibiu, Faculty of Medicine Sibiu, Romania 2 Academic Emergency Hospital Sibiu, Romania 3 “Foișor” Hospital for Orthopedics, Traumatology and Osteoartiular TB Bucharest, Romania 43 Background The change in the epidemiology of Clostridium difficile infection (CDI) during the last years, with an increase in incidence, is a reality associated with healthcare services. A review of surgical patients was rarely performed. We performed a prospective study of factors associated with CDI in hospitalized patients within the surgical departments of the Academic Emergency Hospital Sibiu, Romania between August 2013 and July 2015. Methods We analyzed the cases of CDI that were diagnosed in the surgical departments summarizing 126 cases. We analyzed the risk factors, the comorbidities and the type of surgery related with CDI. Results Of the total number of CDI cases hospitalized n=335, a number of 126 cases were associated with the surgical services (36.72%). There were 59 confirmed cases in general surgery department, 14 with cholecystectomy, 10 with interventions performed on colon, 9 cases were associated with surgeries performed for gastric cancer, 6 cases with appendectomy, 5 cases with inguinal/femoral hernia surgery and 3 cases of eventration after abdominal interventions. 7 cases were associated with gastro-intestinal interventions and pancreatitis, 5 cases of minor interventions on the thyroid gland or in the cervical region. 17 cases presented a relapse, of which 5 were associated with cholecystectomy and other 3 patients with post cholecystectomy syndrome. 6 cases were associated to skin and soft tissue infections or limb amputations. From the vascular surgical department, 8 cases associated CDI and angioplasty. 10 cases were hospitalized in the neurosurgical department. In either of the department of urology and the department of orthopedics 17 cases were diagnosed with CDI. 9 cases were from the Gynecology department and 2 cases presented CDI after caesarian surgery. The most common comorbidities were cardiovascular (74 patients), malignancies (33), gastric ulcer (20), diabetes mellitus (14) and chronic renal failure (10). Most patients received antibiotic treatment (112), followed by the therapy for suppressing secretion of gastric acid (70) and non steroid or steroid antiinflamatories (65). Of the antibiotics that were administered, the most used were aminopenicillins with beta-lactamases inhibitors (55) fallowed by 2nd and 3rd generation of cephalosporins (46) and fluoroquinolones (45). Conclusions Surgical services were responsible for 36.72% of the cases of CDI. In particular the most problematic are surgeries performed in the general surgery department, associated with antibiotics and therapy for suppressing secretion of gastric acid. We encountered a relapse rate of 31.48%. The effectiveness of the fecal microbiota transplant based on the experience of the Academic Emergency Hospital Sibiu. Victoria Birlutiu1,2*, Adrian Gheorghe Boicean1,2, Rares Mircea Birlutiu3 *[email protected] 1 “Lucian Blaga” University Sibiu, Faculty of Medicine Sibiu, Romania 2 Academic Emergency Hospital Sibiu, Romania 3 “Foișor” Hospital for Orthopedics, Traumatology and Osteoarticular TB Bucharest, Romania Background Clostridium difficile infection (CDI) is a serious public health issue responsible for the annual illnesses of 8/100,000 inhabitants and over 29,000 deaths; the increasing incidence being attributed to usage of antibiotics, immune suppressed status, chronic conditions, age over 65 years, surgical interventions and antibiotic treatment, gastric acid inhibitors, anti-inflammatory drugs, cytostatic therapy and prolonged hospitalization. CDI may be associated to a severe evolution, sepsis or death in 2-7% of cases (15% caused by hypervirulent strains). The risk of relapse at 30 days after the first episode CDI is 25%, 40% after the first relapse and 60% after the third episode. Methods Considering the challenges that the CDI treatment involves and the increased number of hospitalized and managed cases in the Academic Emergency Hospital Sibiu, Romania, we performed fecal microbiota transplant (FMT) in cases with CDI recurrence, to evaluate the cure rate defined as the presence of normal stools at 30 and 90 days after the FMT. Results FMT was performed in the Internal Medicine Department I Sibiu, from January to July 2015 in 42 patients with CDI, 8 male patients and 32 women patients. 34 patients had over 65 years. With one exception, all the patients were multihospitalized patients with multiple comorbidities like: cardiovascular disease (37 cases), digestive disorders (cirrhosis associated with HCV, diverticulitis, colonic polyps, chronic gastritis and gastroduodenal ulcer, and so on in 15), malignancies (4), 8 patients associated chemotherapy for hematological malignancies, diabetes (10) or renal impairment (8). 10 patients underwent recent surgery (8 cholecystectomies and 2 interventions for gastric cancer and perforated diverticulitis) and one case of femoral neck fracture recently discharged from the orthopedic department. Other risk factors included: antibiotic 44 treatment, 24 patients received therapy for suppressing secretion of gastric acid, inflammatory drugs (16). 57.14% of patients were at their second relapse, 38% at their third episode of CDI and 4.77% of patients at their fourth relapse. 40 patients presented normal bowel transit movements, both at 30 days and 90 days from the FMT (95.24%) and only 2 cases required to repeat the FMT. Conclusions The FMT represents a method of therapy with a high efficacy (in our study 95.24%) for the cases with CDI recurrence in patients over 65 years with comorbidities (cardiovascular, digestive, diabetes, renal impairment and hematologic diseases) or recent surgical intervention. Acute rotavirus infection complicated with cerebellitis and aphasia in a child – case presentation Gheorghita Jugulete1,2*, Adina Stancescu2, Cristina Popescu2, Luminita Marin1,2, Magdalena Vasile2, Virgil Ionescu2, Endis Osman2, Madalina Maria Merisescu1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Acute rotavirus infection represents a health problem both worldwide and nationally, especially in children under 5. Currently, due to polymorphic clinical manifestations of the disease in children, many authors describe the concept of rotaviral disease. Frequently reported extra-intestinal manifestations comprise of respiratory, neurological, hepatic, cutaneous, renal and hematological manifestations. Case report We present the case of a 8 year old child admitted in the 9th Pediatric Department of the National Institute for Infectious Diseases “Prof. Dr. Matei Balș” between 25.04-15.05.2015, with the diagnosis of acute rotavirus infection complicated with cerebellitis and aphasia. Diagnosis was established based on epidemiological criteria (2 siblings with the same infection), clinical criteria (fever, vomiting, abdominal pain, diarrhea, gait abnormalities, aphasia) and laboratory criteria (Rotavirus testing in stool samples and CSF). Also, diagnosis was supported by other investigations such as EEG and brain MRI. Onset of illness took place 5 days prior to admission with fever, vomiting, abdominal pain and diarrhea, and afterwards drowsiness, lack of appetite, gait and speech abnormalities (bradylalia, bradypsyhia and aphasia). Upon admission, the child presented with an altered general state, was feverish, pale, and drowsy with speech and gait abnormalities. Based on epidemiological, clinical and laboratory data, the diagnosis of acute rotavirus infection was established. Also, the neurological consult with EEG and brain MRI highlight associated complications: cerebellitis and aphasia. Under treatment with dexamethasone, cerebral depletives, i.v. human immunoglobulins, B vitamins and Cerebrolysine, evolution was slowly favorable. 4 weeks after onset, the patient was cured but with a slight intellectual disability. Conclusions Infection with rotavirus can present in various clinical forms, ranging from mild to severe with complications. Although rare, neurological complications are severe and can pose a high risk of sequelae and death in the absence of proper treatment. Incomplete Kawasaki disease in a child with IgA deficiency- Case presentation Gheorghita Jugulete1,2*, Adina Stancescu2, Cristina Popescu2, Luminita Marin1,2, Endis Osman2, Madalina Maria Merisescu1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Kawasaki disease represents an array of symptoms caused by an autoimmune mechanism, characterized by prolonged fever, inflammatory syndrome and multi-system involvement: mucocutaneous, cardiovascular, gastrointestinal, hepatic and renal. Case report We present the case of a 1 year old female child, admitted in 9th Pediatric Department of the National Institute for Infectious Diseases “Prof. Dr. Matei Balș” between 17.07 – 27.07.2015, with the diagnosis of acute febrile syndrome. Complex investigations were performed (hematological, biochemical, virological and bacteriological) alongside chest radiographs, cardiac and abdominal ultrasound, myelogram as well as specialty consults (ophthalmology, cardiology, rheumatology and otorhinolaryngology). Onset of illness took place 8 45 days prior to admission with fever, lack of appetite, abdominal pain and diarrhea. The child was first admitted in a Pediatric clinic where conjunctival hyperemia and slight hepatosplemegaly were noticed. Because the febrile syndrome persists despite broad spectrum antibiotic treatment and corticosteroids, with rising titers of inflammatory markers, the child is transferred in our clinic. Based on clinical and laboratory data, alongside with interdisciplinary consults (which exclude a lymphoproliferative disorder, sepsis and systemic illness), the diagnosis of incomplete Kawasaki disease is established. Treatment with human immunoglobulins is instituted for 5 days, with a favorable outcome (cessation of fever and inflammatory syndrome). Also, specific immunological tests reveal a selective IgA deficiency in a child with no relevant medical history. Conclusions Kawasaki disease is a condition which can have a severe outcome with complications such as coronary involvement that can lead to death. In our case, the coronary involvement was minimal, although the incomplete clinical aspect could have led to delay in diagnosis and proper treatment. The IgA deficiency could be an important trigger of the disease. Although rare, Kawasaki disease remains a frequent cause of prolonged fever associated with inflammatory syndrome in the absence of a proven infection. Methods Retrospective descriptive study of HIV infected adults diagnosed with PJ pneumonia hospitalized in HIV adult department of Dr Victor Babeș Hospital during 01.01.2011-30.07.2015. Case confirmation was carried out by RT-PCR or specific coloring bronchoalveolar lavage. Statistical analysis was performed with t-test and chi-square test. Results During 1.1.2015-30.7.2015 there were registered 23 patients with PJ pneumonia, of which 17 were HIV new cases (73%) with average age 39 years, predominantly men (60%). Testing factors associated with death in PJ pneumonia in HIV adults were found with statistical semnification the following variables: HIV viral load at diagnosis (p=0.024), oxygen saturation measured at admission (p=0.050), distance in days between HIV diagnosis and PJ pneumonia (p=0.016), associated comorbidities (p=0.002) and corticosteroid treatment (p=0.034). The mortality rate was 39.14%. 12 cases (52%) were confirmed by RTPCR for PJ from sputum or bronchoalveolar lavage. Conclusions Pneumonia with PJ still has a high mortality rate. Early detection and treatment of HIV infection could prevent this opportunistic infection. Suspicion of PJ pneumonia by other medical specialties from the first contact of the patient with medical system could lead to better outcome. Prognostic factors in Pneumocystis jiroveci pneumonia in HIV infected adults Splenic abscess – difficulty of diagnosis Amelia Blescun1* 1 1 Olivia Burcos *, Filofteia Banicioiu Cojanu , Simona Erscoiu1,2, Ionut Popa1, Cristina Pãtru1, Tatiana Stoicev1, Maria Nica2, Andreea Todiran1, Graţiela Ţârdei1, Emanoil Ceauşu1,2, Daniel Chirita1 *[email protected] 1 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Pneumonia with Pneumocystis jirovecii (PJ) represents the second opportunistic infection as a mortality rate even in the highly active antiretroviral therapy era. Objectives: to determine factors associated with exitus in pneumonia with PJ. *[email protected] 1 “Dr. Teodor Andrei” Lugoj County Hospital, Lugoj, Romania Background The splenic abscess is rarely encountered in pathology – being identified in 0.05-0.7% of autopsies, this percentage being influenced by the country developing these statistics. Common clinical signs are fever and pain in the abdomen, usually in the upper part. Case report. The patient, 72 years old, with diabetes mellitus, treated with oral antidiabetic agents is admitted on the day of the disease onset with fever 40 degrees C and fainting. At admission examination: patient is scarcely cooperating, is hardly responding to verbal stimuli, rhythmic cord, left basal rales, SaO2 83%, relaxed abdomen. Paraclinic: neutrophilic leukocytosis, metabolic imbalance, the thoracic 46 radiography reveals a fine clouding of the left lung field. It is interpreted as sepsis with pulmonary starting point. Therapy with piperacillintazobactam is established. Under treatment with antibiotics (three days) fever reappears, the patient is still hardly cooperating. Lumbar puncture is performed – CSF normal. CT for abdomen and pelvis with contrast is performed, detecting splenic abscess and thrombosis in the lower branch of the right pulmonary artery. Surgery is proposed (with a high surgical risk DSA IV E), but the family requests discharge, the patient dying at home after five days. Conclusions Basal pneumonia not responding to therapy can sometimes hide an infectious abdominal process in the upper part even without any obvious abdominal signs. A favorable evolution of the splenic abscess cannot be achieved only by treatment with antibiotics, surgical intervention in due and good time being beneficial and a saving solution in many cases. References 1. Ng KK, Lee TY, Wan YL, et al. Splenic Abscess: diagnosis and management. Hepatogastroenterology 2002;49(44):567-71. 2.Ghidirim G, Rojnoveanu G, Mişin I, Gagauz I, Gurghiş R. Splenic abscess--etiologic, clinical and diagnostic features. Chirurgia (Bucur). 2007;102(3):309-14. 3. Losanoff JE. Splenic abscess. www.medscape.com Infections during pregnancy are not associated with atopic dermatitis – a cross-sectional study in Romanian population Mihaela Panduru1*, Nicolae Mircea Panduru1 Methods This was a cross-sectional study performed on 1007 subjects, aged from two months to 18 years within 5 southern counties of Romania. All data were obtained from standardized questionnaires distributed in schools and kindergartens. The questionnaire comprised two parts: the first part which contained the ‘core’ questions of the ISAAC (International Study of Asthma and Allergies in Childhood) questionnaire and a second part containing questions regarding the factors involved in atopic dermatitis development. The prevalence of infections during pregnancy was compared between subjects with and without atopic dermatitis using a chi square test. The association between infections during pregnancy and atopic dermatitis was assessed using the simple binary logistic regression followed by multi-parametric logistic regression. The data analysis was made with MedCalc software, version 12.1.3.0. Results The analysis showed a prevalence of atopic dermatitis of 9.5%. In addition, 14.6% (n =14) patients with atopic dermatitis had infections exposure during pregnancy compared with 12.1% (n=110) of those without atopic dermatitis (p=0.58). The simple binary logistic regression showed that infections exposure during pregnancy was not associated with the atopic dermatitis occurrence (OR=1.24; p=0.48). The multiparametric logistic regression confirmed that infections in intrauterine life were not associate with atopic dermatitis (OR=0.54; p=0.15), when adjusted for paternal history of allergy (OR=1.69; p<0.0001) and the trimester of antibiotic exposure (OR=1.63; p=0.007). Conclusions The study showed no association between atopic dermatitis and infections exposure during pregnancy in this Romanian population. *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Atopic dermatitis represents the first manifestation of atopic march preceding allergic rhinitis and asthma. Identifying possible risk factors for atopic dermatitis may prevent the development of the disease and the atopic march. Although the hygiene hypothesis suggested that early exposure to infections could stimulate the immune system and prevent atopic dermatitis, there are also contradictory studies. In this context, the aim of our study was to investigate the association between intrauterine infections exposure and atopic dermatitis occurrence, in Romanian children. Some clinical peculiarities of imported malaria in the Republic of Moldova Valentin Cebotarescu1*, Victor Pântea1, Gheorghe Plăcintă1, Lilia Cojuhari1, Petru Paveliuc1, Oleg Dmitriev2, Ion Chiriac2 *[email protected] 1 State Medical and Pharmaceutical University “Nicolae Testemiţanu”, Chișinău, Republic of Moldova 2 Toma Ciorbă Clinical Hospital for Infectious Diseases, Chișinău, Republic of Moldova 47 Background European countries annually recorded 10-12 thousand cases of imported malaria. The geographical location of Moldova, intense relations with different countries with unfavorable situation in malaria, increased migration, climatic conditions, inadequate performance of prophylactic measures determine the development of malaria epidemic process. Methods In the study we included 122 patients with malaria, hospitalized in the Toma Ciorbă Clinical Infectious Diseases Hospital. The analysis parameters were: age, sex, clinical manifestation, therapy. Results The results of this study showed that there is a predominance of malaria in males- 94% cases, people aged from 40 to 60 years- 62%. Among those aged 20-40 years malaria occurs in 36% cases. All cases of malaria were imported, 80% of whom traveled to Sudan. 59% of patients received chemoprophylaxis with mefloquine for the period of their stay in endemic area. Most cases were actively detected through examination of the patients on their return to Moldova. In most cases (95%) patients were diagnosed malaria caused by P. falciparum. The P. vivax and P. ovale malaria infections were rarely encountered (2% and 3% respectively). Malaria evolved with mild severity in 67% cases and had a medium severity in 29.5% patients. The most common symptom was fever in 64% of cases with a various frequency of other symptoms: chills, sweating, headache, general weakness, fatigue, hepatosplenomegaly. Blood samples revealed leukocytosis in 37% patients and accelerated sedimentation rate in 36% with moderate changes in liver function tests, increased alanine transaminase and total bilirubin in 23% and 26% patients accordingly. The diagnosis of malaria was confirmed by parasitological method with minimal parasitemia in most patients (93%) and moderate parasitemia (++) only in 7% patients. Treatment was effective in monotherapy with artemisin derivatives in 33.6% cases and two antimalarials were required in 65.6% patients. Only 0.8% patients required a second course of treatment related to persistent parasitemia. Conclusions Among 122 patients in our survey prevailed mild and medium forms of imported malaria, determined by P. falciparum coming from Africa; 59% of the cases received the chemoprophylaxis. Clinical signs were suggestive in 64% of patients while 36% of patients were afebrile with minor clinical symptoms. The diagnosis was confirmed in all patients by parasitological method, with the prevalence of minimal parasitemia. Treatment was effective in all cases and only 0.8% required a repeated course of treatment. Genetic characterization of Cryptosporidium spp. infections in humans in Romania Ionela Mirela Neagoe1,2*, Lidia Lazar2,3, Andreea Toderan4 *[email protected] 1 Cantacuzino National Institute for Research and Development for Microbiology and Immunology, Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Colentina Universitary Hospital, Bucharest, Romania 4 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania Background Cryptosporidium infection is a worldwide parasitic cause of diarrhea in both immunocompromised and immunocompetent patients, being firstly identified in 1985 in Romania. However, the genetic Cryptosporidium profile, especially in developing countries, is still poorly known. The aim of the present study was to establish the genotypes/species and subtypes of Cryptosporidium among hospitalized Romanian patients with diarrhea enteritis and their clinicoepidemiological significance. Methods During 2006-2011 period, stool specimens from 1940 Romanian patients with digestive complains, admitted in three clinical hospitals from Bucharest, have been collected. Diagnosis was carried out by microscopic detection of Cryptosporidium oocysts using acid fast staining and enzyme immunoassay testing for specific antigens. The molecular characterization of the genotypes/species of Cryptosporidium was conducted using PCR with subsequent restriction fragment length polymorphism (RFLP) analysis of the small subunit rRNA gene (SSU rRNA). Subtyping was performed by PCR targeting the 60kDa glycoprotein gene (gp60) and sequence analysis. Results An overall of 49 (2.52%) human cryptosporidiosis cases were detected and a subset of thirty-six isolates of Cryptosporidium were submitted for DNA typing. Based on the combined genotyping, two species of Cryptosporidium were identified belonging to C. parvum and C. hominis in 20 (56%) and 16 (14%) of the isolates, respectively. Sequence analysis of the polymorphic gp60 gene revealed five subtype families, two C. parvum (IIa and IId) and three C. hominis (Ia, Ib and Id). In the allele family IId, the sequence polymorphism was higher by detecting at least three different genetic 48 variants. The most cases were reported for the subtype families Ib and IId (ratio 11:13). Subtypes IIdA16G1 and IIdA22G1a identified in this study exhibited a 100% homology with sequences of isolates derived from infected calves, lambs and goats. Among C. hominis allele families, the subtype IbA10G2 was commonly detected. The subtypes of