Germs doi: 10.3390/germs16040028

Authors: Fardousi Akter Sathi Sultana Jahan Tuly Meiji Soe Aung Shyamal Kumar Paul Nazia Haque Sangjukta Roy Nobumichi Kobayashi

Background: Molecular typing data for Candida albicans from Bangladesh remain limited. Materials and Methods: This single-center descriptive study characterized 46 C. albicans isolates collected at Mymensingh Medical College Hospital during three sampling periods between 2021 and 2024. Forty-four isolates were recovered from patients with vulvovaginal candidiasis and two from neonatal bloodstream infections. Diploid sequence types (DSTs) were assigned using the consensus seven-locus multilocus sequence typing scheme, and their allelic and sequence relationships were explored using network and phylogenetic analyses. Results: Forty-two DSTs were identified, of which 41 had not previously been recorded in the PubMLST database. Six DSTs were related to selected established clonal complexes, while DST4161 grouped with clade 13. Using a study-specific network definition based on connections involving differences at no more than three loci, 30 of 42 DSTs, representing 34 of 46 isolates, were distributed across five connected groups. The largest group comprised 16 DSTs and 20 isolates but also included profiles related to four established clonal complexes. Conclusions: These findings document substantial, previously unrecorded allelic diversity among C. albicans isolates sampled at a single hospital in Bangladesh. Broader and systematically sampled studies are required to determine whether the observed profiles represent locally enriched lineages and to assess their clinical or epidemiological significance.

Germs doi: 10.3390/germs16040027

Authors: Pingping Wu Simiao Duan Min Xu Danhua Zhu Yunbo Chen

Background: Clostridioides difficile infection (CDI) in liver transplant (LT) recipients often occurs during complex postoperative care. We compared clinical characteristics and total hospital length of stay (LOS) between LT-CDI and non-LT CDI records. Materials and Methods: We analyzed 562 CDI-associated hospital records from 2014 to 2024 (35 LT-CDI; 527 non-LT CDI). The primary endpoint was total hospital LOS; LOS > 30 days was the main secondary endpoint, and >60 and >90 days were post hoc exploratory thresholds for very prolonged stays. LOS was available in 35 LT-CDI and 521 non-LT records. Results: Median LOS was 59 versus 20 days. The crude median difference was 39.0 days (95% CI, 7.0 to 64.0), and the care/antimicrobial-adjusted difference was 28.5 days (95% CI, 0.5 to 50.3). Median LT-to-CDI time was 13 days [IQR, 7 to 36; n = 34]; in 25/35 records (71.4%), infection occurred within 30 days. The adjusted RR for LOS > 30 days was 1.15 (95% CI, 0.85 to 1.55); exploratory RRs were 2.33 (95% CI, 1.45 to 3.73) for >60 days and 2.28 (95% CI, 1.11 to 4.67) for >90 days. Conclusions: LT-CDI records had longer total LOS, clustered early after transplantation, and had a clinically complex course. These findings provide a same-center benchmark for overall hospitalization burden among CDI records by transplant status; estimating CDI-attributable LOS would require an LT group without CDI.

Germs doi: 10.3390/germs16040026

Authors: Madalina (Preda) Solomon Mihaela Corina Radu Oana Popescu Lăcrămioara Sîrbu Daniela Voinea Daniela Trandafir Beatrice Mahler Justin Aurelian Raluca-Elena Hanu Eduard-Marcel Cernat Loredana Sabina Cornelia Manolescu

Background: Candida species are among the most frequently isolated fungi from respiratory specimens in hospitalised patients, yet the clinical significance of their presence—infection versus colonisation, treatment versus observation—remains an unresolved challenge in clinical microbiology. Data from dedicated pulmonology centres in Eastern Europe are scarce. This study aimed to characterise the three-year epidemiology, species distribution, temporal trends, colony-load profiles, and longitudinal mycological trajectories of fungal respiratory isolates at a Romanian tertiary pulmonology hospital. Methods: We retrospectively analysed 1000 microbiological records from bronchial aspirates and other respiratory specimens collected between January 2022 and December 2024. Variables included patient demographics, clinical ward, primary diagnosis, fungal species, and semi-quantitative colony counts. Patients with multiple records were identified and analysed as a longitudinal sub-cohort. Results: Candida albicans predominated (45.5%), with a declining proportional trend across the study period. Candida krusei—intrinsically resistant to fluconazole—increased from 5.3% of isolates in 2022 to 9.7% in 2024. The intensive care unit (ICU) accounted for 25.8% of all records. Patients were predominantly male (67.5%) with a mean age of 63.4 years; acute respiratory failure was the most frequent underlying diagnosis (41.7%). High-load colonisation (>100 colony-forming units/mL) was documented in 19.0% of quantified specimens. Among 91 patients with serial cultures, 26 demonstrated inter-sample species shifts—several consistent with antifungal selection pressure—and 29 showed escalating colony loads, suggesting progression from colonisation toward probable infection. Conclusions: In a clinical setting where fluconazole has historically served as the default empirical antifungal agent, a C. krusei proportion approaching 10% of annual isolates constitutes a clinically actionable finding. Species-level identification of all fungal respiratory isolates is strongly warranted, as it directly influences therapeutic decision-making in approximately one in ten cases.

Germs doi: 10.3390/germs16040025

Authors: Ainar Kossylganova Joseph Bagi Suleiman Aigulsum Izekenova Elmira Bitanova Maryam Azlan Albina Atakanova Assem Mukhitdenova Maira Zhaparkulova Karlygash Zhaparkulova

Background: Human brucellosis remains an important One Health problem, yet no vaccine is licensed for human use despite decades of antigen discovery and experimental vaccine development. This review examines why promising Brucella vaccine candidates have not progressed toward human application, with particular attention to the relationship between immune-evasion mechanisms, experimental evidence of protection, and the barriers that arise during translation. Methods: A critical narrative review of peer-reviewed literature on Brucella immunopathogenesis, immune evasion, protective immunity, antigen discovery, vaccine platforms, and human translational requirements was conducted. The evidence was interpreted according to experimental maturity, distinguishing computational or hypothesis-generating studies, mechanistic in vitro or ex vivo evidence, animal immunogenicity studies without challenge, and challenge-supported protection. Additional consideration was given to safety, durability, cross-species protection, model relevance, manufacturing, and regulatory requirements. Results: Brucella uses multiple mechanisms to limit innate recognition, alter intracellular trafficking and antigen presentation, and modulate host immune responses. These mechanisms provide a biological rationale for mechanism-informed vaccine design, but direct evidence that individual vaccine strategies overcome specific immune-evasion pathways remains limited. Across the vaccine literature, many candidates remain at the computational, antigen-production, or immunogenicity stages, whereas fewer have demonstrated protection after experimental challenge. Even challenge-supported candidates rarely address durability, cross-species breadth, human-relevant correlates of protection, extended safety, reproducible manufacturing, or readiness for clinical development. Conclusions: The absence of a licensed human brucellosis vaccine is better explained by attrition across successive stages of development than by a shortage of candidate antigens or vaccine platforms. Progress is likely to depend on advancing fewer, better-supported candidates through an integrated evidence pathway that links mechanistic rationale and challenge protection with durability, safety, species breadth, product quality, and human clinical relevance.

Germs doi: 10.3390/germs16040024

Authors: Diana-Elena Vulpe Catalin Anghel Andreea Alexandra Anghel Dana-Georgiana Nedelea Vasile Potop Serban Dragosloveanu Cristian Scheau Oana Săndulescu