C. hominis reported in this study were never identified previously in Romania. Conclusions This study showed that C. parvum infections are slightly dominant and subtype families Ib and IId are more common among the Romanian investigated patients. Close phylogenetic relationship between certain C. parvum subtypes suggest a potential zoonotic transmission and support further research work. Second-line treatment effectiveness for HIVinfected patients failing first-line therapy in the Republic of Moldova Pavel Micsanschi1*, Tiberiu Holban1,2, Constantin Spînu1,2, Ina Bîstrițchi1, Angela Nagîț3, Svetlana Popovici3 *[email protected] 1 Faculty for Continuing Medical Education, Nicolae Testemițanu State Medical and Pharmacy University, Chișinău, Republic of Moldova 2 National Public Health Center, Republic of Moldova 3 Hospital of Dermatovenerology and Communicable Diseases, Chișinău, Republic of Moldova Background The emergence of drug resistance is a major threat in effectiveness of antiretroviral treatment both globally and in the Republic of Moldova. Recently we can observe an increasing number of patients who need a second-line antiretroviral therapy after failure of first-line treatment among HIV-infected persons. We performed a critical assessment of the outcomes of second-line antiretroviral therapy are particularly relevant in settings where monitoring strategies may be inadequate. Methods In this study we included 34 patients who corresponded with the immunological and clinical criteria for antiretroviral treatment failure and were initiated on second-line therapy (tenofovir/ abacavir /zidovudine/ emtricitabine/ lamivudine/ lopinavir/ ritonavir) in 2011-2015. Included patients were aged between 23-69 years (38.7±0.3 years). Second-line antiretroviral treatment was defined for individuals who either failed first-line antiretroviral therapy (HIV RNA viral load measurement >400 copies/mL after 5 months). Results At the initiation of second-line antiretroviral treatment approximately 2/3 of patients had viral load >100,000 copies/mL. All the 34 patients who were confirmed with failure of first-line antiretroviral therapy were initiated the second-line treatment. After that, 30 patients had HIV RNA < 25 copies/mL at 5 months from the initiation of therapy but four of them responded more difficult to treatment. Out of all patients included in the study, 28 patients were detected with CD4 counts <350 cells/cmm, out of which 20 patients were detected with CD4 counts <200 cells/cmm and 8 patients of them were detected with CD4 counts <50 cells/cmm that is associated with increased risk for morbidity or death. The duration from initiation of first-line antiretroviral treatment until failure and initiation second-line antiretroviral therapy was also significantly different for each patient but the median time was 4.14 years (interquartile range: 110 years). Conclusions In spite of the fact that the majority of patients with HIV and treatment failure had viral load >100,000 copies/mL and the average CD4 cell count was 201.61 cells/cmm, second-line antiretroviral treatment was successful. Our study outcomes support the need for early identification of first-line treatment failure to improve second-line ART outcomes. Chlamydia pneumoniae infection – atypical manifestations Nicoleta Negrut1* *[email protected] 1 Faculty of Medicine and Pharmacy, University of Oradea, Romania Background: Chlamydia pneumoniae is an intracellular Gram negative bacterium that causes acute respiratory disease. Clinical manifestations of infection can be mild or asymptomatic, but it may be more severe in adults. Case report A 60 year-old patient presented fever, headache, vomiting, abdominal upper right quadrant pain. The physical examination revealed hepatomegaly and pulmonary rales. Paraclinical: inflammatory syndrome, elevated liver enzymes, normochromic normocytic anemia, thrombocytosis, Chlamydia pneumoniae IgM = 1.5 (positive), IgG = 20 AU/mL 49 (negative) – ELISA test. Chest radiography showed an infiltrate located in the pulmonary right lower lobe. Under antibiotics, hepatoprotective and antiinflammatory drugs complete resolution of the clinical manifestation appeared in one week. Correction of the liver enzymes, anemia and thrombocytosis remitted in three weeks. Conclusions Hepatitis and thrombocytosis are rare complications of Chlamydia pneumoniae infection. Prevention of recurrent Clostridium difficile infection Nicoleta Negrut1* *[email protected] 1 Faculty of Medicine and Pharmacy, University of Oradea, Romania Background Recurrence of Clostridium difficile disease (CDD) can appear in 20% of the correct treated cases. Methods The aim of the study was to determine recurrences of active CDD, in the first 90 days after initial episode. Inulin (10 g daily) was given to the patients in the study group, for a period of 90 days, after initial treatment with Vancomycin /Metronidazole. The program IBM SPSS statistics version 22 was used for analysis of the data. Results During 1 year (01.03.2014-01.03.2015), 67 patients with CDD were enrolled in the study. In the first 90 days of the initial episode of CDD, diarrhea recurred in 11.76% (4) of the cases in the study group (n = 33) and 32% (11) of patients in the control group (n = 34) (p = 0.048, chi-square test). Conclusions Treatment with prebiotics may decrease the number of relapses in the case of CDD. Circulating HPV genotypes in Romania Oana Săndulescu1,2*, Cristina Vasiliu1,3, Simona Elena Albu1,3, Anca Streinu-Cercel1,2, Irina Hanganu1, Adrian Streinu-Cercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 3 Department of Obstetrics and Gynecology, University Emergency Hospital of Bucharest, Romania Background Infections with human papillomavirus (HPV) are often subclinical but associate a potentially high risk for development of cervical cancer. Given the advent of effective vaccines, we considered it important to perform HPV genotyping in a subset of female patients monitored in the Department of Obstetrics and Gynecology, University Emergency Hospital of Bucharest, Romania. Methods We performed HPV genotyping through polymerase chain reaction in 33 female patients positive for HPV cervical infection. In parallel, epidemiological data was collected and colposcopy and Pap smear were performed in the University Emergency Hospital of Bucharest. Results The mean age and standard deviation were 36.6±8.9 years, and five of the patients (15.2%) were postmenopausal. Eight of them (24.2%) had infection with low-risk strains, 21 (63.6%) with high-risk strains, and 5 (15.2%) with strains that were not classified into these two categories. HPV genotype 16 was present in 10 cases (30.3%) while genotype 18 was identified in 2 cases (6.1%). Seven of the patients (21.2%) had concomitant infection with multiple (2, 3, or 4) HPV strains. High-risk and low-risk HPV strains were identified in similar proportions in patients below 30 years old (6/9, 66.7% high-risk and 4/9, 44.4% low-risk) compared with patients above 45 years old (4/6, 66.7% high-risk and 2/6, 33.3% low-risk), p=1.000 for both comparisons. Colposcopy results were computed into high Swede scores (5-8) and high Reid colposcopic index (5-8) in 8 cases (24.2%). Only 3 of the patients (9.1%) had no cellular atypia on Pap smear, 4 (12.1%) had inflammatory changes, 13 (39.4%) had atypical squamous cells of undetermined significance (ASCUS), 9 (27.3%) had low-grade squamous intraepithelial lesions (LSIL) and 4 (12.1%) had HSIL (high-grade squamous intraepithelial lesions). All patients with inflammatory changes or with HSIL on Pap smear had infection with high-risk HPV strains (p=0.375) but not with low-risk HPV strains (p=0.407). Conclusions The relatively small sample size in this study did not allow the identification of statistically significant differences in colposcopy or Pap smear results according to HPV genotype, but we have identified an important prevalence of high-risk HPV strains in female patients, suggesting the need for further testing, counselling, and vaccination in the female population. 50 Physico-mathematical modeling elements, retrospective and prospective, for formulating some epidemiological considerations on HIV AIDS in Constanta, Romania Iulia Gabriela Serban1*, Liviu Serban2 *[email protected] Clinical Infectious Diseases Hospital of Constanța, Romania 2 BMW, Munchen, Germany 1 Background 1. The Epidemiology offer great potential to algorithm, physico-mathematical modeling, statistical interpretations. 2. The physicist’s role in the multidisciplinary team, in physicomathematical-statistical modeling, algorithmic, epidemiological, qualitative interpretation, phenomenological, physical and philosophical, mathematical results obtained, is important! Methods We conducted three studies on epidemiological elements of HIV- AIDS in Constanta County comparing the periods: 1987-1993, 2008-2012 and the first 6 months of 2013. We had associated, on factorial mode, certain epidemiological categories and we calculated, statistically and mathematically, various sizes. We have interpreted the qualitative results. Results Establish the working algorithms, mathematicalphysical models that find their echo in epidemiology. It is fundamental the thinking specialized in physics, expressed by mathematical algorithms, with qualitative interpretation and application in epidemiology, the study design choice. First study: V=96.40% - variability of the lot, 1987-1989 subgroup homogenous (V = 3o%). 1987-1989 cohort (N = 1438), the average degree of dispersion (sigma-0.7722953), Pearson's coefficient of variation of 31.86694%. OR = 99.76471 exposed, unexposed OR = 4, OR = 24.94118> 1. The exposure is a risk factor. Sensitivity = 98.148%, specificity = 32%. Second study: increasing the number of survivors is found with Mantel Haenzel method, estimate Odds Ratio (OR = 0.08829). Third study - Reduced number of patients of this study not allow formal conclusions. We are in a retrospective modeling phase, focused on past -epidemiological events, with highlighting interpretations on causation. Conclusions 1. The importance of using prospective modeling, foresight, to foreshadow the expected impact clinical medical, economic, social, epidemiological. Role in the correct collection of epidemiological data and the development of a specific model focused on Constanta geographic region. 2. Future advances in environmental quality management, hospital especially, with applications for measures of organization and epidemiological isolation. The strategic decisions on short and long term increases the quality of medical act and public health, the favorable impact on social and the economic benefits (reduced medical costs). 3. The need to use predictive models and mathematical physical projection in epidemiology, useful in collecting data, understanding of disease transmission, in interpreting trends observed, in assessing the impact of specific interventions, in strategies for disease prevention planning. 4. The physico-mathematical modeling elements, retrospective and prospective, are important to formulate epidemiological considerations on HIV AIDS in Constanta, Romania. The usefulness of metronidazole for the treatment of non-severe Clostridium difficile infection (CDI) Gabriel Adrian Popescu1,2*, Alice Atomoaie1, Florentina Paraschiv1, Daniela Bunescu1, Madalina Simoiu1, Adrian Abagiu1, Georgeta Preda1, Florin Duna1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background A few antibiotics are used for CDI treatment; oral metronidazole remains in the very recent ESCMID, ACG and Romanian guidelines the preferred treatment for non-severe initial disease and, controversial, for the first recurrence of CDI. However, it is a concern about decreased clinical efficacy of metronidazole for CDI, possibly related to emergence of more resistant strains of Clostridium difficile; the aim of our study was to evaluate the efficacy of oral metronidazole in a patient population with high prevalence of C. difficile ribotype 027. Methods We analysed the record files of patients admitted with CDI in the 6th Department of Infectious Diseases of NIID Matei Balș from January through June 2015. The patients were stratified according to severity of disease and the rank of the CDI episode (initial, first or multiple recurrences). Severity assessment included comorbidities, creatinine blood level and ATLAS score. The relation between outcome and antibiotic treatment was analysed for 51 non-severe initial disease or first recurrence of CDI. Results Fifty-four patients were admitted for CDI during the study period. The diagnosis of non-severe initial CDI was established for 19 patients and 11 patients had a non-severe first recurrence; other 24 patients were diagnosed with severe CDI (n=21) or multiple recurrences (n=3). The treatment for nonsevere initial disease or first recurrence patients included oral metronidazole (n=15) and oral vancomycin as first option or after metronidazole discontinuation (n=17, one patient with metronidazole failure and another with metronidazole side effects). The treatment with metronidazole and vancomycin resulted in clinical cure obtained in 86.7% CI95% (62.1; 96.3) and 93.8% CI95% (71.7; 98.9), respectively (p= .51). The time to diarrhoea resolution was 5.69 ±1.14 days in metronidazole group and 5.53±1.33 days in vancomycin group (p=.85) No statistical differences were registered in comorbidities or mean age (57.3 ± 20.3 years – metronidazole group vs. 59.3±23.2 years – vancomycin group); the only significant difference was the preference for vancomycin in first recurrence CDI (10 cases with vancomycin versus one patient with metronidazole). Conclusions Our findings suggest that metronidazole retains the efficacy for the treatment of non-severe CDI, at least for the initial disease. Profile of critically ill patient with infectious disease Irina Niculescu1,2*, Florentina Dumitrescu1,2, Livia Dragonu1,2, Andreea Cristina Stoian1, Lucian Giubelan1,2, Augustin Cupsa1,2, Iulian Diaconescu1,2, Dan Hurezeanu1,2, Mirela Ciucu2 *[email protected] 1 University of Medicine and Pharmacy Craiova, Romania 2 “Victor Babeș” Clinical Hospital of Infectious Diseases and Pneumology, Craiova, Romania Background Infectious diseases (ID) are a major cause of death worldwide; acute pneumonia is an important cause of morbidity and mortality, occupying the 3rd position after myocardial infarction and stroke; severe sepsis and septic shock, infection-induced syndromes have an increasing incidence and high mortality requiring a rapid diagnosis and an appropriate therapeutic attitude. Objectives: to establish the profile of critically ill patient with ID. Methods Retrospective study (January-June 2014) on 2437 patients hospitalized in Infectious Diseases Clinics of "Victor Babes" Hospital Craiova. The case definition of critically ill patient with ID was as follows: patients having at least one of: organ failure, severe sepsis, septic shock, or severe pneumonia (CURB-65≥4). Results We identified 153 critically ill patients with ID. General data of the study lot: the median age was 67 (IQR: 16-95) years, sex ratio M:F=0.91, with a slight predominance of rural patients (52.94%). The repartition of study lot by age groups was: over 65 years old-52.94% of patients, between 45-65 years old-24.18%, under 35 years old-18.30% and between 35-45 years old-4.57%. Other associated conditions was identified in 86.93% of patients (one or combinations) as follows: chronic cardiovascular diseases-41.01% of patients, pulmonary-10.60%, renal-10.14%, liver-9.22%, diabetes-8.76%, HIV infection-5.53%, cancer5.99%, alcoholism-4.61%, neuropsychiatric-3.68%, pregnancy-0.46. ID was: pulmonary infections (67.32%), gastrointestinal (19.61%), liver (3.92%), renal (3.92%), neurological (2.61%), skin and soft tissue (1.96%), cardiovascular (0.65%). The etiology has been identified in 28.11% of cases, as follows: gram-positive cocci (27.91%), gramnegative bacilli (25.58%), Mycobacterium tuberculosis (23.26%), hepatitis B virus (11.63%), Clostridium difficile (9.30%), Toxoplasma gondii (2.32). The distribution of patients by case definition of critically ill patients with ID was: organ failure-51.63%, severe sepsis 36.60%, severe pneumonia (CURB-65≥4)-6.54% and septic shock5.23%. Deaths were recorded in 3.92%, unfavorable outcome-in 18.30% (transferred to intensive care units). Conclusions The profile of critically ill patients with ID is as follows: elderly patient associated comorbidities, most commonly chronic cardiovascular diseases, presenting most frequently pulmonary or gastrointestinal infection caused by gram-positive cocci or gram-negative bacilli and most often developing organ failure or severe sepsis with poor prognosis. The clinical and paraclinical peculiarities of patients with Lyme disease treated in “Toma Ciorbă” Infectious Disease Hospital Ion Chiriac1*, Tiberiu Holban2 *[email protected] 52 1 Toma Ciorbă Clinical Hospital for Infectious Diseases, Chișinău, Republic of Moldova 2 State Medical and Pharmaceutical University “Nicolae Testemiţanu”, Chișinău, Republic of Moldova very important point in informing general practitioners, cardiologists, rheumatologists and dermatologists of the possibility of first LD presentation as illnesses treated by them. Background As Lyme disease (LD) is becoming more frequent worldwide, climate changes and broad openings are all together contributing to increasing number of Lyme disease (LD) cases in the Republic of Moldova. There are a lot of controversies about chronic LD diagnosis and length of treatment. This disease has a huge burden on most national health services. Methods We analyzed the clinical and paraclinical peculiarities, evolution, treatment and outcomes in 39 patients suffering from acute LD in the Clinic of Infectious Disease ”T.Ciorbă”, Chișinău, Republic of Moldova. The diagnosis was established based on presenting clinical data, epidemiological findings and was confirmed by ELISA serology lab detecting anti Borrelia burgdorferi (Bb) IgM antibodies within 22-28 days interval from tick bite. Results In the study group, 24 patients were women and 36 men with the age ranging from 15 to 60 years - on average 38.5 years of age. In 37 the tick bite was present prior to the disease start. Among women the interval from tick lesion until first symptoms (incubation period) was 13.42 days whereas in men it was 14.5 days. The most commonly noticed symptom was erythema migrans (EM) in 66% cases, followed by arthralgia and myalgia in 64%, local burning sensations in 58%, headache in 46% and fever in 30% of cases accordingly. EM syndrome and joint pain was more frequently presented by women than men. Only 3 patients had minor abnormalities in liver function tests. Among 39 analyzed patients in 25 (64.1%) the diagnosis was confirmed by detecting IgM anti-Bb. Patients were hospitalized for a 12.3 days period in average for men and 10.6 days - for women. For the treatment we used ceftriaxone 1g, i/v BD or doxycycline 100 mg BD given orally for 12 days. In all cases treatment proved to be effective and the outcomes favorable. Conclusions The highest incidence of LD was in May and July and the infection was more common among women – in 61% cases. EM primary lesion was noticed in 66% cases, arthralgia and myalgia in 64% cases, local burning sensations in 58%, headache in 46% and fever in 30% cases. There is a necessity of enhancing antiepidemic measures and possibly including LD in notified diseases list. There is a The antimicrobial resistance of Staphylococcus aureus strains isolated in Matei Bals Institute Cristina Popescu1,2, Anca Leustean1*, Carmen Dragu2, Alexandru Rafila1,2, Olga Dorobat1, Daniela Talapan1,2, Mona Popoiu1, Alina Lobodan1,2, Raluca Mihailescu1, Catalin Tiliscan1,2, Mihaela Radulescu1,2, Gabriel -Adrian Popescu1,2, Iulia Caragea1, Constanta Zamfirache1, Adriana Manea1, Victoria Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background The antimicrobial resistance of Staphylococcus aureus (SA) increased in the last years. Romania is one of the European countries with high incidence of methicillin resistant SA (MRSA). The local epidemiological data regarding antimicrobial resistance are very important in order to make a correct empirical therapy. Objectives: 1.To evaluate the antimicrobial resistance of SA and to establish which therapeutic options remain active in SA infections; 2.To evaluate the trend of SA resistance. Methods We made a retrospective analysis of SA strains isolated in Matei Bals Institute in 2013. We compare the data with the results of a previous study (MART study, 2008-2010). Results In 2013 were isolated 371 strains of SA: 57% from skin/ soft tissue infections (SSTI), 23% from blood culture (BC), 9% from respiratory tract infections (RTI) and 11% from other foci. MRSA prevalence was 51%. The resistance level of SA strains was: 30.1% for clindamycin, 53.2% for macrolides, 21.7% for rifampin, 19% for fluoroquinolones, 54.3% for cyclines, 25% for gentamycin, 0.8% for trimethoprim/sulfamethoxazole. There were no isolated resistant strains of SA for vancomycin and linezolid. Resistance level was different according to the site of the infection. From SSTI the level of MRSA was 53.4%, higher than BC (46.8%) or RTI (50%). The resistance to macrolides was: 47.4% for BC, 53.3% for RTI and 56.5% for SSTI. The resistance to clindamycin was: 51.3% for BC, significantly higher than SSTI -23.2% or RTI – 53 16.7%. The same situation was recorded for rifampin: 34.6% resistance for BC versus 24.1% for RTI and 15.3% for SSTI. The fluoroquinolones resistance was higher for the strains isolated from RTI (26.7%) versus BC (13%) and SSTI (20%). We also recorded a high level of resistance for cyclines: 49.4% for blood culture, 53.3% for RTI and 56.5% for SSTI. Comparing to 2008-2010 period, The resistance level increased for all antimicrobials: for oxacillin from 36.3% to 51%, for doxycycline from 47.3% to 54.3%, for clindamycin from 12% to 30.1%, for rifampin from 12.4% to 21.7% and for fluoroquinolones from 8.5% to 13.9%. Conclusions: Glycopeptides, linezolid and trimethoprim/sulfamethoxazole remain very active against SA and might be used as empirical therapy in SA severe infection. The antimicrobial resistance level of SA increased for all other tested antimicrobials. More than half of SA strains were MRSA. We also found a high level of resistance to macrolides and cyclines (>50%). This worrying situation became a real public health problem. Tigecycline in the treatment of Clostridium difficile associated diarrhea Eliza Manea1*, Irina Lapadat1, Serban Benea1,2, Ruxandra Moroti1,2, Raluca Jipa1, Irina Panait1, Sorinela Diaconu1,2, Adriana Hristea1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background The incidence and severity of Clostridium difficile (CD) infections have increased over the past decade. Tigecycline is a broad spectrum antibiotic, active against a number of drug-resistant organisms and it has also shown in vitro activity against CD. Our aim was to analyze the differences between patients with CD associated diarrhea (CDAD) treated with tigecycline, in monotherapy or in association with oral vancomycin versus those treated with vancomycin. Methods We performed a retrospective cohort study on adults admitted in our institution between September 2014-February 2015 for CDAD. We included the patients in whom all data were available to calculate the Atlas severity score and those who received at least 3 days of tigecycline. Results We identified a total of 167 CDAD episodes in 150 patients. Thirty five (23%) patients received tigecycline (group 1) and the median duration of treatment with tigecycline was 9 days (IQR=6-13). The 115 patients treated with vancomycin only (group 2) had a median duration of treatment of 13 days (IQR=8-16). Median age 69 years) for both groups and gender distribution, 15 (43%) male in group 1 and 45 (47%) in group 2 were similar. A concomitant systemic infection was identified in 19 (54%) patients in group 1 versus 39 (30%) patients in group 2 (p=0.006, OR=2.83, 95%CI=1.32-6.07). Forty six (28%) patients had recurrences of CDAD, without significant association between the two groups: 9 (26%) in tigecycline group versus 37 (32%) in vancomycin group (p=0.78). During the study period we noted 17 relapses and 5 (41%) of the patients with recurrences received tigecycline versus 30 (22%) of the patients without recurrences. The median Atlas severity score was 4 (IQR: 3-5) for the patients in group 1 versus 3 (IQR=2-4) for patients in group 2 (p<0.001). The median length of hospitalization was 17 days (IQR=12-23) in tigecycline group versus 14 days (IQR=9-17) in vancomycin group, without significant difference between the two groups. We noted a favorable outcome in 28 (80%) in group 1 vs 121 (92%) in group 2 (p=0.048, OR=0.36, 95%CI=0.13-1.02). Conclusions Tigecycline was used in patients with more severe forms of CDAD (a higher Atlas severity score). These patients, due to the severity of the disease, had a poorer outcome. Most patients in group 1 had another concomitant systemic infection. The relapse rate of CDAD did not differ between the two groups. The use of tigecycline did not prevent the recurrences. The antimicrobial resistance of Pseudomonas aeruginosa strains isolated in “Matei Bals” Institute Cristina Popescu1,2*, Loredana Tutuianu2, Alexandru Rafila1,2, Olga Dorobat1, Ioana Badicut1, Smaranda Botea1, Alina Borcan1,2, Alina Orfanu1,2, Anca Leustean1, Daniela Munteanu1, Raluca Nastase1, Violeta Moagic1, Catalin Tiliscan1,2, Mihaela Radulescu1,2, Mirela Dinu1, Raluca Popescu1, Doina Cristea1, Gabriel-Adrian Popescu1,2, Victoria Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 54 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background: Pseudomonas aeruginosa (PA) antimicrobial resistance represents a serious problem of public health. Antimicrobial stewardship programs which can improve the patients’ outcome need a good understanding of local epidemiology of antimicrobial susceptibility. Mortality rate in Pseudomonas aeruginosa infections depends on appropriateness of empiric antimicrobial therapy Objectives: to evaluate the antimicrobial resistance of PA strains isolated in our laboratory and to evaluate the trend of resistance between 2008 and 2013 Methods Retrospective analysis of antimicrobial resistance of PA strains isolated in 2013 in Matei Bals microbiological laboratory. The data were compared with the resistance reported in MART study during 2008-2010. Results In 2013 237 strains of PA were isolated: 38.8% from skin and soft tissue infections (SSTI), 32.1% from urine, 15.2% from respiratory tract infections (RTI), 9.7% from ocular and ear secretions and 4.2% from blood (by blood culture). Overall, the level of PA resistance was more than 50% for the majority of antimicrobials: piperacillin-tazobactam – 54.6%, ticarcillin-clavulanate – 79.4%, ceftazidime – 52.9%, cefepime – 56.2%, fluoroquinolones – 52.7%, fosfomycin – 76.4%. Only the resistance to colistin (1.5%), antipseudomonas aminoglycosides (45.5%) and carbapenems (44% for imipenem and 39.5% for meropenem) were below 50%. The resistance to aminoglycosides was 20% for PA isolated from blood culture, 41.6% for PA isolated from SSTI and 65% for PA isolated from urine culture. The resistance to cephalosporins was 30% for PA isolated from blood culture, 53% for PA isolated from SSTI and 64.45% for PA isolated from urine culture. The resistance to carbapenems was 35.2% for PA isolated from SSTI, 45% for blood culture and 53.3% for urine culture. The trend of PA resistance between 2008-2010 and 2013 was: for piperacillin-tazobactam from 45.8% to 54.6%, for cephalosporins from 48.3% to 52.9%, for imipenem from 43.4% to 44.1%, for meropenem from 55.8% to 39.5%, for amikacin from 39.1% to 45.3%, for fluoroquinolones from 55.7% to 52.7% and for colistin from 3% to 1.5%. Conclusions 1. For the majority of antimicrobials the PA resistance increased. 2. For fluoroquinolones and meropenem the PA resistance decreased (after a stewardship program introduced in Matei Bals Institute in 2012). 3. The level of resistance was very high for the majority of antimicrobials. Only colistin remains a good option in infections with PA. Persistent pruritic dermatitis in an HIV-infected late presenter patient Iosif Marincu1*, Patricia Poptelecan1, Valeria Bică1, Livius Tirnea1, Rodica Lighezan1 *[email protected] Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 1 Background The persistent cutaneous modifications that are resistant at the dermatological therapy can be an important clue in the detection of an undiagnosed HIV infection. We present the case of a patient with generalized and persistent pruritic dermatitis that evolved in the background of a HIV infection. Case report The patient is a 34 years from the rural area, unmarried, that presented unspecific cutaneous modifications with tendency to extend, and resistant pruritus at the prescribed medication. The patient interrupted his studies in the VIIIth grade and he is employed as an unqualified worker in a company that produces cables. He remained without his parents at the age of 14, he is living with a male partner for almost 3 years. In the last months, the cutaneous maculo-papular erythematous-congestive lesions extended on the face, upper limbs, chest, abdomen, buttocks and lower limbs, accompanied by upsetting pruritus. The patient was admitted in the DermatoVenerology Clinic in Timisoara. The blood tests performed raised the suspicion of HIV infection, and the patient was sent in the Clinic of Infectious Diseases for further investigations. The positive diagnosis was established based on clinical elements (nonspecific generalized pruritic and persistent cutaneous rash, weight loss, anorexia, asthenia). The physical examination data (macules, erythematous-congestive papules with cutaneous lesions due to the scratching, whitish persistent deposits on the tongue, enlarged and painless laterocervical, axillar and groin lymph-nodes), accompanied with the laboratory data (the leukocyte count (WBC), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), fibrinogen, lingual swabs, ELISA test for HIV Ab, Western blot test, viral load (VL), CD4 count, etc.). From the blood tests we highlight: WBC=14340/µL, ESR=100 mm/1h, CRP=43.23 mg/L, Fibrinogen=6.27 mg%. The chest radiography and 55 the electrocardiogram were normal. The culture of the lingual swab using Sabouraud medium isolated Candida albicans. The results of the virological and immunological tests (HIV Ab=positive, Western blot HIV test positive, VL=153,234 copies/mL, CD4=7 cell/µL) allowed the diagnosis of AIDS, stage C3. The patient had multiple male sexual partners, accepting the status of men having sex with men. All formalities were made in order to declare the case and establish the antiretroviral therapy. The patient's current partner was also confirmed with HIV infection. Conclusions The presence of unspecific cutaneous lesions that are difficult to classify for a definite diagnosis require an effective interdisciplinary collaboration in order to detect as early as possible the patients with HIV. The fatal evolution of a patient with A/H1N1 flu and recently diagnosed HIV infection Iosif Marincu1*, Patricia Poptelecan1, Valeria Bică1, Livius Tirnea1, Rodica Lighezan1 *[email protected] Dr. Victor Babeş Clinical Hospital of Infectious Diseases and Pneumology, Timişoara, Romania 1 Background Immunocompromised patients are people at highrisk for the viral infections. We present the case of a patient with A/H1N1 flu, complicated with bronchopneumonia and severe acute respiratory failure on the background of a newly diagnosed HIV infection. Case report A 26 years old female patient, living in the rural area, married, was admitted in the Intensive Care Unit from the Infectious Diseases Clinic Timisoara presenting fever, sweats, dyspnea at rest and dry cough. The positive diagnosis was established based on the clinical elements (fever, weight loss, cough, anorexia, asthenia), the physical examination data (broncho-alveolar disseminated rales, dyspnea, tachypnea), laboratory data (leukocyte count (WBC), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), fibrinogen, tongue swabs, throat swabs, blood culture, sputum culture, ELISA test for HIV Ab, Western blot test, PCR for influenza) and the results of the paraclinical investigations (chest radiography, fibrobronchoscopy). The assessment of PCR was performed in the National Flu Reference Centre Laboratory, Bucharest. From the blood tests we highlight WBC=13240/µL, ESR=25 mm/1h, CRP=32.83 mg/L, Fibrinogen=3.77 mg%, chest X-ray confirmed pneumonic lesions disseminated on both lung areas, with tendency to confluence. The RT-PCR test results confirmed the presence of flu virus A/H1N1. The lingual swab culture on Sabouraud medium isolated Candida albicans. The fibrobronchoscopy revealed bilaterally congested bronchial mucosa, and infiltrated with mucous and puss deposits that can be partially aspired after a lavage with saline. All bronchi are permeable and with preserved ciliary motility. After 3 hours from the admittance, the patient requires endotracheal intubation and mechanical ventilation (decreasing SpO2, hypoxemia). After two days, the general condition of the patient alters, the Astrup parameters indicate severe hypoxemia with increasing CO2 and respiratory acidosis. Under an intensive treatment with Imipenem/cilastatine, Vancomycin, Oseltamivir, Fluconazole, corticosteroids, mucolytics, bronchodilators, analgesics, antipyretics, diuretics, opioid and miorelaxants, electrolyte and caloric rebalancing solutions, the evolution was severe and the patient died. Afterwards, the results of the biological lab tests (HIV Ab positive, Western blot HIV positive) have confirmed the HIV infection that until then was undiagnosed. Subsequently, her husband was also diagnosed with HIV infection. Conclusions Patients with HIV infection and flu may develop severe complications, life-threatening, that require rigorous clinical and therapeutical monitoring in the specialized intensive care units. Infectious endocarditis due to Streptococcus anginosus in a patient with mitro-aortic insufficiency and diabetes Iuliana Alexandra Caramangiu1*, Ovidiu Rosca2, Monica Cialma2, Sorina Mitrescu1, Oana Saceanu1, Andreea Ardeleanu1, Iosif Marincu2 *[email protected] Dr. Victor Babeş Clinical Hospital of Infectious Diseases and Pneumology, Timişoara, Romania 2 Dr. Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania 1 Background Patients with diabetes and mitro-aortic insufficiency represent a risk group for developing infectious endocarditis. We intend to approach a clinical case of infectious endocarditis due to Streptococcus anginosus, who presented a 56 favorable evolution, despite the complications that occurred in the case of an infectious endocarditis. Case report We present the case of a 61 years patient, known with newly diagnosed diabetes, hypertension, rheumatic mitral insufficiency, rheumatic aortic insufficiency, who was hospitalized in the Clinic of Infectious Diseases “Victor Babes “ Hospital Timisoara. Symptoms started two days before admission, with malaise, fever (39°C), shiver, nausea, skin rash on palms and plants with erythematous patches form, conscious, respiratory balanced, hemodynamic: Blood pressure=167/90 mmHg, heart rate=108 bpm. Based on the clinical outcomes associated with biological samples (number of leukocytes, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), serum glucose, blood culture) and the results of laboratory investigations (cardiac ultrasound) we established diagnosis of endocarditis with Streptococcus anginosus. During hospitalization, the patient received treatment with: ceftriaxone1g, 2x2g/day (36 days), ciprofloxacin 100 mg f, 2x4 f/day (3 days), then, levofloxacin 500 mL 1 fl/day (32 days), levofloxacin 250 mg, 1 tb/day (32 days), paracetamol 100 mL 1 fl/day when required, ranitidine f, 1 f/day, fraxiparine 0,4 mL, 2x1 syringe/day, infusion solutions with NaCl 0,9% 500 mL 1 fl/day, ringer solution 500 mL 1 fl/day and insulin therapy according to the recommended schedule. On admission we performed biological investigations which revealed: marked leukocytosis (21300/µL), increased ESR (95 mm/h), hemoglobin=9.3 g/dL, CRP=121.49 mg/L, glucose=218 mg/dL. Cardiac ultrasound revealed: mitral regurgitation grade I/II, pseudotumoral mass (vegetation) attached to the non-coronary cusp of 1/1.5 mm, mobile, aortic regurgitation grade III, tricuspid regurgitation grade II. After treatment is initiated, the patient became afebrile with good general condition. Biological: L=9530/µL, ESR=75 mm/h, CRP=26.39 mg/L, serum glucose=126 mg/dL. Ultrasound revaluation states: little vegetation remaining in the left aortic valve, aortic regurgitation grade III with regurgitation process 85 mmHg, mitral regurgitation grade II, slightly lower hypokinesia. It has solving surgical indication about a year. Conclusions Detection of infectious endocarditis in diabetic patients, requires therapeutic clinical monitoring rigorous associated with interdisciplinary collaboration with infectious disease specialists, diabetologists and cardiologists. Acute viral hepatitis E outside endemic areas Nina-Ioana Șincu1,2*, Brîndușa Țilea1,2, Anca Meda Georgescu1,2, Cristina Gîrbovan1,2, Erzsebet Iringo Zaharia Kezdi1,2, Andrea Incze1,2, Magdolna Fejer2, Andreea Bodea1,2, Lucia Carmen Chiriac1,2 *[email protected] 1 University of Medicine and Pharmacy Tîrgu Mureș, Romania 2 Clinic of Infectious Diseases I Tirgu Mures, County Clinical Hospital Mures, Romania Background Acute viral hepatitis E is most frequently encountered in endemic areas in South-East Asia, Africa and Central America, while sporadic cases are also reported in European and North-American countries, mostly in travelers returning from endemic regions. The main route of infection is fecal-oral transmission, by contaminated water, food or other environment elements. Case series We analyze three cases of acute viral hepatitis E registered in 2015 in Romanian patients with no recent voyages to endemic areas for hepatitis E virus infection. All patients have been hospitalized in the Clinic of Infectious Diseases I Tirgu Mures, Romania. All three patients – one male and two female were adults: 33 – 51 years-old, from urban area. All patients denied voyages outside Romania during the previous 12 months, as well as contact with a traveler returning from an endemic area for hepatitis E virus infection. Two patients represented an intra-familial infection (husband and wife). All patients presented with digestive symptoms: nausea, vomiting, loss of appetite, followed by jaundice, emission of hyperchrome urine and discolored stool. Laboratory analysis revealed elevated liver enzymes 1700 – 3500 IU/L and hyperbilirubinemia. Serological tests ruled out acute viral hepatitis A, B and C – anti-hepatitis virus A IgM antibodies, HBs antigen and antihepatitis C virus antibodies were all negative. Antihepatitis E virus IgM antibodies were positive, establishing the diagnosis of acute viral hepatitis E. One female patient developed a prolonged cholestatic form. No patient developed severe forms of illness. None of the two female patients was pregnant, as risk factor for severe forms. All patients received hepatotropic agents, symptomatic therapy and rehydration, while being isolated in hospital conditions. Clinical outcome was good in all three cases, with clinical and biological improvement within 2-3 weeks from onset. The epidemiologic link could not be established in any of these cases. 57 Conclusions The appearance of acute viral hepatitis E cases outside endemic areas, in patients with no epidemiologic risk factors for this illness, should raise a question mark regarding the real – possibly underestimated – prevalence of this infection in our country and its means of transmission. Aspects of infection with Clostridium difficile in children Mirela Indries1* Radiographic and laboratory findings in the elderly with pulmonary tuberculosis Madalina Irina Mitran1, Cristina Iulia Mitran1, Mircea Tampa1,2, Simona Roxana Georgescu1,2, Maria Isabela Sarbu1, Octavian Costin Ioghen2*, Mircea Ioan Popa2 *[email protected] 1 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania *[email protected] 1 Faculty of Medicine and Pharmacy, University of Oradea, Romania 2 Clinical Infectious Diseases Hospital of Oradea, Romania Background The increasing prevalence of infections with Clostridium difficile (ICD) in the last 4 years in our country will inevitably increase morbidity in children, although Clostridium difficile (CD) colonizes more than 50% of children under 1 year. The CDC estimates that annually there are about 17,000 ICD in children between 1 and 17 years, with no differences between genders, most between 12 and 23 months. Objectives: This study sought to assess ICD in children in our service and risk factors of this condition in children. Methods This is a retrospective analysis of cases of Clostridium difficile infection in children over a period of 15 months, admitted to the Infectious Diseases Section Oradea. We excluded all cases where data were not sufficient to support the diagnosis of ICD (CD toxin negative). Results During study period there were 113 cases of patients with ICD. Of these, only 6.19% were children aged 2 months to 10 years. Most of the children had between 4-5 years. The main driver remains and antibiotics in children, but more than 2/3 of children from the community ICD, unlike adults where the ICD have 2/3 of nosocomial aspect. Prematurity, artificial nutrition and anemia were other factors in the case of a relapse in an infant of two months. Conclusions In recent years there has been an upward trend in the prevalence of ICD among children, mostly between 1 and 4 years. Background Pulmonary tuberculosis (TB) is an important health issue, in Romania. The elderly represent a group at risk for TB often overlooked. Immunosenescence leads to impairment of the immune response, which increases the risk of latent TB reactivation. Even more numerous studies have shown that elderly patients present diagnostic and therapeutic peculiarities. Methods We retrospectively analysed data on the radiological appearance and laboratory findings for 70 patients aged ≥65 years, diagnosed with pulmonary TB, from January 2009 to December 2011. Results Most patients included in the group were new TB cases (91.4%). Radiologically the lesions were most commonly located in the upper lung lobes (right lobe 18.6%, left lobe 21.4%, both upper lobes 14.3%). Extensive pulmonary lesions involving the two lungs were noticed in 21.4% of the patients. The caseous lesions were most frequently seen (44.3%), followed by ulcerated (41.4%) and cavitary (40.0%) lesions. Fibrosis was identified in 12.9% of the patients. Acid-fast bacilli (AFB) smear was negative in 22.9% of the cases. A percentage of 12.9% of the patients received a different diagnosis on admission. Laboratory findings revealed leukocytosis (28.6%), neutrophilia (37.1%), lymphopenia (60%) and anemia (37.1%) Conclusions Radiographic findings in the elderly consisted of extensive caseous, ulcerated and cavitary lesions. Lymphopenia was the most common abnormality of the blood count. The negative AFB smear, frequently observed among elderly patients, may lead to a delayed or mistaken diagnosis. 