Background: Periprosthetic joint infection (PJI) remains one of the most severe complications following total hip and knee arthroplasty. Early identification of patients at increased risk remains challenging, particularly when routine laboratory biomarkers are within normal reference ranges. This study investigated whether routine preoperative laboratory biomarkers could reveal interpretable patterns associated with subsequent PJI using medically guided feature engineering and transparent machine-learning methods. Methods: We conducted a retrospective case–control study including 152 patients undergoing primary total hip or knee arthroplasty, comprising 75 PJI cases and 77 aseptic controls. PJI was defined according to International Consensus Meeting criteria, and aseptic controls had at least 12 months of infection-free follow-up. Thirty-eight routine preoperative laboratory biomarkers obtained one day before surgery were harmonized and analyzed. Original markers, medically derived ratios, clinically guided interaction and polynomial terms, and LASSO-based penalized selection were evaluated using 20 repetitions of nested stratified 5-fold cross-validation, with all data-dependent preprocessing and model selection confined to the corresponding training partitions. Results: Original laboratory markers showed modest discrimination (ROC-AUC 0.554; 95% CI, 0.461–0.646), while medically derived ratios performed similarly (ROC-AUC 0.556; 95% CI, 0.464–0.650). Clinically guided interaction features achieved the highest discrimination (ROC-AUC 0.643; 95% CI, 0.555–0.730), with a Brier score of 0.235 and a calibration slope of 0.349. Compared with the original-marker model, the interaction model improved ROC-AUC by 0.089 (95% CI, 0.017–0.159; p = 0.016), although this difference did not remain statistically significant after Holm adjustment (adjusted p = 0.066). Direct LASSO showed lower discrimination (ROC-AUC 0.582; 95% CI, 0.491–0.674). Conclusions: Routine preoperative laboratory biomarkers contained a modest PJI-associated signal, with clinically guided interactions yielding the highest discrimination among the evaluated laboratory representations. Overall performance remained modest, and penalized feature selection did not improve discrimination, supporting its interpretation primarily as a stability-assessment procedure. These findings should be considered exploratory and require external validation in larger, independent, preferably multicenter cohorts before clinical application.

Germs doi: 10.3390/germs16030023

Authors: Bianca Andreea Stoia Ioana Arbanas Vana Spoulou Oana Gabriela Falup-Pecurariu

Neonatal sepsis remains a major cause of morbidity and mortality worldwide, while early diagnosis is challenging due to nonspecific clinical manifestations and the limited accuracy of currently available biomarkers. Serum amyloid A (SAA), a rapidly responding acute-phase protein, has emerged as a potential adjunctive biomarker. This review searched PubMed/MEDLINE, the Cochrane Library, and the Directory of Open Access Journals to identify original studies published between 2000 and 2026 evaluating SAA’s diagnostic value in neonatal sepsis. Study quality was assessed using QUADAS-2. Following screening of 281 records, 13 studies comprising 1827 neonates were included. Due to methodological heterogeneity and limited availability of comparable diagnostic accuracy data, findings were synthesized qualitatively. Reported diagnostic performance was highly variable, with specificity generally higher than sensitivity and area under the receiver operating characteristic curve values ranging from approximately 0.60 to above 0.90. In studies evaluating kinetic patterns, SAA demonstrated earlier rise and more rapid decline compared with C-reactive protein. Relatively high negative predictive values were observed in some studies of preterm infants with late-onset sepsis, suggesting potential utility as a rule-out marker in selected contexts. Despite substantial heterogeneity, SAA appears promising as an adjunctive biomarker, although further standardized prospective studies are required before routine clinical implementation.

Germs doi: 10.3390/germs16030022

Authors: Corina Daniela Negrila Luana-Maria Gherasie Sebastian Mihai Armean Petru Armean