58 Resistance pattern of multi-drug resistant strains of Mycobacterium tuberculosis the recommendations regarding the TB prevention and control is an absolute necessity. Cristina Iulia Mitran1, Madalina Irina Mitran1, Mircea Tampa1,2, Simona Roxana Georgescu1,2, Maria Isabela Sarbu1, Mihaela Roxana Huhu2*, Mircea Ioan Popa2 Severe form of varicella, complicated with acute respiratory distress syndrome and bronchopneumonia. Case presentation *[email protected] Csep Andrei Nicolae1* 1 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Multi-drug resistant tuberculosis (MDR-TB) is a major concern in the medical community, its incidence being on the rise. Knowledge about the drug resistance pattern of Mycobacterium tuberculosis strains plays an essential role in prescribing an appropriate treatment, especially in the absence of rapid techniques for the assessment of resistance to anti-TB drugs. Methods We collected data regarding the susceptibility to anti-TB drugs of 158 MDR strains of Mycobacterium tuberculosis, isolated during 20092011. We analysed susceptibility to first and second line anti-TB drugs (isoniazid INH, Rifampicin RIF, Ethambutol EMB, Streptomycin SM, Ethionamide ETH, Cycloserine CS, Para-aminosalicylic acid PAS, Ofloxacin OFL, Kanamycin KM). Results Of the 158 MDR strains analysed, 62.7% were resistant to all first line anti-TB drugs available. A small percentage (8.7%) showed resistance only to INH and RIF. There were a larger number of strains resistant to the INH + RIF + SM association (23.4%), than to the INH + RIF + EMB association (5.1%). We identified that 44.9% of the strains exhibit resistance to at least one second line antiTB drug, most of isolates being resistant to KM (23,4%), followed by OFL (8,2%) and ETH (7%). The majority of the strains were resistant to an increased number of anti-TB drugs. Most of them were resistant to four anti-TB drugs (38.6%) but strains resistant to seven or eight anti-TB drugs (1.3%) were also identified. Conclusions MDR strains of Mycobacterium tuberculosis display an increased resistance to first line anti-TB drugs. That is a signal for the application of antiTB drug susceptibility testing as often as possible. Extension of resistance to second line anti-TB drugs narrows the therapeutic options. Until new anti-TB drugs are discovered the implementation of *[email protected] 1 Faculty of Medicine and Pharmacy, University of Oradea, Romania Background One of the most important complications in varicella was acute pneumonia. Case report We hereby present the case of a 33 year old female from an urban medium, who was admitted in May 2015 at the Infectious Disease department, County Hospital Oradea, complaining of altered general status, fever, chills, productive cough, mixed dyspnea (SaO2=88%), with a diagnosis of varicella manifested by papulovesicular eruptions, followed by a generalized pustular rash. On the second day of admission, the dyspnea was aggravated (SaO2=77%). From a paraclinical point of view, there was a marked leukocytosis (22.000/cmm) with neutrophilia (89%), and increased markers of inflammation- CRP 303 mg/dL, ESR 55/110 mm/hr. The chest x-ray described an aspect of ARDS, reason for which the patient was transferred in the Intensive Care Unit. Under treatment with Acyclovir 500 mg t.i.d and Ertapenem 1g q.d, the general status of the patient remained altered. The SaO2 decreased up to 40-45%, requiring ventilation with CPAP for 10 days. After 4 days of treatment, the dose of Acyclovir was increased to 750mg t.i.d and Amikacin 500mg t.i.d was introduced. After 7 days of treatment, the general status of the patient improved slightly. The control chest x-ray described an aspect of bronchopneumonia. Treatment with antibiotic was continued with Acyclovir 750mg t.i.d for 7 more days together with Meropenem 1g t.i.d + Vancomycin 250mg t.i.d for 14 days. Conclusions Treatment with Acyclovir i.v at an increased dosage, associated with carbapenem and aminoglycoside, and later with glycopeptide was effective in this case. 59 Acute pneumonia with Morganella morgannii Csep Andrei Nicolae1* *[email protected] 1 Faculty of Medicine and Pharmacy, University of Oradea, Romania Background Morganella morgannii was first isolated from the feces of infants with acute enterocolitis. The aim of this paper is to study a particular case of acute pneumonia with bacteria that mostly affects male and female urogenital tract. Case report We hereby present the case of a 58 years old female patient coming from a rural medium, who presented at the Infectious Diseases Clinic in Oradea in January 2015 for a febrile syndrome lasting about 10 days. Her family doctor treated her with Augmentin 1g b.i.d for 5 days, followed by Clarithromycin 500 mg b.i.d, with the fever still persisting. On admission the patient had the following symptoms: 38,50C fever, chills, chest pain, productive cough, urinary frequency (pollakiuria). Laboratory findings: leukocytosis (15,450/cmm) with lymphocytosis, hepatic cytolysis syndrome (ALAT 75 U/L, ASAT 71 U/L). The chest X-ray described bilateral accentuated pulmonary markings, and the sputum culture isolated Morganella morgannii bacteria. Symptoms persisted despite treatment with Ceftriaxone 2 g b.i.d + Gentamicin 80 mg b.i.d. After the result of the sputum culture, a combination of: Cefoperazone / Sulbactam 2g b.i.d + Ciprofloxacin 400 mg b.i.d was administered. Inflammatory markers and clinical signs improved after 12 days of treatment. Conclusions The association of fluoroquinolone with a thirdgeneration cephalosporin in combination with a beta-lactamase inhibitor was effective in the eradication of Morganella morgannii infection. Antimicrobial resistance and nosocomial infections Dana Negru1*, Teodora Olariu2, Mariana Nagy3 *[email protected] 1 Arad Public Health Department, Romania Arad Vasile Goldis West University, Romania 3 Arad Aurel Vlaicu University, Romania 2 Background Acquired antimicrobial resistance is a major problem, Intensive Care Units patients being particularly at risk for nosocomial infections as a result of mechanical ventilation, use of invasive procedures and their immunocompromised status. Inadequate antibiotic therapy is associated with poor outcome and emergence of bacterial resistance. Methods We have used descriptive and analytical statistics in describing antimicrobial resistance and its consequences in nosocomial infections registered in 2014 in Arad County, using also MedCalc and SPSS 17.0 for Windows. Results There were 254 nosocomial infections reported in 2014. Arithmetic mean for age was 60, extreme values being less than 1 year - 95 years old. Even if the patients gender distribution was equal, Relative Risk for death was 1.496 times higher for men compared to women, p= 0.0228. According to wards where these patients were treated, Relative Risk for death was 6.92 times higher in Intensive Care Units compared to others. According to the site of infection, the most frequent infections were: enterocolitis 29.4%, urinary tract infections 20.4%, nosocomial pneumonia 20%, wound infections 16.6%. The most frequent involved germs in nosocomial infections were: Clostridium difficile (29.9%), Pseudomonas aeruginosa (11.9%), Acinetobacter baumannii (8.4%), Klebsiella pneumoniae (8.4%), E coli (7.7%) and Staphylococcus aureus (7.7%). Odds ratio for deaths in cases where Acinetobacter baumannii was present was 3.8 times higher compared to nosocomial due to Clostridium difficile, p = 0.0101. Antimicrobial resistance registered to more than three classes of antimicrobials was for: Acinetobacter baumannii 100%, Pseudomonas aeruginosa 61.29%, Klebsiella pneumoniae 95.83%, Staphylococcus aureus 75%, p<0.0001. Resistance to more than six classes of antimicrobials was recorded in 45.45% of Acinetobacter baumannii isolates, 15% of E coli, 37.50% of Enterobacter spp, 37.50% of Klebsiella pneumoniae, 32.26% of Pseudomonas aeruginosa isolates, p<0.0001. Antimicrobial resistance to cephalosporins third-generation, aminoglycosides and carbapenems exceeded the national average for E coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Resistance to fluoroquinolones exceeds the national average only for E coli. Additional hospitalization for patients with associated infections was significantly increased over 10 days, p<0.0001 in the presence of multiresistant germs. 60 Conclusions Nosocomial infections with resistant germs is a huge menace to patient safety. We are facing situations where infected patients cannot be treated adequately because the responsible bacterium is totally resistant to available antibiotics. The therapeutic management of a patient with psoriasis vulgaris and chronic infection with hepatitis B virus: can the combination of etanercept and entecavir be the solution? Anca Raducan1*, Maria-Magdalena Constantin1,2, Traian Constantin2,3 *[email protected] 1 nd 2 Clinic of Dermatology, Colentina Clinical Hospital, Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 Urology Department, “Prof. Dr. Th. Burghele” Clinical Hospital, Bucharest, Romania Background The aim was to assess the risk-benefit relation of anti-TNF therapy used concomitantly with antiviral therapy with entecavir in a patient with moderatesevere psoriasis and chronic hepatitis B, in the light of recent studies underlining the increased risk of viral reactivation in patients treated with anti-TNF agents. Case report We present the case of a 38 years old patient, diagnosed 18 years ago with psoriasis, who presented with large erythematous-squamous infiltrated plaques, with clearly outlined borders, covered with thick, white, easily detachable scales, located on extensor surfaces (elbows, forearms, dorsal aspects of the hands, knees, shins), abdomen, as well as finger and toe nails involvement (subungual hyperkeratosis, distal onycholysis, pitting, “oil spot”). Also the patient suffered from knees and elbows arthralgia and morning joint stiffness. A skin biopsy was performed confirming the diagnosis of psoriasis and paraclinical investigations showed positive AgHBs, positive AcHBs, positive AgHBe, negative IgG antiHVD, PCR ADN-VHB=2341650. Results In this context, the patient was diagnosed with moderately severe psoriasis vulgaris (PASI Psoriasis Area and Severity Index =24,3; DLQIDermatology Life Quality Index = 25), chronic HBV hepatitis with positive AgHBe. The therapeutic algorithm included the start of the antiTNF therapy with etanercept 2 x 50 mg/week combined with entecavir, an antiviral treatment administered continuously since the diagnosis of the HBV hepatitis, with hepatic function and viral load monitored. He reached PASI 75 in the 12th week and registered a significant drop in DLQI and viral load (below the detection limit of 20 copies/ml) but without changes of the viral markers. After the first 3 months of treatment with etanercept he passed to the dose of 50 mg/week combined with entecavir 0.5 mg/day, which he continued until week 36, when psoriasis lesions cleared out (PASI=0,6; DLQI=0) with no adverse effects and no proof of HBV viral replication or changes of the viral markers. Conclusions In conclusion, by presenting this case we wish to emphasize that the use of etanercept in a patient with psoriasis and hepatitis B is a successful therapeutic alternative, which may be used safely concomitantly with the administration of entecavir and the regular monitoring of the viral load and of the hepatic function tests. Highschool students survey on awareness of HIV and acceptance of HIV infected persons Anca Raducan1*, Maria-Magdalena Constantin1,2, Rodica Olteanu1, Alexandra Zota1, Traian Constantin2,3, Irina-Magdalena Dumitru4,5, Sorin Rugina4,5 *[email protected] 1 2nd Dermatology Clinic, Colentina Clinical Hospital, Bucharest, Romania 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3 Urology Department, “Prof. Dr. Th. Burghele” Clinical Hospital, Bucharest, Romania 4 Infectious Diseases Hospital, Constanța, Romania 5 Infectious Diseases Department, “Ovidius” University, Constanța, Romania Background The aim of the study was to assess teenagers awareness concerning HIV infection and acceptance of HIV infected persons. Methods We performed a study among 119 sexually active high school students, 61.34% males and 38.65% females, aged 16 -17 years old, who were asked to complete a 23 items questionnaire designed to evaluate their knowledge on HIV prevention and transmission, sexual behavior and to which extent they would accept a HIV infected person in their entourage. Results When asked which is the first word that comes to mind when they hear HIV/AIDS, 36.97% teenagers answered “death”, 20.16% wrote “sex”, and 61 16.80% “incurable disease”, while other answers included: sexually transmitted disease, fear, drugs, self-destruction. Out of 119 students, 19 teenagers (15.96%) have begun their sexual life (73.68% males, 26.31% females), 36.84% at the age of 14, 36.84% after 14 years, and 26.31% before 14 years, most of them having more than one sexual partner (68.42% more than 4 partners), and preferring vaginal and oral intercourse. The preferred method of contraception and protection among the participants was the use of condoms. Also, 74.78% high school students have correctly answered multiple choice questions concerning the transmission route for HIV, yet 59.63% teenagers believe they should receive more information on sexually transmitted diseases. Furthermore, 89.07% of all participants to the study have not been vaccinated against HPV. Regarding HIV infected persons, 34.45% of high school students in the present study would not accept HIV positive persons in their entourage, 40.33% stated that it would depend on the HIV infected persons behavior, while only 25.21% were willing to accept HIV positive persons. Conclusions This study indicates that while most students are aware of the risks for HIV infection, they report sexual activity at early age, multiple partners and lack of HPV vaccination. Furthermore, the degree of acceptance of HIV infected persons is low in this category, which is a matter of high concern. Facultative anaerobic bacteria involved in the etiopathogeny of abscesses in oral and maxillofacial region Gabriela Bancescu1*, Adrian Bancescu1 *[email protected] maxillofacial region presented to the Oro-MaxilloFacial Surgery Department of the U.M.F. “Carol Davila”, Bucharest, during 2013-2014. Methods The identification of the 50 stored strains of facultative anaerobic bacteria (isolated from: vestibular abscesses, palatal abscesses, sublingual space abscesses and submandibular space abscesses) at genus and species level was based on conventional methods and API systems (BioMérieux, Marcy-l’Etoile, France): the Rapid ID 32 STREP and ID 32 STAPH system, respectively. Results Thirty-five isolates of this facultative anaerobic strains collection were oral streptococci and they belonged either to the anginosus group (13 strains of S. anginosus and 4 strains of S. constellatus) or to the mitis group (17 strains of S. oralis and only one strain of S. mitis). The rest of the facultative anaerobic bacteria were identified as staphylococci, as follows: 2 strains of S. aureus, 11 strains of S. epidermidis and 2 strains of S. haemolyticus. Conclusions The facultative anaerobic microorganisms isolated were only strains of Gram-positive cocci and the predominating species were S. anginosus and S. oralis. Identification at species level contributes to a better understanding of the etiopathogenical aspects concerning the oral and maxillofacial infections. Acknowledgement This study was part of the internal research plan for 2013-2015 of the Microbiology Department, Faculty of Dentistry, and Epidemiology Department, Faculty of Medicine, U.M.F. “Carol Davila”, Bucharest. Dr. Mihai Dumitru, a graduate student of the Faculty of Dentistry, U.M.F. “Carol Davila”, Bucharest, contributed partially to the microbiological investigation of these strains. No conflicts of interest to declare. 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background The oral and maxillofacial infections are mainly mixed infections, which involve both aerobic and anaerobic microorganisms. The bacterial isolation and identification are not commonly performed in such infections, being considered too timeconsuming. The aim of this study was to identify at species level a collection of 50 facultative anaerobic bacteria stored in ultrafreezer at the laboratory of the Microbiology Department, Faculty of Dentistry, University of Medicine and Pharmacy (U.M.F.) “Carol Davila”, Bucharest. These strains had been isolated from pus samples collected by needle aspiration from 35 subjects among patients with abscesses in the oral and Determinants of staphylococcal virulence in commensal and clinical strains Oana Săndulescu1,2*, Coralia Bleotu3,4, Ioana Mădălina Aldea3, Anca Streinu-Cercel1,2, Alexandru Rafila1,2, Daniela Tălăpan1,2, Olga Dorobăț2, Mariana Carmen Chifiriuc4,5, Alina Cristina Neguț1,2, Ioana Berciu1,2, Adrian StreinuCercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 62 Ștefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania 4 Faculty of Biology, University of Bucharest, Romania 5 Research Institute of the University of BucharestICUB, Life, Environment and Earth Sciences, Bucharest, Romania 3 Background Staphylococci are able to synthesize a multitude of virulence factors, such as surface proteins, cytotoxins, superantigens, enzymes, etc. Given the fact that complex regulation systems drive staphylococcal virulence, we have performed a study to evaluate the different parameters that influence the expression of virulence factors in commensal and clinical strains [1,2]. Methods Seventy-six staphylococcal strains were inoculated on dedicated solid media in order to assess the expression of hemolysins, caseinase, amylase, lipase, esculin and lecithinase. The bacterial strains were isolated from asymptomatic nasal carriage (n=36) and hard-to-treat infections (n=40). Results Most of the bacterial strains in this study (65 strains, 85.5%) expressed 4, 5 or 6 of the evaluated virulence factors. Hemolysis was present for 50/76 (65.8%) of the strains (20 strains displayed αhemolysis and 30 β-hemolysis), and it was correlated with tetrad cell arrangement (p=0.038). Caseinase expression was positive in 73/76 (96.1%) of the strains, and high expression was correlated with internalization (p=0.004) and marked cyto-adherence (p=0.007). Amylase production was expressed by 42/76 (55.3%) of the strains, at minimal (95.2%) and moderate levels (4.8%), but was not correlated with other strain characteristics. Lipase production was expressed by 65/76 (85.5%) of the strains, and was associated with high cyto-adherence (p=0.031). Esculin expression was identified in 53/76 (69.7%) of the strains mostly at low levels (67.9%), and was higher in S. aureus (p=0.009) and cyto-adherent strains (p=0.001). Lecithinase expression was positive in 70/76 (92.1%) of the strains, and was higher in strains displaying internalization (p=0.000), marked cyto-adherence (p=0.001), and tetrad cell arrangement (p=0.009). Conclusions The expression of enzymatic virulence factors in Staphylococcus spp. may be correlated with strain characteristics such as tetrad cell arrangement, internalization, or cyto-adherence. Acknowledgement This paper is partially supported by the Sectoral Operational Programme Human Resources Development (SOP HRD), financed from the European Social Fund and by the Romanian Government under the contract number POSDRU/159/1.5/S/137390. References 1. Sulla F, Bussius DT, Acquesta F, Navarini A, Sasagawa SM, Mimica MJ. Vancomycin minimum inhibitory concentrations and lethality in Staphylococcus aureus bacteremia. Germs 2015;5:39-43. 2. Lucia Preoţescu L, Streinu-Cercel O. Prevalence of nasal carriage of S aureus in children. Germs 2013;3:49-51. Genetic characterization and phylogenetic analysis of human influenza A (H3N2) viruses in two consecutive seasons Mihaela Lazar1,2, Alina Ivanciuc1,2*, Gheorghe Necula1,3, Emilia Lupulescu1 *[email protected] 1 Cantacuzino National Institute for Research, Bucharest, Romania 2 Faculty of Biology, University of Bucharest, Romania 3 Horia Hulubei National Institute for R&D in Physics And Nuclear Engineering, Bucharest, Romania Background Influenza A(H3N2) viruses have circulated worldwide since 1968. The constantly evolving A(H3N2), is the dominant subtype in most seasonal influenza epidemics causing high rates of morbidity and mortality. Genetic variability in the hemagglutinin (HA) gene of influenza viruses results in the emergence of new strains, potentially with increased pathogenicity. The aim of this study was to investigate the molecular evolution and vaccine strain match of the A(H3N2) influenza viruses, having been circulated throughout the population of Romania in two seasons, 2013/14 and 2014/15. Methods As part of virological surveillance of influenza in Romania respiratory specimens were collected from patients with influenza-like illness during the 2013/14 and 2014/15 influenza seasons. Sequencing and phylogenetic analysis using maximum-likelihood method of the HA gene amino acid sequences (1650 nt) were performed to characterize the H3N2 circulating strains. Results Analysis of hemagglutinin gene revealed several amino acid substitutions in comparison to the hemagglutinin of the A/Texas/50/2012 vaccine strain. The HA gene accumulated substitutions at the amino acid positions 128, 138, 142, 145, 159, 63 160, 225, 276, 311, 326. Phylogenetically, the HA gene sequences from 19 Romanian samples from 2013/14 season were included in subsets 3C.2 (representative strain A/Stockholm/1/2013) and 3C.3 (A/Samara/73/2013), distinct subsets from A/Texas/50/2012 which belongs to the 3C.1. The subset, 3C.2 and 3C.3 have a substitution at position 159, which has shown to be one of seven positions responsible for the major antigenic changes between 1968 and 2003 A(H3N2). During the 2014/15 season a total of 21 influenza A(H3N2) viruses were analysed: 7 viruses represented a new drifted A(H3N2) type, cluster 3C.3a (A/Switzerland/9715293/2013), 8 belonged to another cluster, 3C.2a (A/Hong Kong/5738/14), antigenically low reactor cluster, and 6 viruses belonged to 3C.3b, vaccine-like subset (A/Newcastle/22/2014). Conclusions Genetic characterization of the influenza viruses A(H3N2) in two consecutive seasons highlighted considerable variability in their HA sequences and gives an indication of the molecular evolution of this virus. Surveillance of genetic changes in the HA gene during seasonal influenza epidemics could provide indication of emerging clusters. Relaunch of bacteriophage therapy in Romania – case presentation Alina Cristina Neguţ1,2*, Maria Magdalena Moţoi1, Anca Streinu-Cercel1,2, Oana Săndulescu1,2, Adrian Streinu-Cercel1,2, Mircea Ioan Popa2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Staphylococcus aureus is considered a dangerous pathogen not only because of its high resistance profile but also because of the capacity of forming biofilm and intracellular invasion [1]. Case presentation A 37 year-old female with morbid deformity of the spine and multi-allergic status presented in our clinic in October 2014 for cellulitis of the back with purulent secretion and loss of substance with onset dating back 6 months. At one year old the patient had been diagnosed with spinal sarcoma and underwent surgery and radiotherapy with complete tumor removal. Consequently, the patient developed important kyphoscoliosis and required the implantation of two rods for sustaining the spine and correcting the disorder. Over the years she had another 10 spinal surgeries, the last one being performed in Ankara in November 2013. Before presenting to our clinic, the patient had received treatment with cefuroxime with persistence of the purulent secretion. At admission the patient had normal leukocytes, mild inflammatory response, and cultures positive for methicillin-susceptible S. aureus from the back ulcer with over 90% neutrophils on the smear. Upon cutaneous allergy testing for ciprofloxacin, clindamycin, oxacillin, teicoplanin, linezolid and vancomycin, she was allergic to all drugs. We evaluated the strain’s susceptibility to bacteriophages [2]; PYO and INTESTI phages displayed activity (Eliava BioPreparations, Tbilisi, Georgia). Having the local bioethics committee approval and the patient’s signed informed consent for bacteriophage therapy, we initiated local therapy with INTESTI phages together with oral cefuroxime. The cultures became negative after three days of treatment and at discharge the purulent secretion was absent. She continued combined therapy for a total of 3 months, when she received plastic surgery for covering the loss of substance with latissimus dorsi flap. Three months after her surgery the local site and the lab tests remain in normal range. Conclusions In hard to treat infections caused by multidrugresistant bacteria, biofilm formation, intracellular invasion, metal prosthesis, hard to sterilize sites, antibiotics might need an adjuvant factor for destroying the bacteria. Bacteriophages can be a solution, and further in vitro and in vivo studies are needed. References 1. Sulla F, Bussius DT, Acquesta F et al. Vancomycin minimum inhibitory concentrations and lethality in Staphylococcus aureus bacteremia. Germs 2015;5:39-43. 2. Neguț AC, Săndulescu O, Popa M, et al. Experimental approach for bacteriophage susceptibility testing of planktonic and sessile bacterial populations - Study protocol. Germs 2014;4:92-6. Acknowledgements 1. POSDRU/159/1.5/S/141531 2. Carol Davila University of Medicine and Pharmacy, Young Researchers Grant, no 28341/2013 Septic cutaneous emboli associated with a severe case of Klebsiella pneumoniae liver abscess syndrome (KLAS) Florentina Paraschiv1*, Alina Borcan1,2, Mihai Lazar1,2, Gabriel Adrian Popescu1,2 64 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background In the last years, Klebsiella pneumoniae liver abscess syndrome (KLAS) emerged outside SouthEastern Asia and several cases already been reported in Romanian patients. Case report A 58-years- old female with diabetes mellitus was transferred in Matei Balș National Infectious Diseases Institute with high fever and confusion after a two days hospitalization with antibiotic treatment in another hospital from Bucharest. Physical examination and laboratory tests revealed meningitis, unilateral visual loss, septic skin emboli and MODS (septic shock, renal dysfunction and disseminated intravascular coagulation). The abdominal ultrasound retrieved a large liver abscess and KLAS diagnosis was confirmed after the isolation of a hypermucoviscous strain of K. pneumoniae from septic skin lesions. However, the blood cultures and CSF culture remain negatives for bacterial agents. The patient evolution was favorable after abscess percutaneous drainage and antibiotic treatment with ceftriaxone (latter switched to oral amoxicillin-clavulanate, 1g tid). Conclusions This report supports the possibility of KLAS in our country, including some cases with most salient metastatic complications of this syndrome: meningitis and uveitis. We emphasize the benefit to sample each septic focus in patient with severe infections, especially if an antibiotic treatment has been started. Epidemiological and clinical features of acute hepatitis A in adults in Brasov area Maria Elena Cocuz1,2*, Ligia Rodina2, Iuliu Gabriel Cocuz3 *[email protected] 1 Faculty of Medicine, Transilvania University, Brașov, Romania 2 Infectious Diseases Hospital, Brașov, Romania 3 University of Medicine and Pharmacy Tîrgu Mureș, Romania Background Acute viral hepatitis A is a worldwide public health problem, spread by fecal-oral transmission, highly contagious, often favored by inadequate food and personal hygiene conditions. Adult clinical forms are varied, often medium and rare severe, but the disease cause high costs for hospitalization (treatment and isolation). Hepatitis A is a vaccinepreventable disease. Aims: To analyze some clinical and epidemiological features of acute hepatitis A in adults, in order to improve the prevention and the management of the disease. Methods Retrospective study on a group of 73 adult patients hospitalized with acute hepatitis A in the Infectious Diseases Hospital of Brașov in the period JanuaryDecember 2014. We analysed epidemiological aspects (age and gender of patients, urban or rural origin, seasonality of the hospitalizations), clinical aspects (onset types, clinical forms), laboratory aspects (cholestasis, hepatic cytolysis, bilirubin). Results Number of admission for acute hepatitis A in adults increased over the last 4 years, from 19 cases in 2011 to 106 cases in 2014. The group of the 73 analysed patients presented the following epidemiological and clinical features: age groups more affected 18-25 years and 26-35 years (63% cases), frequency almost equal male-female (48%52%); 59% of patients came from urban area; frequently hospitalizations in September (19.17% cases) and October (27.39% cases). Digestive onset was found in 98.63% patients, associated with fever in 42.46% cases; 94.52% of the clinical forms were medium and only 5.48% severe. Jaundice was present to 93.15% patients and cholestasis to 71.23% of them. The values of ALT were higher than 2000 IU/l in 46.57% cases and bilirubin over 5 mg/dl to 57.16% patients. Conclusions Incidence of acute hepatitis A in adult patients is low but persistent in the Brașov area, with current trend to increase. In 2014 the illnesses prevailed in young adults, especially from urban areas. The digestive onset often associated with fever and medium forms of the disease were dominant, with cholestasis in a large proportion of cases. Vaccination of adults against hepatitis A can be a solution for decreasing the incidence of disease. Aspects of Clostridium difficile infection in Second Department of the Infectious Diseases Hospital Galati Liliana Baroiu1*, Mihaela Camelia Vasile1, Nicușor Baroiu2, Miruna Drăgănescu2 *[email protected] 65 1 2 Infectious Diseases Hospital Galați, Romania ”Dunărea de Jos” University of Galați, Romania Background The incidence of Clostridium difficile infection (ICD) in our department has doubled in the period 01.12.2014-01.06.2015 (75 cases) than 01.12.201301.06.2014 (34 cases) and 01.06.2014-30.11.2014 (39 cases), while in the month of June 2015 aims to double the average of the last semester (20 cases in June /12.5 average/month). Purpose: To evaluate the prevalence of ICD associated risk factors, treatment response, relapse rate and duration of hospitalization. Methods Retrospective study based on statistical analysis of encoded data from the dossiers of the patients hospitalized with ICD in the period 01.06.201430.07.2015. We analysed: demographic data (age, sex, residence), data on risk factors, comorbidities, ATLAS score, treatment, evolution and relapses. Results There were 97 patients admitted in study diagnosed with ICD. 55 women (56.7%), 42 men (43.29), average age 63 years (5-86), 71 in urban areas (73.19%). Positive diagnosis was established on the basis of immunochromatographic tests for detection in stool: toxin A-5 patients, toxin A+B-83 patients, toxin B-2 patients, only positive GDH-2 patients. Score severity: 47 patients ATLAS 0-1, 36 patients ATLAS 2-3, 12 patients ATLAS 4-5, 4 patients ATLAS 6-7. Risk factors: hospitalization in the last 28 days-76 patients (78.35%), recent antibiotic therapy 61 patients (62.88%), use of PPI 16 patients (16.49%), abdominal surgery-13 patients (13.4%), age over 60, 68 patients (70.1%) and comorbidities: immunosuppression 31 patients (31.95%) (cancers, diabetes, autoimmune diseases), consumptive and debilitating chronic diseases 46 patients (47.42%) (liver cirrhosis, chronic hepatitis, chronic obstructive lung disease, renal failure, cardiac failure, stroke and dementia), invasive medical procedures 23 patients (23.71%) (recent surgery and colonoscopy), tuberculosis on treatment 5 patients (5.15%). The treatment was performed with Metronidazole 23.89%, Vancomycin 62.83%, Metronidazole +Vancomycin 13.27%, Tygacil 0.88%. Relapses: 15 patients at first relapse (15.46%), 1 patient with three recurrences (1.03%). Mean hospitalization days: 10.84, above the average value of the hospital. Conclusions The study confirms the prevalence of risk factors mentioned in the literature and frequency signals the presence of: recent hospitalizations, invasive medical procedures, immunosuppression and chronic consumptive / associated debilitating. The multiple combination of these risk factors prompted the need for prolonged treatment and hospitalization of patients admitted in the study. Current clinical and epidemiological aspects of acute hepatitis A in children in Brasov area Ligia Rodina1*, Felicia Constandis1, Nicoleta Ceposu1, Maria-Elena Cocuz1,2 *[email protected] Infectious Diseases Hospital, Brașov, Romania Faculty of Medicine, Transilvania University, Brașov, Romania 1 2 Background Acute hepatitis A is an infectious and contagious disease, that mainly affects children, transmitted interpersonal by fecal-oral route, favored by agglomerations and poor hygiene. In children the disease is usually asymptomatic or mild. Hepatitis A is preventable by vaccination. Aims: To analyze some current epidemiological and clinical aspects in acute hepatitis A in children and evaluation of specific vaccination opportunity in order to decrease the frequency of disease. Methods Retrospective study on 413 pediatric patients hospitalized in Infectious Diseases Hospital of Brasov during January-December 2014. We analysed some epidemiological aspects (age, gender, urban-rural origin of the patients, seasonality of the hospitalizations), clinical aspects (onset types, clinical forms of the disease), laboratory aspects (hepatic cytolysis, bilirubin, cholestasis, prothrombin concentration). Results The number of admission for acute hepatitis A in children gradually increased from 2011 to 2014 (2011 – 14 cases, 2012 – 75 cases, 2013 – 113 cases, 2014 – 413 cases). Cases of hepatitis A hospitalized in 2014 were characterized by: the most affected age group was 3-7 years (45% cases), male-female frequency 54%-46%, urban-rural frequency 20%-80%; frequently hospitalizations in September (29.54% cases) and October (16.95% cases); digestive onset in 98% cases; 88.86% of the clinical forms were medium, with jaundice in 62.47% patients and cholestasis in 17.92% cases; prothrombin concentration was decreased below 50% in 17.43% children. Conclusions Incidence of acute hepatitis A in children is persistent in the Brasov area, with current trend to increase. Hospitalized cases in 2014 were numerous, especially from rural areas. The digestive onset and medium forms of the disease were dominant, with cholestasis in a significant 66 number of cases. For decreasing the number of illnesses and hospitalizations for hepatitis A we consider that routine childhood vaccination is required. Nosocomial infections: a permanent challenge Cristina Vasiliu1,2, Ana Bădănoiu2*, Anca StreinuCercel1, Oana Săndulescu1, Simona Elena Albu1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Obstetrics and Gynecology, University Emergency Hospital of Bucharest, Romania prevalence in our study was only 1%, which means that this entity is still under-diagnosed and underreported. The study identified some risk factors and the most common pathogens, providing necessary data for an effective infection control program. The study also revealed the necessity for implementation of guidelines for NI. Thyroid disorders in HIV infected patients case series and review of the literature Manuela Arbune1,2*, Teodora Dragomir-Ananie1 *[email protected] 1 "Dunarea de Jos" University from Galați Infectious Diseases Hospital Galați 2 Background Nosocomial infections (NI) are a challenge for modern medicine: they are a major cause of morbidity and mortality in hospitals and are associated with high costs. Only recently have they been correctly defined and reported and their true prevalence in our hospitals is not known. The aim of our study was to observe the magnitude and characteristics of NI in a department of surgical gynecology in an University Hospital. Methods We performed a retrospective observational study evaluating the nosocomial infections diagnosed in the department of Gynecology in the Emergency University Hospital Bucharest between 01.07.2014 – 01.07.2015. Results In the above interval, 1748 patients underwent different surgical procedures and 16 developed NI (1%). The major sites affected were surgical wounds (11 cases), followed by blood stream infections (2 cases), gastrointestinal infections (one case) and peritonitis (one case). The main etiologic agents associated with these NI were E. coli (5 cases), methicillin-resistant Staphylococcus aureus (4 cases), followed by Enterococcus spp. (2 cases), Acinetobacter spp. (one case) and Clostridium spp. (one case). Each patient had at least one risk factor for NI and the most commonly encountered were arterial hypertension, obesity, and chronic renal failure with hemodialysis. All patients were treated with antibiotics according to antibiograms when the pathogenic agent was identified and with broad spectrum antibiotics when the incriminated germs were not identified. The hospitalization time varied from 7 to 40 days with a mean value of 18 days. In most of the cases, NI were present in patients with major surgical procedures and advanced age. Conclusions The prevalence of NI in various European countries shows rates between 3.5% and 11.6%. The Background Human Immunodeficiency virus (HIV) infection is associated with endocrine dysfunction. Increased prevalence of various thyroid disorders in HIV patients has been reported, especially after highly active antiretroviral therapy. Case reports Five patients from Galați (Romania) with HIV and thyroid disorders are reported. Case 1 is a 60 years old women, with history of polinodular goiter, thyroid carcinoma suspicion, surgical thyroidectomy and substitution treatment with Lthyroxin. She was diagnosed with hepatitis B virus (HBV), HIV - CDC stage B3. First line of HAART was failed and needs to choose another combination. Case 2 is a 26 years old boy with nosocomial pediatric HIV infection - CDC stage C2. He was experienced in 9 HAART combinations during 17 years. He developed progressive lipoatrophy, dyslipidemia and osteopenia. In the last year he was diagnosed with hypothyroidism with L-thyroxin treatment. Case 3 is a 26 years old girl with pediatric nosocomial infection, with coinfection HBV and HIV - CDC stage C3. She developed Basedow - Graves’ disease from the age 19, probably related to immune reconstruction with consequent autoimmune thyroiditis after HAART. Case 4 is a 52 years old women, co-infected with HBV and HIV CDC stage - C3. Severe neurocognitive disorders related to JC virus and a thyroid node have been concomitant diagnosed. Baseline euthyroidia was changed after 2 months of HAART, because she developed a toxic adenoma of the thyroid. Case 5 is a neonate myxedema in a baby-girl, with perinatally exposure to HIV. His mother was 25 years old and she has a treatment history with 6 HAART combinations in the last 10 years. All cases illustrate different thyroid disorders related to HIV and HAART. Co-infection HIVHBV was identified in 4/5 cases with thyroid 67 dysfunctions. Females represent 4/5 cases. Interactions of antiretroviral drugs and thyroid hormones pathways or thyroid drugs are discussed, reporting to the review data from the literature. Conclusions These case reports demonstrate the difficulties to manage HIV infection from the perspective of thyroid co-morbidities. Screening for thyroid function of newly diagnosed HIV patients should be considered by the national guideline for HIV monitoring and by the insurance services from Romania. Urogenital candidiasis after penian subcutaneous self-injections with nonconventional expanders Carmen Giuglea1,4*, Crenguta Coman1, Silviu Marinescu3,4, Ruxandra Moroti2,4 600mg/day, along with urinary catheter removal in the first day, with an initial rapid favorable course: skin healing, normal urogenital functions, disappearing of urethral discharge, diminishing of inguinal adenopathies. After the antifungal agent cessation, there was an insidious increasing of inguinal lymph nodes sizes, which began to be tender and developed necrosis. Imagery of the pelvic area was normal. An obvious immune deficit was ruled out (HIV-negative, T lymphocytes CD4 count lower but in normal range and normal level of gamma globulins). With a second longer antifungal cure – Fluconazole 400mg daily, 3 months, the recovery was complete. Conclusions Identification and correct treatment of a superposed infection permit a proper healing in this case with a compromised surgical outcome. In uro-genital fungal infections there is need for long course antimicotic treatment. *[email protected] 1 Clinical Emergency Hospital “Sf Ioan", Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 3 Clinical Emergency Hospital “Prof. Dr. Bagdasar Arseni”, Bucharest, Romania 4 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania The importance of a multidisciplinary team in the management of recurrent, treatment nonresponsive tonsillitis – case presentation Ana-Maria Blănaru1*, Alina Cristina Neguţ1,2, Alina Hristu1, Luminiţa Bradu1, Anca StreinuCercel1,2, Maria Magdalena Moţoi1, Mihai Olariu1, Adrian Streinu-Cercel1,2 *[email protected] Background Unfortunately, injecting all kinds of foreign substances in the penian area is a frequent habit among young males and represents a relatively large source of penile defects for plastic surgeon practice. This procedure is commonly followed by tumefaction and a various degree of skin necrosis that requires surgical treatment, meaning debridement and skin grafting. Case report We described a case of a young patient (16 years old) who had injected vaseline, a non-conventional expander used quite rarely, in his penian area for an augmentation effect and who subsequently developed massive tumefaction and skin necrosis. After two procedures of surgical debridement and skin grafting, along with large spectrum antibiotics, his local evolution was unfavorable, with persistent penian cellulitis, skin graft lysis, dysuria, minimal urethral discharge, mild pelvic pain and inguinal lymph nodes enlargement. He was addressed to infectious diseases department, where he was found to be infected with Candida albicans and Candida parapsilosis, isolated from skin lesions, urethral secretions, urine culture and urinary catheter. Both species were Fluconazole susceptible. He received an initial 21 days treatment with Fluconazole 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Rosai-Dorfman disease (RDD) is a rare pathology, with about 650 cases reported since the first presentation in the medical literature in 1969 and it is characterized by overproduction and accumulation of histiocytes in the lymph nodes, including cervical ones [1]. The diagnosis of RDD is made on biopsy with identification of S100 and CD68 markers. Case presentation We present the case of a vaccinated 14-year-old boy who presented three episodes of high fever, sore throat, asthenia and bilateral latero-cervical swelling over the course of 5 months. The last episode had started three days before admission and persisted despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). The clinical exam revealed fever, important submandibular and cervical lymph nodes of high consistency, sensitive to touch, relatively immobile on the plans above and underlying, discrete 68 hyperemic pharynx, discreet hyperemic and hypertrophic tonsils, covered by pseudomembranes, hepatomegaly and splenomegaly. The lab reports showed leukocytosis with neutrophilia, moderate inflammatory syndrome, hyperuricemia and negative IgM and IgG Epstein Barr serology. The pathology was initially labeled as acute tonsillitis and we initiated extended-spectrum antibiotics (ertapenem 1g/day) and NSAIDs, with no response after 72 hours. Because the first episode had responded to corticosteroid therapy, we considered a hematologic disorder as differential diagnosis and we requested a consult. We performed neck MRI which described numerous cervical lymph nodes, 7-31 mm in diameter, hepatic and hilar lymphadenopathy (below 1 cm) and tonsillar hypertrophy. A lymph node biopsy was performed and it revealed CD68 positive marker. So, Rosai-Dorfman disease diagnosis was established. During the febrile episodes, the patient received intravenous paracetamol, as per hematologist recommendations. Five months later, the patient is afebrile, with no lymphadenopathy and with no other symptoms. Conclusions Acute tonsillitis is a common pathology, usually having viral or bacterial etiology. A recurrent tonsillitis non-responsive to therapy needs further investigations and a hematological consult. This is a rare disease. Studies suggest that it affects more often males rather than females and children; adolescents or young adults are more susceptible. RDD is not a life threatening disease, but in 5% to 10% of patients, the progressive evolution may require surgical treatment, steroids, and/or chemotherapy [2]. References 1. National Organization for Rare Disorders. RosaiDorfman Disease. Accessed on 31 July 2015. Available at: https://rarediseases.org/rarediseases/rosai-dorfman-disease/ 2. Komaragiri M, Sparber L, Santos-Zabala ML, Dardik M, Chamberlain R. Extranodal Rosai– Dorfman disease: a rare soft tissue neoplasm masquerading as a sarcoma. World J Surg Oncol. 