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a World Health Organization (WHO) critical-priority pathogen. Its role in chronic otologic infection is poorly characterised. In Romania and most Central-Eastern European settings, the practical management of CRAB is constrained by uneven access to last-line agents. Case Presentation: A 16-year-old male adolescent presented with 9 months of left otorrhoea and conductive hearing loss from attic cholesteatoma, refractory to four ambulatory antimicrobial courses. Two superficial aural-discharge swabs yielded Pseudomonas aeruginosa susceptible to ciprofloxacin; sterile intraoperative sampling identified an extensively drug-resistant (XDR) A. baumannii, non-susceptible in five of the six antimicrobial categories tested and retaining activity only against polymyxins. Transcanal endoscopic extended atticotomy with complete cholesteatoma removal provided source control. Topical colistin was then applied to an endaural pack for a defined 14-day course. Otorrhoea resolved, and epithelialisation was complete at 6 weeks, by which time the mean air–bone gap had fallen from 27.5 dB to 2.5 dB and the pure-tone average from 32.5 to 12.5 dB HL, without recurrence at 8-month follow-up. Conclusions: Complete transcanal endoscopic excision of the cholesteatoma was the decisive intervention, with topical colistin given as a short adjunctive course on the operated surface; otorrhoea resolved, the reconstruction epithelialised, and the air–bone gap closed. Local availability of last-line agents shaped the options that were considered but did not determine the outcome of this localised, surgically controlled infection.

Germs doi: 10.3390/germs16030021

Authors: Victoria Birlutiu Ioana Maria Cobirje Rares-Mircea Birlutiu

Background: Enterococcus faecalis is the third leading cause of infective endocarditis (IE) and remains the predominant enterococcal species involved in this condition, particularly among older patients with multiple comorbidities and healthcare-associated exposure. Its diagnosis may be challenging because the disease often follows a subacute course and may initially present with atypical extracardiac manifestations. Case presentation: We report the case of a 76-year-old man admitted with a 5-day history of fever, chills, profuse diaphoresis, myalgia, abdominal pain, and progressive confusion. On admission, he was febrile, hypotensive, disoriented, and presented with neck stiffness, a grade IV aortic murmur, suprapubic tenderness, hepatomegaly, and hemorrhagic lesions of the left hand. Initial transthoracic echocardiography did not reveal valvular vegetations. Cerebrospinal fluid analysis showed inflammatory changes with marked granulocytic predominance, whereas the multiplex PCR panel for meningitis/encephalitis pathogens and conventional cerebrospinal fluid cultures remained negative. In contrast, all blood cultures yielded E. faecalis. Repeat cranial computed tomography demonstrated a focal parasagittal frontal lesion involving the rostrum and genu of the corpus callosum, consistent with septic embolic involvement. Transesophageal echocardiography performed on hospital day 5 confirmed aortic valve IE, showing vegetative lesions on all cusps, the largest measuring approximately 8 mm, and severe aortic regurgitation. The clinical course was further complicated by cardiac decompensation and acute inflammatory involvement of the left knee, with synovial fluid analysis demonstrating a neutrophil-predominant inflammatory effusion, although cultures remained sterile. The patient received ampicillin plus vancomycin, followed by ampicillin plus linezolid after vancomycin-associated renal impairment. Follow-up blood cultures became negative after 3 weeks of treatment, but persistent severe aortic valve involvement required referral for cardiac surgical evaluation. The patient was readmitted to the cardiology department and subsequently developed multi-organ system failure, resulting in death one week after discharge. Conclusions: This case highlights the diagnostic complexity of. E. faecalis IE when meningocerebral and osteoarticular manifestations dominate the initial presentation, emphasizing the importance of repeated blood cultures and early transesophageal echocardiography.

Germs doi: 10.3390/germs16030020

Authors: Roxana Surugiu Virginia-Maria Rădulescu Anca Deleanu Anca Lăcătuș Mirela Mustață Dana Fărcășanu Iulia Vișinescu Alexandra Aurora Dumitra Gheorghe Gindrovel Dumitra