2013;11:63. Quality of life among people living with HIV in Romania – between stigma, coping and resilience Florin Lazar1*, Adrian Luca1 Background Romania has a group of long-time survivors of people living with HIV (PLHIV), whose quality of life (QoL) is little known from studies. Our aim was to identify the factors associated with the quality of life of PLHIV. Methods Adult PLHIV recruited online, from clinics and NGOs filled in a self-reported questionnaire (N=252, November 2014 – March 2015). In multivariate linear regression the dependent variable was computed (29 items) from the six domains of WHOQOL-HIV BREF (Physical, Psychological, Level of Independence, Environment, Social relationships, Spirituality). Independent variables were subscales extracted from validated scales: HIV Stigma Scale (alpha: .943), Brief-COPE (alpha: .843), Resilience Scale for Adults (alpha: .943) and CESD-R (alpha:.946). The final linear model has an adjusted R square of .765. Results A better quality of life are more likely to have those with a positive perception of the future (ß CI95%: .343 [.767 1.662], p<.000), without fatigue symptoms of depression (ß CI95%: -.326 [-3.385 1.599], p<.000), those with a more positive perception of self (ß CI95%: .195[.305 1.344], p<.002), who are less concerned with the public attitudes about PLHIV (ß CI95%: -.154 [-.372 .050], p<.011), those who use instrumental support (ß CI95%: .138 [.297 2.328], p<.012), accept their HIV condition (ß CI95%: .127[.387 3.449], p<.015), use positive reframing (ß CI95%: .120[.156 2.404], p<.026) but not active coping as strategy (ß CI95%: -.109[-2.302-.063], p<.039). Conclusions QoL is a complex concept, associated with coping, resilience and affected by depression and stigma dimensions such as “fatigue” and “concerns over the attitudes of the public about PLHIV”. Health and psychosocial professionals need to address these factors negatively influencing QoL and enhance the positive perspective of the future, of the self and encourage them to see the “half full” side, accept their status and use the available instrumental support. Acknowledgement This paper was co-financed from the European Social Fund, through the Sectorial Operational Programme Human Resources Development 20072013, project number POSDRU/159/1.5/S/138907 "Excellence in scientific interdisciplinary research, doctoral and postdoctoral, in the economic, social and medical fields -EXCELIS", coordinator The Bucharest University of Economic Studies. *[email protected] 1 University of Bucharest, Romania 69 Thyroid elastography in patients with chronic viral hepatitis C Oana Săndulescu1,2*, Anca Streinu-Cercel1,2, Monica Andreea Stoica2, Daniela Manolache2, Aniela Bodac1, Adrian Streinu-Cercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Thyroid stiffness is increased in various nodular pathologies, and shear-waves elastography may play an important role in differentiating benign from malignant thyroid nodules [1]. However, there is an acute lack of data regarding thyroid stiffness in patients with chronic infection with hepatitis C virus (HCV). As new treatment options for hepatitis C become available [2], it is important to choose the patients that benefit most from interferon-free treatment, and thyroid evaluation could prove important in this scenario. Methods Using Aixplorer (SuperSonic Imagine, Aix-enProvence, France), we performed thyroid shearwaves elastography in patients with chronic HCV infection and in a control group of subjects without viral hepatitis. Results We evaluated 42 patients with chronic HCV infection and 20 control subjects. The mean age and standard deviation were 50.6±11.2 years in the HCV group and 44.9±10.4 years in the control group. All patients in the HCV group had chronic infection with HCV genotype 1b. The mean and standard deviation for thyroid stiffness were slightly higher (25.0±10.1 kPa) in the HCV group compared with the control group (21.1±8.2 kPa), but the differences were not statistically significant due to the relatively small sample size (p=0.145). We identified thyroid nodules in 11 patients (26.2%) in the HCV group and in 2 (10.0%) controls (p=0.192). Thyroid stiffness was significantly higher in patients with thyroid nodules (28.3±10.4 kPa) than in those without nodules (22.4±9.1 kPa, p=0.048) and in patients with thyroid disease (30.1±11.9 kPa) than in those without (22.4±8.5 kPa, p=0.019). Thyroid stiffness was not statistically associated with patient age (p=0.243), IL28B genotype (p=0.221), timespan since diagnosis of HCV infection (p=0.157), liver stiffness (p=0.371), necroinflammatory activity on ActiTest (p=0.659), ALT (p=0.716), AST (p=0.662), thrombocytes (p=0.412), fibrinogen (p=0.767), cholesterol (p=0.396), triglycerides (p=0.479), fasting plasma glucose (p=0.457), TSH (p=0.881), FT3 (p=0.985), or FT4 (p=0.434). Conclusions We identified a slightly higher thyroid stiffness in patients with chronic HCV infection compared with the control group. To reach statistical significance, we intend to increase the study sample size. Elastography appears to be a good predictor of thyroid nodules or disease, regardless of the presence or absence of viral infection. References 1. Sebag F, Vaillant-Lombard J, Berbis J, Griset V, Henry JF, Petit P, Oliver C. Shear wave elastography: a new ultrasound imaging mode for the differential diagnosis of benign and malignant thyroid nodules. J Clin Endocrinol Metab 2010;95:5281-8 2. Streinu-Cercel A. Hepatitis C in the interferonfree era. Germs 2013;3:114. Management of acute maxillary sinusitis after sinus bone grafting procedures with simultaneous dental implants placement Lucian Chirilă1,2, Cristian Rotaru3,4, Iulian Filipov4,5, Mihai Săndulescu1,3* *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 “Dan Theodorescu” Clinical Hospital of Oral and Maxillo-Facial Surgery, Bucharest, Romania 3 Dental Concept Studio, Bucharest, Romania 4 MINEC Romania 5 Opera Dental, Bucharest, Romania Background Dr. Tatum first described sinus lift procedure in 1974 and it has proven to be a predictable procedure. The complications of this surgical procedure are reported in the literature to be low, and can include acute maxillary sinusitis, scattering of the grafting material in the sinus cavity, wound dehiscence and Schneiderian membrane perforations. We aimed to evaluate the rate of acute maxillary sinusitis after sinus lift procedures and the appropriate management strategies. Methods Between 2013 and 2015, 245 dental implants were placed in 116 patients (76 males and 40 females) with concomitant bone augmentation of the maxillary sinus floor. The sinus lifting procedure was bilateral in 35 patients and unilateral in 81 patients (a total of 151 sinuses). Results Maxillary sinusitis occurred in 5 patients (4.3%). The clinical signs of infection were: headache, 70 locoregional pain, cacosmia, inflammation of the oral buccal mucosa and rhinorrhea or unilateral nasal discharge. A mucosal fistula was observed during inspection in one patient. The management included only the removal of the grafting material in 3 patients, in 1 patient the grafting material was removed together with all the implants, and in 1 patient only 2 implants and the grafting material were removed, 1 implant being left in place. The inflammatory sinus mucosa was also removed in all patients, the sinus cavity was irrigated with metronidazole solution and an antibiotic therapy was prescribed for 10 days with clindamycin and metronidazole. All signs of infections disappeared within 5 to 7 days and normal sinus function and drainage was restored. Conclusions Although sinus lift is regarded as a safe and reliable technique, acute sinusitis is a possible complication which has to be managed immediately in order to reduce the risk of further complications like pansinusitis, osteomyelitis of the maxillary bone, spreading of the infection in the infratemporal space or orbital cavity. To minimize risk, caution must be taken with all the steps of the procedure, but the risk for developing acute sinusitis appeared to be higher in patients with an obliterated ostium, chronic conditions of sinus membrane and when a large bone graft volume was placed, impairing maxillary sinus clearance. Secondary bone infections in oral bisphosphonates patients – a rising issue Lucian Chirilă1,2, Cristian Rotaru3,4, Iulian Filipov4,5, Mircea Baldea2, Mihai Săndulescu1,3* *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 „Dan Theodorescu” Clinical Hospital of Oral and Maxillo-Facial Surgery, Bucharest, Romania 3 Dental Concept Studio, Bucharest, Romania 4 MINEC Romania 5 Opera Dental, Bucharest, Romania Background Bisphosphonates are antiresorptive and antiangiogenic medication used in the management of metastatic osteolytic bone lesions originating from breast, prostate, pulmonary cancer and multiple myeloma, but also in postmenopausal osteopenia/osteoporosis and in other rare diseases of the bone (osteogenesis imperfecta, Paget’s disease, etc.). Bisphosphonates can be administered orally or parenterally. Although bisphosphonates treatment has clinically proven benefic effects and it enhances the quality of life in both cancer and osteoporosis patients, it can also induce specific necrosis of the maxillary bones. This clinical condition is known as bisphosphonate-related osteonecrosis of the jaw (BRONJ) or more actual medication-related osteonecrosis of the jaw (MRONJ) as the AAOMS position paper update 2014 recommends. Although it is more frequent in cancer patients receiving intravenous bisphosphonates (0.9-12%), it has an increasing incidence in low-grade risk patients receiving oral bisphosphonates for osteoporosis treatment. MRONJ staging includes 4 stages, but in stages 2 and 3 secondary bone infection is present. The most commonly involved bacteria are Actinomyces spp., but some studies have described the presence on the exposed bone of a complex biofilm formed of bacteria, fungi and viruses. Methods We evaluated between January 2012 and June 2015 63 patients (23 male and 40 female) with osteonecrosis of the jaw (ONJ) with associated bone infection. Results Out of the total number of patients with ONJ, 11 (17.4% – 10 female and 1 male) were diagnosed with stage 2 and 3 MRONJ caused by oral bisphosphonates treatment. The oral antiresorptive medication was prescribed for osteoporosis in 9 (14.2%) patients and for bone metastases in 2. One of the risk factors for MRONJ is the duration of treatment, which was between 1 and 8 years, with an average of 3.81 years. The lower jaw was more frequently affected (8 cases) than the upper jaw (3 cases). The number of patients with MRONJ induced by oral medication related to the semesters of the evaluation period indicates an increase in the last 3 semesters (9 patients) compared to the first 3 semesters (2 patients). Conclusions The increase in the number of patients with secondary bone infections caused by oral bisphosphonates treatment may be due to the increase in the total duration of the treatment, but also to the increased number of patients receiving this type of medication. The lack of prevention when starting oral bisphosphonates treatment and the neglecting of early signs of disease may further increase the incidence of MRONJ. Clinico-epidemiological aspects of flu in children from Constanta between 2013 -2015 Ana Maria Iancu1*, Maria Margareta Ilie1, Dalia Sorina Carp1, Simona Claudia Cambrea1,2 *[email protected] 71 Clinical Infectious Diseases Hospital of Constanța, Romania 2 Faculty of Medicine, “Ovidius” University, Constanța, Romania 1 Background The annual surveillance of influenza cases is very important to identify circulating influenza virus strains. It is also performed in order to inform about the severity, impact and timing of seasonal epidemics, and to detect any emerging influenza viruses. Methods It is a retrospective study, based on the data obtained from database software of the Clinical Hospital of Infectious Diseases from Constanta and on the observation charts of hospitalized children in our clinic during the cold season 2013-2015. The specimens used were nasopharyngeal swabs and the detection of influenza virus was made by using nucleic acid amplification tests (RT-PCR) Results We noticed that during this period 675 nasopharyngeal swabs, collected in patients of all ages, were positive. The annual distribution of influenza cases was: 2013 -169 cases (17 casesinfluenza A, 122 cases - influenza AH1, 5 casesinfluenza AH3, 25 cases – influenza B); 2014 – 147 cases (24 cases – influenza AH1, 108 cases – influenza AH3, 15 cases - influenza B); 2015 – 359 cases (56 cases – influenza A, 27 cases – influenza A subtype H1N1, 276 cases –influenza B). From all cases, 213 were isolated from children between 1 and 14 years of age, with the next distribution by age: 1-4 year – 51 cases, 5-10 years – 106 cases, 11-14 years – 56 cases. Influenza A was more common in age group 1-4 years, while influenza B was more frequent in children older than 5 years. In terms of gender distribution, 53,5% of cases were diagnosed in boys. All cases occurred in unvaccinated children. Influenza A was more common during cold season 2013 and 2014, while influenza B was frequently in last season, 2015. Most cases occurred in Mars, representing 43.66% from all cases. The onset was variable, with respiratory symptoms or with digestive and respiratory complaints or with myalgia. The main complications were pneumonia, meningismus and myositis. Conclusions According to the data from literature, in the last cold season, influenza B predominated in children. It generally causes milder disease than type A, so no SARI was diagnosed in children. Influenza represents a significant public health threat, so it is important to perform vaccination in all groups of population including children. Could rifaximin be an ally in the prevention of Clostridium difficile infection recurrences? Violeta Molagic1*, Catalin Tiliscan1,2, Cristina Popescu1,2, Cristina Dragomirescu1, Irina Duport1, Irina Lepadat1, Raluca Nastase1, Mihaela Radulescu1,2, Raluca Mihailescu1, Daniela Munteanu1, Anca Negru1, Alina Lobodan1, Cristina Covaliov1, Victoria Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Clostridium difficile infection (CDI) remains an increasingly common hospital-associated diarrhea. Recurrence of symptoms is one of the greatest challenges of CDI management. There is still no effective therapy to prevent CDI recurrences. Rifaximin is a rifamycin-based non-systemic antibiotic with a negligible impact on the intestinal microbiome and in-vitro activity against Clostridium difficile. We aimed to assess the efficacy of rifaximin in prevention of CDI recurrences. Methods We enrolled all CDI patients admitted to the Adulti III department of Prof. Dr. Matei Bals National Institute of Infectious Diseases, Bucharest between July 2014 - July 2015. We report our experience with rifaximin added at conventional treatments (metronidazole and/or vancomycin) and as sequential therapy following vancomycin in patients to prevent CDI recurrences. Results We included 110 patients with a mean age 62.37±18 years. Male/female ratio was 0.52. Clostridium difficile 027 strain was identified by PCR in all patients. Most of them (53.6%) presented with an initial CDI episode, the rest having one (25%) or more recurrences (2-5) (9.3%). The median ATLAS score was 2 (IQR=1;7) Most patients (76.36%) had previously received antibiotic therapy, most frequently cephalosporins (19.1%) and fluoroquinolones (15.5%). There were nine (8.2%) deaths, of which only three cases are due CDI complications (toxic megacolon). Rifaximin 800mg/day for 14 days was added at conventional treatment in 54/110 cases (49%) to reduce the risk of bacterial translocation. The patients who received rifaximin have more comorbidities, severe hypoalbuminemia (median 2.90g/dL), lymphopenia (median 0.7 X 109 /L),elevated C-reactive protein (median 62.7mg/L) and were older with mean age 65.98±17.91 years 72 versus 58.98±17.66 years for patients without rifaximin (p=0.044). There were no statistical differences between patients with rifaximin versus patients without rifaximin regarding the CDI outcomes or recurrences (p=0.971). In 9 cases (8%) we used serial therapy with vancomycin, followed by rifaximin 800 mg/day for 14 days or 60 days. This scheme was used in four patients with more than one CDI recurrences and in five patients after first CDI episode. All patients had no further diarrhea episodes after stopping rifaximin treatment. Conclusions Rifaximin may be an alternative for some patients to reduce the risk of CDI recurrences. It still needs randomized trials to evaluate the efficacy of rifaximin in the treatment of CDI. Cutaneous myiasis – unwanted souvenir from Peru Violeta Molagic1*, Carmen Chiotan1, Ramona Barac2, Carmen Cretu2, Raluca Popescu1, Adrian Streinu-Cercel1,2, Victoria Arama1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Myiasis is defined as the infestation of live human and vertebrate animals by larvae of the order Diptera. Myiasis can cause a broad range of infections and is classified in: cutaneous, enteric, ophthalmic, nasopharyngeal, auricular, oral, urogenital. In cutaneous myiasis the common sites for lesions are the scalp, face, forearms, and legs for the myiasis causing Dermatobia hominis, and the trunk, buttocks and thighs for Cordylobia anthropophaga. Cutaneous myiasis is seen more frequently in travelers from South America or Africa countries. Case report We present the case of a 57 years old female admitted in May 2015 to Adults 3 Department of Prof Dr Matei Balș National Institute of Infectious Diseases with preseptal cellulitis diagnosis. She has acute upper eyelid erythema, swelling and severe pain on left eye. Three weeks prior her admission she was in Peru where she was bitten by an insect on the eyelid left eye and presents local pruritus. After five days shows discrete erythema and edema with local worsened after several days and with severe pain. She reach ophthalmologist and receives local treatment with dexamethasone and antibiotics eyewash and later Augmentin 1 gX2/day for 4 days. Because the local sign did not improve she was admitted in our clinic. Eye exam revealed patients with periorbital edema, erythema and increase in local hyperemia but without proptosis, ophthalmoplegia or visual impairment. Laboratory studies were normal and the culture from eye swab was negative. The patient received iv. treatment with Ertapenem 1 g/day + Vancomycin 2 g/day, Fluconazole i.v and non-steroidal antiinflammatory but later was added Dexamethasone iv. She was referred daily for ophthalmologist exam and local treatment. After 4 days the eyes could be opened but the pain and foreign body sensation persisted. She was refer again to the ophthalmologist were a funnel containing live larva was found under the cilia and the larva was surgical removed. The local evolution quickly resolved with non-steroidal anti-inflammatory and the patients was discharge with favorable local outcome. The parasitological examination diagnosed cutaneous myiasis caused by Dermatobia hominis. Conclusions Because of an increase in international travel, physicians are more likely to encounter myiasis today. In many cases it can be misdiagnoses. A good travel history and interdisciplinary collaboration is a key to the proper diagnosis and, ultimately, the treatment of cutaneous myiasis. Symptomatic congenital CMV infection - case report Monica Luminița Luminos1,2, Anca Cristina Drăgănescu1*, Anuța Bilașco1, Angelica Vișan1,2, Magdalena Vasile1, Diana Slavu1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Congenital CMV infection remains an important subject because it is the most common congenital infection in newborns and also a major cause of sensorineural hearing loss and neurological disability with long-term impact in children. Even if most newborns are asymptomatic, approximately 10% will develop sensorineural hearing loss in the first 5 to 7 years of life. Antiviral therapy is recommended in the first 30 days of life for symptomatic CMV infection that includes CNS disease and severe focal organ disease: anemia, neutropenia, refractory thrombocytopenia, hepatitis, colitis, pneumonia and myocarditis. Isolating the virus in urine samples within the first 73 3 weeks of life establishes whether the CMV infection is congenital or acquired after birth. Case report We present the case of a premature newborn with symptomatic congenital CMV infection with neurological, hematologic, hepatic involvement and sensorineural hearing deficiency. The medical history of the newborn was really relevant: maternofetal infection with group B Streptococcus for which she received treatment with penicillin; transfontanellar ultrasonography and cerebral MRI had shown evidence of grade 3 periventricular hemorrhage and cerebral micro calcifications. We started treatment using ganciclovir (12 mg/kg/day) in two divided doses for 20 days. The treatment was stopped because of toxic phenomena (anemia, severe increase in urea, hypoglycemia, important hepatic cytolysis syndrome and progressive cholestasis syndrome. After resolution of toxic phenomena, we decided to continue treatment with valganciclovir (16 mg/kg/day po in two divided doses) for 3 weeks. The evolution was favorable in time with clinical recovery of neuromotor development, mild sensorineural hearing deficiency, normalization of liver and kidney function; the very low levels of viral load in serum and urine and negative in the CSF made us stop the treatment. The level of viremia was measured with quantitative CMV DNA PCR. Following discontinuation of therapy, the infant is still monitored for evidence of long-term effects of CMV such as: hearing loss, intellectual disability, eye disease and dental disease. Conclusions The first-line antiviral agents for congenital symptomatic CMV infection are ganciclovir and valganciclovir. The main benefit of taking antiviral therapy in the first 30 days after birth is the prevention of hearing disorders. In the absence of clinical evidence of disease progression, studies have shown that a rise in viremia alone is not a criterion to continue treatment for more than 6 weeks. Acute myocarditis, recurrent fever, septic shock and monocytosis in an apparently immunocompetent patient Maria-Sabina Tache1*, Aida Roxana Agurida1, Alina Cristina Negut1,2, Maria Magdalena Motoi1, Luminita Mariana Bradu1, Anca Streinu-Cercel1,2, Adrian Streinu-Cercel1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Acute myelogenous leukemia can present itself with a mosaic of signs and symptoms before it is diagnosed. Case report A 37 year-old male in apparently good health, developed fever, chills and toothache three weeks prior to the admission to our clinic. He presented to the dentist where he underwent endodontic therapy and received the indication of amoxicillin/ clavulanic-acid that he could not take because of gastric intolerance. A few days later his clinical state worsened and he was admitted to the Cardiology department with the diagnosis of acute myocarditis. He received cefoperazone and levofloxacin therapy with apparently favorable evolution. At discharge fever, chills and altered clinical state reappeared alongside with abdominal pain and diarrhea. Nine days afterwards he was admitted to the Intensive Care Unit department with the diagnosis of septic shock and he received meropenem and linezolid therapy with the decline of fever and diarrhea remission. The patient was transferred to our clinic the following day with a satisfactory general state, afebrile, without palpable lymph nodes, with balanced