Introduction: Improving adult pneumococcal vaccination is a public-health priority in Romania, and evidence regarding patient-level outcomes following different approaches to physician training remains limited. Materials and methods: This non-randomised, multicentre, quasi-experimental implementation study examined patient-level changes across three geographically distinct Romanian settings between August and November 2025. Physicians in Iași and Dolj counties received in-person training combining medical content with communication techniques based on motivational interviewing, whereas physicians in the webinar group received online medical training without a dedicated communication module. Eligible adult patients completed questionnaires before and after counselling and reported whether they had been vaccinated or had scheduled a vaccination appointment. Results: The analysis included 295 questionnaire pairs from patients nested within 29 physicians. Baseline attitudes differed markedly across settings (composite score of 5.64 in the webinar group, 5.29 in Dolj County, and 4.09 in Iași County; p < 0.001), as did strong baseline vaccination intention (75.6%, 48.1%, and 27.2%, respectively). Using a composite score comprising all seven attitude items, with item 7 reverse-coded and vaccination intention analysed separately, the cluster-robust group-by-time model indicated different mean changes between settings (global p = 0.001): +0.28 in the webinar group, +1.02 in Iași, and +0.60 in Dolj. Strong vaccination intention increased within each setting, but the magnitude of change did not differ between settings (group-by-time p = 0.929). The combined self-reported vaccination-or-scheduling outcome was observed in 81.5% of patients in the webinar group, 49.4% in Iași, and 73.3% in Dolj; after adjustment for baseline intention, there was no longer evidence of an overall group difference (p = 0.651). Discussion and conclusions: Because training approach, delivery modality, geographical setting, physician cohort, and patient population were not independently allocated, and because baseline levels differed markedly between settings, the findings should be interpreted as exploratory implementation patterns rather than causal comparative effects.

Germs doi: 10.3390/germs16030019

Authors: Putu Cahyani Paramita Yoga Agatha Viviane Ni Putu Dila Iswarani Dewi

Chikungunya poses a major clinical and public health challenge due to its wide range of manifestations and, consequently, frequent misdiagnoses. This pitfall may lead to compromised long-term outcomes when treatment is inadequate. This scoping review aims to summarize the clinical features, current management strategies, and long-term outcomes of chikungunya infection in adults. The review was designed and reported according to Joanna Briggs Institute (JBI) guidance and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) framework. Three main databases—PubMed, ScienceDirect, and Wiley Online Library—were searched, and additional gray literature from international and national health agencies was consulted. Nineteen studies met inclusion criteria. Chikungunya in adults commonly begins as an acute febrile illness with prominent musculoskeletal symptoms, but may evolve into a chronic, disabling disease, substantially impairing quality of life. Treatment is largely symptomatic for the acute phase, whereas chronic infections require long-term multidisciplinary care, supported by preventive measures through public health interventions. In summary, while most patients recover with appropriate care, a significant number of patients experience persistent sequelae requiring rehabilitation, continued clinical follow-up, and targeted preventive and public health actions.

Germs doi: 10.3390/germs16030018

Authors: Angelo Cianciulli Emanuela Santoro Salvatore Esposito Savino Quaglierella Antonietta Pacifico Michele Nappa Domenico Fornino Roberta Manente Mario Capunzo Giovanni Boccia

Post-COVID-19, influenza A(H3N2) has re-emerged with accelerated genetic diversification. The rise in antigenically drifted subclades raises concerns regarding immune escape and vaccine mismatch. To synthesize the available evidence on the post-pandemic evolution of influenza A(H3N2), with particular attention to emerging subclades and their potential public health implications, a scoping review (PRISMA-ScR) was conducted across six databases in January 2026, including studies on genomic surveillance, antigenic characterization, and vaccine effectiveness (VE). Twenty studies were included. While clade 2a.3a.1 (J lineage) predominated, reports highlighted the rapid emergence of the antigenically distinct K subclade (formerly J.2.4.1). Genetic and laboratory assays (HI/neutralization) confirmed immune escape and reduced vaccine match. Observational estimates indicated diminished VE against drifted strains, though no consistent increase in clinical severity was observed. Post-pandemic A(H3N2) is defined by rapid drift and diversification. Emerging variants like the K subclade challenge vaccine selection and seasonal preparedness. Integrated surveillance remains vital for timely vaccine updates and mitigating public health impact.