cardiovascular and respiratory functions, without abdominal pain but with hepatosplenomegaly. The lab reports showed leukocytosis with monocytosis, anemia with macrocytosis, thrombocytopenia, acute inflammatory syndrome and coagulation disorders. Hemocultures, HIV testing, hepatitis markers and Borrelia serology were all negative, quantiferon testing was positive, tongue scraper cultures identified Candida spp. The patient received meropenem, linezolid, levofloxacin and fluconazole treatment for fifteen days with clinical and paraclinical improvement. On the day of discharge he presented syncope, followed by vomiting, abundant perspiration and pallor. The patient developed pain in the right lumbar region, diarrhea, fever and chills. An abdominal computed tomography (CT) scan revealed an inflammatory infiltration of the cecum and the neighboring peritoneum. Colonoscopy identified ulcerative proctosigmoiditis. We suspected a hematological disorder and bone marrow biopsy was taken and it demonstrated 16-17% leukemic myeloblasts. He was transferred to a Hematology hospital. The diagnosis was acute myelogenous leukemia and the patient started the induction followed by consolidation chemotherapy and in July 2015 he underwent bone marrow transplant with favorable evolution. Conclusions More and more often complicated cases must be evaluated in a multidisciplinary team. In this case the recurrent fever and chills, leukocytosis, anemia, thrombocytopenia, hepatosplenomegaly, cecum 74 inflammatory infiltration, the acute myocarditis and the septic shock could have dual cause: infectious disease and acute myelogenous leukemia. An atypical presentation of secondary syphilis Mihaela Anca Benea1*, Serban Nicolae Benea2, Simona Roxana Georgescu3, Adriana Hristea2, Vasile Benea3, Mircea Tampa3, Otilia Benea2, Ruxandra Moroti2 established. Ceftriaxone treatment was continued for a total of 7 days. After that two doses of 2.4 million IU of benzathine penicillin were administered one week apart. The evolution was favorable with no fever and gradual normalization of the laboratory tests (except VDRL and TPHA); the patient was discharged. Conclusions We consider this to be an atypical presentation of secondary syphilis as acute hepatitis is uncommon and the pancreatic reaction is even more unusual. *[email protected] 1 Sana Medical Centre, Bucharest, Romania 2 ”Dr. M. Bals” National Institute for Infectious Diseases, Bucharest, Romania 3 ”Dr. V. Babes” Clinical Hospital for Infectious and Tropical Diseases- Dermato-venereology Department, Bucharest, Romania Background Secondary syphilis reflects the hematogenous dissemination of the spirochetes after the resolution of the primary lesion. It is associated with countless different exanthemas and enantems and it was known as the great imitator. Secondary syphilis can also produce systemic changes by affecting the lymph nodes, kidneys, spleen, CNS and very rarely the liver. Case report We are presenting the case of a 31 years old male patient who addressed the infectious diseases clinic accusing fever, chills, aqueous rhinorrhea, dry cough, odynophagia and generalized adenopathies. The symptoms first appeared one month prior and four days before the hospitalization he experienced pain in the right hypocondrium and a maculopapular eruption involving the torso that later generalized. He self-medicated with NSAIDs. The patient’s medical history was irrelevant for the case. The clinical examination revealed a generalized, erythematous maculo-papular eruption, lymphadenopathy and no other abnormalities. The laboratory tests showed leukocytosis with neutrophilia, inflammatory syndrome, hepatocytolysis syndrome (3 times the normal values), incomplete cholestasis syndrome, pancreatic reaction (4 times the normal values). The diagnosis at this stage was of acute cholangitis with pancreatic reaction and ceftriaxone iv 2g/day was initiated. Because of the roseola-like exanthema we performed a VDRL and TPHA test which came back positive two days later; the HIV testing was negative. At a more detailed history the patient remembered having an ulcerated, selflimited, painless lesion on the glans penis two months before followed by an erythematous eruption. The diagnosis of secondary syphilis was Superpositions of the pathological and clinical diagnosis in HIV neurological involvement Ioan-Alexandru Diaconu1*, Laurentiu Stratan2, Victoria Arama1,2, Luciana Nechita4, Ruxandra Moroti1,2, Alexandra Diaconu3, Anca Negru1, Alina Lobodan1, Daniela Adriana Ion2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 3 "Marius Nasta" Pneumoftiziology Institute, Bucharest, Romania 4 Colentina Clinical Hospital, Bucharest, Romania Background Romania has had little research on its own population of neurohistopathological aimed complications arising from infection with the human immunodeficiency virus 1 (HIV-1). Our study aims HIV central neuropathology through post-mortem histopathological examination, immunohistochemistry and immunofluorescence in correlation with clinical diagnoses issued ante mortem. Methods The analysed material consisted entirely of human brain tissue collected during autopsies performed in the Pathology Department of the Colentina Clinical Hospital, Bucharest, over 18 years (01.1993 – 12.2011) from 33 HIV+ patients hospitalized in the National Institute of Infectious Diseases Prof. Dr. Matei Bals. All cases were examined in parallel by two pathologists and quantified as common criteria, thereby ensuring a uniform evaluation for all the material studied. Results The group of 33 HIV-positive patients was created over 18 years and show marked heterogeneity, both in age, variety of diagnoses, treatment, as well as immunological status. From the group of 33 HIVinfected patients whose brain tissue was examined post-mortem histopathology, 14 received 75 antiretroviral therapy, 4 of them for a shorter period than 5 months. The most common general ante mortem clinical diagnoses were bronchial pneumonia, oropharyngeal candidiasis, meningoencephalitis, pulmonary tuberculosis and HIV encephalopathy. The most common neurological histopathological diagnoses were: hyperemia with edema, cryptococcal meningoencephalitis and HIV encephalopathy. In the non-cART branch, the top neurological histopathology diagnoses were hyperemia with edema (6 cases), non-specific meningoencephalitis (3 cases) and cryptococcal meningoencephalitis (3 cases). The most frequent diagnosis in the cART<5 months branch was HIV encephalopathy (2 cases), while in the cART>5 months branch we had Toxoplasma meningoencephalitis (3 cases), hyperemia with edema (2 cases) and cryptococcal meningoencephalitis (2 cases). Hyperemia and edema was discovered in 8 of the 33 patients, 2 being treated with antiretroviral therapy, and 6 not treated. Conclusions The results outline an overview of new viral activity in the brain and a series of questions about the long term effects of persistent infection at this level. We found that the clinical diagnosis, despite modern methods of imaging and serological investigation, is inconsistently superpositioned with the neurohistopathological diagnosis, considering a heightened difficulty in the differential diagnosis within the plethoric HIV neurological pathology, with a 40% cases of partial or total clinical misdiagnosis in comparison with the histopathological findings. Acknowledgment This article has been written as part of the project ”Cercetarea doctorală şi postdoctorală prioritate a învăţământului superior românesc (Doc-Postdoc)” (Doctoral and Post-doctoral Research as a Priority in the Romanian High Educational System) POSDRU/159/1.5/S/137390. Complicated cases of chickenpox in children in 2015 Monica Luminos1*, Anca Draganescu1, Angelica Visan1, Ancuta Bilasco1, Endis Osman1, Camelia Kouris1, Sabina Schiopu1, Diana Slavu1, George Jugulete1, Madalina Merisescu1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Chickenpox is an extremely contagious disease frequent in children, that usually resolves without any severe complications. In some cases chickenpox can complicate with pneumonia, encephalitis, cutaneous abscesses and even death. Methods We present the situation of all chickenpox cases admitted in The National Institute of Infectious Diseases ”Prof. Dr. Matei Bals” during 01.01. 2015 – 01.07.2015. Also, we present three severe cases of chickenpox complicated with cutaneous sepsis. Diagnosis was established based on clinical, epidemiological and laboratory criteria. Results During the mentioned period, we have registered a number of 62 cases of chickenpox admitted in our clinic. All of them were complicated cases. The most frequent complications were represented by bacterial superinfections (58%), pneumonia (19.6%) and varicella encephalitis (4.4%). Out of all patients, 3 children presented cutaneous sepsis, with multiple cutaneous abscesses, which required surgical treatment. The isolated bacteria were Streptococcus pyogenes strains. All the cases evolved favorably under adequate antibiotic treatment. We have registered one death in a child with chickenpox and newly diagnosed acute lymphoblastic leukemia. Conclusions Lately we have observed a rise in bacterial superinfections in chickenpox cases due to immunodeficiency caused by the illness. The most frequent isolated bacteria involved in superinfection was Streptococcus spp. The total number of complicated cases was significant in our clinic, which is why we highly recommend VZV vaccination in all school aged children. The role of PLEX-ID in diagnosis of Staphylococcus spp. infections in children – case presentation Mădălina Merișescu1*, George Jugulete1, Anca Drăgănescu1, Anuța Bilașco1, Angelica Vișan1, Camelia Kouris1, Magda Vasile1, Endis Osman1, Sabina Șchiopu1, Bianca Bizera1, Dragoș Florea1,2, Adrian Streinu-Cercel1,2, Monica Luminos1,2 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 76 Background Staphylococcal infections are usually determined by Staphylococcus aureus, but in particular situations such immunodeficiency, existence of gateways or invasive medical devices, severe forms of Staphylococcus epidermidis or coagulase negative staphylococcus infections can occur. Case report We want to present in this paper 2 cases. The first case is a 7 year old boy with no relevant medical history, admitted in the Pediatric Intensive Care Unit of National Institute of Infectious Diseases „Prof. Dr. Matei Bals” with the suspicion of acute meningitis. The clinical examination revealed clinical signs of meningitis and the presence of a sacral dermal sinus. The second case, was represented by a 2 years old child known with aplastic anemia. In the first case the lumbar puncture confirmed the acute bacterial meningitis diagnosis. Cultures and biochemical analysis of CSF were performed. The PLEX-ID test was positive for Staphylococcus epidermidis in a few hours. An MRI scan confirmed the presence of a sacral dermal sinus and the absence of two intervertebral discs. Later on, the CSF cultures confirmed the Staphylococcus epidermidis infection. In the second case the diagnosis was established with PCR from a blood sample. The result was positive for Staphylococcus aureus in a couple of hours. Treatment was established based on the antibiogram and evolution was favorable in both cases. Conclusions The particularity of the case was the child’s apparent normal state of health until the age of seven with a sacral dermal sinus. In order to avoid future episodes of meningitis, surgery was performed to close the sinus. Staphylococcus epidermidis determined an acute bacterial meningitis in a patient with a dermal sinus, which was quickly diagnosed through PLEX-Id in the first case. The particularity of the second case was the pre-existent aplastic anemia that predisposes to Staphylococcus infections. Background From 40 to 90 per cent of new HIV infection are associated with symptomatic illness. Identifying patients in the initial stage of HIV infection is essential for initiating early antiretroviral therapy and especially for preventing the spread of disease. The clinical manifestations of acute retroviral infection (or primary HIV infection) usually appear within 3 to 6 weeks after initial exposure. The most common signs and symptoms include fever (8090%), fatigue (70-90%), morbilliform eruption (4080%), headache (30-70%), lymphadenopathy (4070%), pharyngitis (50-70%), myalgia and arthralgia (50-70%), aseptic meningitis (24%), retro-orbital pain, oral and/or genital ulcers (5-20%), gastrointestinal symptoms etc. As many symptoms are nonspecific, without a high degree of suspicion, the diagnosis can frequently be missed. The most characteristic muco-cutaneous manifestations include a maculopapular (morbilliform) or papulosquamous (resembling to secondary syphilis) eruption, oro-pharyngeal and/or genital ulceration and oro-pharyngeal or genital candidiasis. The severity and the duration of the primary HIV infection may have prognostic implications; severe and prolonged symptoms are correlated with rapid disease progression. Case presentation We present the case of a 43 years old man who presented to the dermatology department for several painful genital ulcerations accompanied by inguinal lymphadenopathy. These ulcerations occurred few days before, being related by the patient to local trauma. The patient does not associate other clinical manifestations. Laboratory investigations for syphilis (VDRL, TPHA effectuated in dynamics) and genital herpes were negative, as bacteriological and assay for anti-HIV1/2 antibodies. Instead p24 antigen was revealed in plasma. Based on these data we established diagnosis of genital ulcers in acute retroviral syndrome. The genital ulceration last for two weeks. The patient was referred to the infectious disease department for biologic and immunologic evaluation and treatment of HIV infection. Acute retroviral infection – a case presentation Surgical intervention versus antibiotic use in acute appendicitis Vasile Benea1*, Simona Roxana Georgescu1, Mircea Tampa1, Mihaela Anca Benea1, Diana Leahu1, Cristina Raileanu1, Serban Benea2 Răzvan Vasile Stoian1,2, Daniel Ion2, Simona Elena Albu1,2*, Roxana-Elena Viezuină2, Dan Nicolae Păduraru2 *[email protected] *[email protected] 1 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 University Emergency Hospital of Bucharest, Romania 77 The main mechanism involved in triggering the appendiceal inflammation is the obstruction of its lumen. According to the contemporary data, to the inflammatory process in the appendix, various factors contribute, therefore, acute appendicitis is a polyetiologic disease. Various theories have been developed, such as the infectious one (Aschoff, 1908), the mechanical (Dieulafoy), the chemical theory, cortico- visceral (NN Elanski, 1955) etc. The infectious theory relates to the enteral or hematological infection and sustains that its confinement in appendix lining triggers a nonspecific inflammatory process. There is an unanimous agreement in considering the infectious and the obstructive factors as determinants of appendicular inflammatory process. Our study was conducted over a period of 5 years, and evaluated a number of 73 cases, planned to make an analysis of the cases in which it was decided in delaying surgery care in terms of remission or improvement of the acute symptoms determined by antibiotics. Depending on the obtained data, the clinic state of the patient, laboratory investigations and close cooperation with the infectious disease doctor, an antibiotic administration protocol has been established. Laboratory examinations were used sequentially. The results advocate for rational and selective antibiotics in patients who had a favorable outcome after 24 hours after starting antibiotic. Prophylaxis and therapeutic strategies in postoperative infections Daniel Ion2, Răzvan Vasile Stoian1,2, Simona Elena Albu1,2*, Roxana-Elena Viezuină2, Dan Nicolae Păduraru2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 University Emergency Hospital of Bucharest, Romania Infections occurred after surgical interventions may cause pain, unfavorable outcome in terms of postoperative wound healing and require continuous antibiotic treatment, and postoperative care in the Surgery Clinic. These kind of situations cause an increase of the hospitalization period, increased costs of hospitalization, and can cause serious surgical complications such as sepsis, multiple organ failure or even the patient’s death. Postoperative suppuration remains the most common and most feared complication of this kind of surgical interventions, so there have been proposed a variety of measures to prevent it. Our study is trying to make an analysis of this redoubtable complication, but controllable in terms of precise knowledge of the pathogen agent involved, noting that any bacterial contamination is not necessarily followed by an established infection. Depending on this parameters, prophylaxis with antibiotics, antibiotic targeted strategy with aseptic and antiseptic rules associated with preoperative preparation and postoperative wound care, can lead to the patient’s and physician’s therapeutic success. The presented study refers to a number of 53 cases of suppurations or postoperative wound infections in the last 5 years in which therapeutic efficiency was achieved through close collaboration between the surgeon and the infectious disease doctor. During the process there were followed: patient’s risk factors for infection, methods of infection prevention, caution in choosing the correct dosage of the antibiotic before and after surgery. All these data are major factors in determining the therapeutic decision, and draws attention to extremely favorable results from interdisciplinary collaboration. Influenza virus associated with acute transverse myelitis in children Monica Luminos1*, Madalina Merisescu1, Anca Draganescu1, Angelica Visan1, Ancuta Bilasco1, Sabina Schiopu1, Endis Osman1, Camelia Kouris1, Bianca Bizera1, George Jugulete1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Involvement of the CNS in influenza virus infection are a relatively rare and serious complication, but since the 2009 H1N1 pandemic an increase in the neurologic complications associated with influenza virus infections has been described. Case report We report a series of cases of H1N1-associated with acute transverse myelitis among the pediatric population of Romania. During the winter of 20142015, three cases of acute transverse myelitis were addressed to “The National Institute for Infectious Diseases "Prof. Dr. Matei Bals" – Pediatric Department. Along with classic influenza symptoms, the patients also had walking disturbances and progressive neurologic alteration. The etiological diagnosis was made using the mariPOC test and then confirmed by RT-PCR. Two cases were associated with the A H1N1 infection and one with the influenza B virus. Immediate IRM studies were performed which ruled out 78 compressive myelopathies and described diffuse, inflammatory lesions. After, lumbar punctions were performed the markers of inflammation were found to be positive in the cerebrospinal fluid. Antiviral, antibiotic and intravenous corticoid therapies were used, in association with kinetotherapies. Slow but sustained recovery was obtained in all three cases. None of the patients had neurological sequelae at the end of the treatment. Conclusions Influenza virus associated transverse myelitis is an extremely severe complication of the disease that highlights once again the importance of extensive vaccination programs, and must be rapidly considered in the differential diagnosis of patients with influenza-like illness and neurological impairment. A complicated case of nosocomial infection with multiple bacterial pathogens: Staphylococcus hominis, Serratia marcescens, Enterobacter cloacae and Pseudomonas aeruginosa – case presentation Ramona Ștefania Popescu1,2*, Rodica Bacruban2, Madalina Selagea2, Adrian Streinu Cercel1,2 *[email protected] 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania Background Nosocomial infections are defined as acquired in the hospital by a patient admitted for a reason other than that infection. This is why they are also called “hospital-acquired infections”. Examples of most frequent nosocomial infections are: urinary tract infections, central line-associated bloodstream infections, lower respiratory tract infections and surgical wounds infections. Case report A 74 year-old patient was referred to our clinic for the treatment of Clostridium difficile diarrhea diagnosed using a toxin A/B test. Five weeks earlier she underwent laparoscopic surgery for a gastrointestinal stromal tumor (GIST), with subsequent treatment with ceftriaxone under which she developed diarrhea refractory to oral vancomycin. Due to her altered health status she was treated in the Intensive Care Unit with no clinical improvement. At admission she was afebrile, bedridden, pale, with generalized edema, purulent discharge at the abdominal surgical site and at the central venous catheter (CVC) insertion site, right leg necrotic wound after dopamine infusion, with great weight loss and malaise. Laboratory tests revealed normal leukocyte count, anemia, biological inflammatory syndrome, electrolyte imbalance, low albumin level, cholestasis. Polymerase chain reaction (PCR) for C. difficile was negative. The cultures identified Pseudomonas aeruginosa from the surgical site, P. aeruginosa plus Serratia marcescens from the CVC insertion site and S. marcescens plus Enterobacter cloacae from the necrotic wound. Blood cultures obtained from the catheter identified methicillin-resistant Staphylococcus hominis. We initiated treatment according to antibiogram results with meropenem 1g TID and teicoplanin 800mg loading dose then 400mg QD for 10 days. With the appropriate antibiotic and supportive treatment, daily wound cleansing and progressive kinetotherapy the patient fully recovered with no residual impairment. C. difficile infection was ruled out by repeated negative PCR testing, and diarrhea resolved only with symptomatic treatment. Conclusions Intensive care is a risk factor for antibiotic-resistant bacteria. Nosocomial infections are a major challenge to patient safety and are associated with increased morbidity, mortality and additional financial costs. Acknowledgement This paper is partially supported by the SOP HRD, financed from the European Social Fund and by the Romanian Government under the contract numbers POSDRU/159/1.5/S/137390. Cardiac damage in Lyme disease Isabela Loghin1*, Eduard Nastase1, Catalina Luca1, Carmen Dorobat2 *[email protected] 1 “Gr.T.Popa” University of Medicine and Pharmacy, Iași, Romania 2 Infectious Diseases Hospital “Sf Parascheva”, Iași, Romania Background Lyme disease, acute zoonosis, produced by Borrelia burgdorferi spirochete, through the tick of the Ixodes species, describe in multisystemic clinical spectrum cardiac determination, such as myocarditis (5-8%), arrhythmias, atrioventricular block (90%), congestive heart failure, or cardiac syncope, that can lead to sudden death. Diagnosis requires corroboration of clinical and epidemiological anamnestic data of borreliosis like previous tick bite, erythema migrans or neurological involvement, with electrocardiographic abnormalities and symptoms such as chest pain, palpitations, syncope and dyspnea in combination with laboratory exams, 79 serological tests, and echocardiography, which often establish the diagnosis. In literature it is shown that 4 of 10 patients with untreated Lyme disease can develop carditis. Etiological treatment involves antibiotic therapy (amoxicillin) and in systemic forms - Penicillin G, or third generation Cephalosporins. Routine therapy and screening patients with idiopathic dilated cardiomyopathy is of limited utility and should be reserved for patients with clear history of Lyme disease, tick bite, or serological enlightening test. Methods Retrospective study conducted from January 2012 July 2015 on 32 confirmed cases of Lyme disease patients with cardiac manifestations, hospitalized in Infectious Diseases Hospital Iasi. Positive diagnosis was established based on clinical and laboratory data, emphasizing the IgM antibody titers by ELISA and Western-blot subsequent confirmation; cardiac damage evidenced by ECG and echocardiography. Results From the experience of our clinic number of confirmed cases increased from 2012 until today, especially in the summer months. Mostly the cases were from urban areas with a relatively equivalent sex distribution, and the cardiac damage has been reported in 7 cases. Most experienced arrhythmias block of varying degrees, with reversible evolution under appropriate treatment. One case has presented myocarditis, the patient complaining by chest pain, palpitations, anxiety, dyspnea; the ECG highlighting the reduction in amplitude of tracing complexes, ST depression, T wave flattened. The therapy was instituted quickly, depending on cardiac injury. Thus, in patients with minor cardiac events, the antibiotherapy was instituted with amoxicillin, and in patients with severe cardiac disease was chosen Ceftriaxone, for 21 days, with further favorable development. Corticosteroid therapy was used in complicated cases with myocarditis. Conclusions Given the fact that the number of confirmed cases of Lyme disease with cardiac damage is increasing is necessary a good knowledge of this pathology in order to establish a specific antibiotherapy. The clinical cardiac manifestations in patients with Lyme disease are benign but rare cases of death being reported. Lyme disease in Romania - clinical and epidemiological features, 2010-2014 Teodora Ionescu1*, Adrian Matei2, Daniela Pitigoi3,4, Maria Nitescu3,4, Alexandru Rafila3,4, Odette Popovici5 *[email protected] 1 Clinical Emergency Hospital “Sf. Ioan”, Bucharest, Romania 2 Institute of Oncology "Prof. Dr. Al. Trestioreanu" Bucharest, Romania 3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 4 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 5 National Centre for Transmissible Diseases Surveillance and Control (CNSCBT), Romania Background Climate changes and human-induced changes in the environment, among other factors, have greatly influenced the geographic and temporal distribution of vectors as well as the incidence rate of several vector-borne diseases in the past decades. In this context, the surveillance and control of Lyme disease became of both European and national interest. The objective of our study was to describe clinical and epidemiological features of Lyme disease in Romania during 2010-2014. Methods In Romania, all health care providers are required to report nominally each case of Lyme disease since 2007. In 2010 a nationwide surveillance system was introduced using a specifically designed methodology. Cases are currently reported and confirmed according to a case definition that includes clinical criteria (differentiated by stage of infection) in addition to epidemiological and laboratory criteria. Based on the epidemiological analysis performed by the National Center for Communicable Disease Surveillance and Control, we developed a synthesis of the epidemiological and clinical features of Lyme disease during the last five years of enhanced surveillance. Results Between 2010-2014 a total of 4999 suspected cases of Lyme disease were reported in Romania, of which 2376 (47.5%) were considered real cases (confirmed+probable). The average incidence rate of the disease was 2.2 per 100 000 inhabitants, with a peak in 2012 (4.2%ooo). Average gender and agespecific incidence was higher in women (2.5%ooo) and in the age group 50-59 years. A higher incidence rate was observed in urban areas (2.7% ooo). The counties with the highest average incidence were Sibiu (28.5%ooo), Alba (10.7% ooo) and Botosani (10,1% ooo). Only two counties (Covasna and Ialomita) did not report any case during this period. Most cases (79%) presented acute manifestations. Erythema migrans was diagnosed in 79% of cases with acute manifestations. Tick bite was reported for 71% of cases. No death was reported. Conclusions Sustained surveillance is particularly important for evaluating disease trends in Romania and 80 contributing to the Emerging and Vector-borne Diseases Programme in Europe. Physicians should improve their knowledge regarding the clinical manifestations, correct diagnosis and treatment of Lyme disease. Raising awareness among the general population on how to prevent or manage tick bites and recommending early presentation to a doctor in case of acute symptoms represent essential public health measures. In high incidence counties vector control measures are required. Centre of Pediatric Neuro-Psychomotor Clinical Rehabilitation „Dr Nicolae Robanescu”. Conclusions The rapid diagnosis of CNS infection with HSV is important because of the potential morbidity and mortality associated with HSV encephalitis. Acyclovir treatment should be initiated in all patients with suspected herpetic encephalitis. In the case of our patient, earlier treatment improved the chances of a good recovery. A case of severe herpes simplex encephalitis in a baby girl Risk factors for Clostridium difficile infection in children: a case-control study Monica Luminos1,2*, Anca Cristina Draganescu1, Anglica Constanta Visan1,2, Magdalena Vasile1, Madalina Maria Merisescu1,2, Cristina Mihaela Negulescu1, Endis Osman1, Sabina Schiopu1, Diana Slavu1, Anuta Bilasco1 Raluca Tripon1*, Mihaela Sabou1, Cristina Cismaru1, Adriana Slavcovici1 *[email protected] Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania 1 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Background Herpes simplex virus type 1 (HSV-1) is the most common cause of viral fatal encephalitis worldwide (20%) with an annual incidence of 1/250 000 – 1/500 000 in industrialized country. The infection arises in all age groups, with one-third of all cases occurring in children and adolescents. Herpes simplex virus encephalitis (HSVE) is caused by the infection of the central nervous system (CNS) by HSV that could have a devastating clinical course and a potentially fatal outcome particularly without etiological treatment. A delay of 48 hours or more in starting acyclovir is associated with poor outcome. Case report We present a case of 6 month- old girl admitted to the Pediatric Intensive Care Unit at the National Institute for Infectious diseases “Prof. Dr. Matei Bals” for fever, vomiting, focal and generalized seizures, hypotonia and altered mental status. Clinical data correlated with laboratory findings for cerebrospinal fluid specimens (detection of herpes simplex virus DNA by PCR), brain magnetic resonance imaging and electroencephalogram established the diagnosis of herpes simplex virus encephalitis. Early etiological treatment with Acyclovir was started associated with anticonvulsant drugs, antiedema therapy and physical therapy, with good clinical outcome and partial neurological recovery. After her discharge, the girl continued her physiotherapy in the National Background Clostridium difficile infection (CDI) incidence in hospitalized children has increased over the past decade and disease has been reported in the community, particularly in young children aged 1-5 years. Several CDI risk factors have been wellestablished in the adult population, including prior antibiotic use, exposure to C. difficile in healthcare settings, and chronic underlying conditions. Increasing community-acquired CDI in children requires further evaluation of the importance of these risk factors. The aim of the present study is to identify the risk factors for C. difficile infection in children. Methods A retrospective case-control study was performed at the Teaching Hospital of Infectious Diseases Cluj-Napoca, between January 2011 and July 2015, which included children between the ages of 0-18 years. The mean age was 7.8 for Campylobacter and 7.27 for CDI. We defined cases of CDI as the occurrence of diarrhea (≥3 loose stools per day) with a positive test for C. difficile toxin and no other identified causes of diarrhea. Cases with CDI were randomly matched (1:5) to a control pediatric population selected from children with Campylobacter jejuni diarrhea during the same period of time. Results Fourteen children with CDI were compared with 72 children with Campylobacter jejuni diarrhea. Risk factors for severe disease included leukocytosis (>15,000/cmm), number of diarrhea stools per day (>10) and receipt of 2 antibiotic classes in the 30 days before infection (mostly second and third generation cephalosporin and 81 amoxicillin/clavulanic acid). The presence of blood and mucus in stool samples was significantly associated with CDI (OR 20.8, 95% CI 1.19-362, p =0.001). Logistic regression analysis demonstrated that immunosuppression (tumors, corticotherapy, immune deficit), proton-pump inhibitors and antibiotic exposure within 30 days were independent CDI predictors (OR= 12.3, 95% CI 2.06-78; OR= 28, 95% CI 2.87-280; respectively OR=6, 95% CI 1.71-21.5). The inflammation markers were elevated in both groups. No statistically significant differences in clinical presentation were observed between patients. Conclusions The usage of proton-pump inhibitors, antibiotics and immunosuppression were identified as CDI risk factors. Pancytopenia in HIV-infected infants Georgiana Elena Ionescu1*, Elena Tanase2, Mariana Mardarescu1, Rodica Ungurianu1, IoanaAlina Anca2, Giorgiana Dediu3 *[email protected] 1 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 2 The Institute for Mother and Child Protection “Alfred Rusescu”, Bucharest, Romania 3 Bucharest Clinical Emergency Hospital Background Due to the increasing number of children perinatally exposed to HIV in Romania (43 children exposed out of a cumulative total of 49, registered in 2015) the diagnosis and treatment of the infant's pancytopenia are two entities that raise many questions. Case report In this context we present the case of a 2 months old infant, female, originated from an uninvestigated pregnancy, rang III, gestational age37 weeks, birth weight-2750g, Apgar 9, born by Csection, breast fed for a month. She is hospitalized for generalized petechiae, piston movement of the head and green soft faces. The starting point was three days before being diagnosed with micropetechiae, initially at the foot, and then generalized petechiae, for which it was decided to make the hospitalization in a Pediatric Clinic, where she was diagnosed with severe anemia and thrombocytopenia, hepatic cytolysis syndrome and where she is tested positive on an HIV Elisa test. From the family history it results that her mother has been HIV infected from the age of 27, stopped taking the antiretroviral therapy hence with no prophylaxis for MTCT. The patient has a 14 year old brother infected with HIV and a sister who died at the age of nine due to AIDS related causes. The clinical report outlined: severe general condition, generalized petechiae, respiratory rate: 60/min, Sat O2: 95-96%, without rales, irregular ventricular rate: 160-200/min, systolic murmur grade I-II/VI, adeno-hepato-splenomegaly. The patient was investigated through ultrasound, namely: transfontanellar ultrasound which was normal, echocardiography revealed an atrial septal defect, with normal sizes cavities while the abdominal ultrasound revealed hepato-splenomegaly, portal hypertension and severe ascites. Laboratory investigations revealed anemia and severe thrombocytopenia, hepatic cytolysis syndrome, inflammatory biological syndrome, positives antibodies IgM and IgG for cytomegalovirus, CD4: 626 cells/cmm, HIV-RNA: >10,000,000 c/mL. Treatment: there were administrated: red blood cells, broad-spectrum antibiotic, antifungal, diuretic, proton pump inhibitors. Conclusions Pancytopenia in a three months old patient is a medical urgency that has to be treated in an intensive care unit. Diagnosis, treatment and prophylaxis of an HIV infected woman can prevent mother to child transmission of HIV and help avoid severe complications in children perinatally exposed to HIV. Streptococcus pneumoniae susceptibility to antibiotics Andreea Cristina Stoian1*, Augustin Cupșa1, Constantin Bănică2, Florentina Dumitrescu1, Lucian Giubelan1, Cristina Roskanovic2, Lucia Godeanu2, Loredana Ionescu2, Irina Niculescu1 1 University of Medicine and Pharmacy Craiova, Romania 2 “Victor Babeș” Clinical Hospital of Infectious Diseases and Pneumology, Craiova, Romania *[email protected] Background Antibiotic therapy is the key to successful treatment, which is why is needed a constant monitoring of antibiotic sensitivity of the involved bacteria. Objectives: Streptococcus pneumoniae’s phenotype analysis of antibiotics sensitivity at the HIV seronegative adults. Methods Retrospective and comparative study between the period 2007-2010 and 2011-2014, realized in Infectious Diseases Hospital of Craiova, on the 82 evolution of S. pneumoniae’s sensitivity. We considered multiresistant strains those that showed resistance of at least 3 different antibiotics. Differences were considered statistically significant for a threshold of p <0.05 and the regression coefficient (R). Results In 2007-2010, there were 234 strains identified of Str. pneumoniae with the following rates of sensitivity: ceftriaxone 84.61%, moxifloxacin 97.43%, linezolid 97.43%, trimethoprimsulfamethoxazole 50.84%, vancomycin, 97.43%, erythromycin 70.94%, rifampicin 92.73%, penicillin 39.31%, teicoplanin 100%. In the period 2011-2014 there were identified 327 Str. pneumoniae strains, with the following rates of sensitivity to antibiotics: ceftriaxone 44.26%, cefotaxime 96.55%, ceftaroline 100%, ofloxacin 91.97%, moxifloxacin 100%, oxacillin 30.67%, linezolid 96.3%, chloramphenicol 86.15%, trimethoprim-sulfamethoxazole 68.66%, vancomycin 95.31%, clarithromycin 84.76%, ertapenem 47.62%, clindamycin 81.33%, rifampin 95.45%, tetracycline 44.44%. The sensitivity evolution of S. pneumoniae to ceftriaxone recorded a downward trend (R² = 1), and at trimethoprimsulfamethoxazole an ascending one (R² = 1). Multiresistant strains were observed in 61 cases (18.66%) in 2011-2014 versus 23 cases (9.83%) in 2007-2010; p = 0.0039. Conclusions We registered the following changes in the phenotype of sensitivity to antibiotics of Str. pneumoniae: reduction of sensitivity to ceftriaxone, increasing to trimethoprim-sulfamethoxazole, and the high prevalence of multiresistant Str. pneumoniae in the 2nd period of the study. The sensitivity to vancomycin, linezolid, moxifloxacin, rifampicin was maintained increased and average for macrolide (erythromycin, clarithromycin). Cross-sectional study on quality of life in women living with HIV and barriers to healthcare access Anca Streinu-Cercel1,2,*, Mariana Mărdărescu2, Sorin Rugină3,4, Otilia Elisabeta Benea1,2, Simona Erscoiu1,5, Victoria Nicuțari6, Augustin Cupșa7, Oana Săndulescu1,2, Adrian Streinu-Cercel1,2 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania 3 Infectious Diseases Hospital, Constanța, Romania 4 Infectious Diseases Department, “Ovidius” University, Constanța, Romania 5 Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babeș”, Bucharest, Romania 6 Hospital of Infectious Diseases, Ploiești, Romania 7 University of Medicine and Pharmacy Craiova, Romania Background We performed a cross-sectional international study (ELLA) to observe the population and disease characteristics, the barriers to care and quality of life for women living with HIV in different countries across the globe. In this paper we communicate the country data concerning the barriers to healthcare of the women living with HIV in Romania. Methods This observational cross-sectional study described the demographic distribution of women living with HIV, their reproductive choices, HIV disease characteristics and comorbidities, the prevalence of barriers to healthcare according to the frequency of HIV care, the availability of antiretroviral (ARV) regimens, use of ARV guidelines, and the adherence to reported guidelines Women consenting to participate in this crosssectional epidemiological research agreed to sign the Site Data Recording Form which captures data about the site, services available and standard of care for HIV-1 infected patients. Patients were asked to complete 4 questionnaires. The Barriers to Care Scale (BACS) was one of the instruments used for evaluating patient-reported outcomes. Descriptive statistics were used to summarize the data. Results Out of the 1931 women living with HIV that participated in the study, 200 were from Romania. The mean age was 31.6 (standard deviation: 10.3). Community HIV/AIDS stigma was considered a major barrier to access to healthcare by 44.5% of the participating women, with more than 13% difference when comparing with other Central and Eastern Europe (CEE) countries. One third of the women from Romania considered the lack of supportive/understanding work environments a major problem, while only one fourth of the patients from the other CEE shared the same opinion. Lack of employement opportunities was considered a major problem by 49.5% of the Romanian women living with HIV, unlike other CEE countries were this percentage was only 22.9%. Community HIV/AIDS knowledge was evaluated as a relevant barrier to healthcare access by the women living with HIV in Romania; 59.5% 83 of them reported it as being either somewhat of a problem or a major problem that they had to face. Conclusions We have identified important differences regarding patient-reported barriers to healthcare in Romania compared with other CEE countries. Our findings can contribute to the design of country-specific management strategies for women living with HIV in Central and Eastern Europe. The HPV cervical pathology induced at the seropositive woman Mihai Mitran1*, Carmen Georgescu1, Sorin Puia1, Andreea Velișcu1 1 Clinical Hospital of Obstetrics and Gynecology “Prof. Dr. Panait Sîrbu” Bucharest *[email protected] Objective Highlighting the major role of HPV/HIV coinfection in the cervical oncogenesis Although the HPV infection (especially the one with high-risk roots) is well-known as a decisive factor in the cervical oncogenesis, the increased presence of a coinfection at the HIV positive women is demonstrated in our research to be a major risk factor. Methods The complex examination of the patients - clinical and colposcopical examination, the cytological test Babes-Papanicolau, the selection of the HIV infected patients for the HPV-DNA testing. Conclusions The incidence of the HPV roots with HR and implicitly of the oncogenic risk at this group of patients is higher due to the socio-material conditions, level of education and the sexual practices Acknowledgement „This paper was co-financed from the European Social Fund, through the Sectorial Operational Programme Human Resources Development 20072013, project number POSDRU/159/1.5/S/138907 "Excellence in scientific interdisciplinary research, doctoral and postdoctoral, in the economic, social and medical fields -EXCELIS", coordinator The Bucharest University of Economic Studies”. The childbirth at the HIV positive pregnant woman – update. The experience of the Clinical Hospital of OG “Prof.Dr.Panait Sîrbu” Bucharest Mihai Mitran1,*, Ioana Roșca1, Sorin Puia1, Marcela Șerban1, Carmen Georgescu1, Mariana Mărdărescu2 1 Clinical Hospital of Obstetrics and Gynecology “Prof. Dr. Panait Sîrbu” Bucharest 2 National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania *[email protected] Background Since 1992, the Clinical Hospital of Obstetrics and Gynecology “Prof. Dr. Panait Sîrbu” Bucharest has been the medical unit to consult, record and monitor pregnancies, births and miscarriages associated with transmittable diseases- including HIV positive patients- from Bucharest, SAI and the surrounding counties, as the hospital has the necessary professional expertise and intrahospital networks. In time, within the “Prof. Dr. Panait Sârbu” Clinic, we have systematized and implemented an obstetric protocol for the prevention of HIV vertical transmission. Methods The aim of this protocol has been to reduce the HIV vertical transmission rate from 30-35 %, the value in 2000, to 2-3%, the rate recorded in the European developed countries. Starting from the primordial objective to decrease mother-to-child vertical transmission rate, we established the cesarean section as the method of delivery for all HIV positive women, at 37-38 weeks, on intact membranes, outside labor. The result was a significant decrease in the number of HIV positive babies. Results The results of the past 7 years have been most encouraging, with a 0 rate of vertical transmission through cesarean section, and an 23.63% transmission for vaginal delivery. Conclusions Attentive monitoring of pregnancy by the obstetrician in cooperation with the Infectious Diseases specialist, delivery by cesarean section, complex antiretroviral therapy for both mother and child and ablactation have been the main means hrough which a spectacular decrease in HIV vertical transmission has been achieved. 84