Germs doi: 10.3390/germs16030017

Authors: Lavinia-Eugenia Lipan Karina-Doris Vihta Andra-Daniela Marcu Irina Avramescu Dumitru Jardan Andi Palade Anca Colita Simona-Olimpia Dima Ileana Constantinescu Iuliana Iordan Alexandra Marcoci Oana-Gabriela Craciun Cristina Negulescu Alina Daniela Tănase

Intestinal microbiome dysbiosis has been associated with transplant-related mortality and graft-versus-host disease in allo-HSCT patients. We assessed how pre-transplant antibiotic and antineoplastic exposures, together with multidrug-resistant colonization, are associated with baseline gut microbiome diversity at allo-HSCT. We conducted a prospective, single-center cohort study at Fundeni Clinical Institute (Bucharest, Romania) between August 2024 and June 2025, enrolling 52 allo-HSCT recipients and 27 healthy controls. Fecal samples were collected before conditioning. Gut microbiome composition was assessed via 16S rRNA gene sequencing and analyzed using QIIME2 and R. Associations were evaluated using Wilcoxon test, multivariable linear regression, and PERMANOVA. Shannon diversity was significantly lower in patients (median 4.71, IQR 3.97–5.44) than in healthy controls (median 6.09, IQR 5.87–6.28; p < 0.001). In bivariate analyses, carbapenem (p adj = 0.02) and oxazolidinone exposure (p adj = 0.005) were associated with reduced diversity, while immunotherapy was associated with higher diversity (p adj = 0.042). Broad-spectrum penicillin (p adj = 0.062) and ESBL colonization (p adj = 0.066) did not reach significance. In the multivariable antibiotic model, although the overall model was statistically significant (model p = 0.039), no individual antibiotic class remained significantly associated with Shannon diversity after adjustment for co-exposures. Beta diversity differed modestly with carbapenem exposure (R2 = 0.033, p = 0.019). Pre-transplant antibiotic exposures were associated with lower gut microbiome diversity at allo-HSCT admission, with patterns consistent with a cumulative rather than a class-specific association. These findings support antibiotic stewardship in pre-transplant care.

Germs doi: 10.3390/germs16030016

Authors: Ferdinand W. N. M. Wit Marc van der Valk Bart J. A. Rijnders Casper Rokx

Background: Demonstrating durable viral suppression after switching to dolutegravir/lamivudine in clinical practice solidifies its use. Methods: This was a prospective cohort (DUALING) study conducted in 24 Dutch HIV treatment centers. HIV-RNA-suppressed cases undergoing triple-drug antiretroviral therapy without prior virological failure or resistance who switched to dolutegravir/lamivudine (cases) were 1:2 matched to controls, who remained on triple-drug antiretroviral therapy. Matching was stratified by dolutegravir use in the triple-drug antiretroviral therapy, and further by age, sex, HIV acquisition route, CD4+T-cell nadir, and HIV-RNA zenith. The primary endpoint was the treatment failure rate at 2 years, determined using intention-to-treat and on-treatment analyses with a 5% noninferiority margin. Results: The 2040 mostly male (84.3%) participants included 390 cases of dolutegravir-based triple-drug regimens with 680 controls, and 290 cases of non-dolutegravir-based triple-drug regimens with 580 controls. In the dolutegravir-based cases and controls, treatment failure occurred in 12.6% and 23.3% of patients in the intention-to-treat analysis (difference: −10.7%, 95%CI: −15.3% to −6.1%) and 2.6% and 2.4% of patients in the on-treatment analysis (difference: +0.2%, 95%CI −1.9% to +2.3%). The treatment failure risk in non-dolutegravir-based cases and controls was 15.2% and 19.9% in the intention-to-treat analysis (difference: −4.7, 95%CI: −10.0% to +0.6%) and 1.2% and 1.9% in the on-treatment analysis (difference +0.7%, 95%CI −2.6% to +1.1%). Therapy modifications unrelated to virological failure explained the higher treatment failure rate in the intention-to-treat analysis. In dolutegravir/lamivudine cases, a shorter time of prior triple-drug antiretroviral therapy, age < 50 years, and non-Western origin were associated with treatment failure in the multivariable analysis. Viral blips occurred in 6.8% of cases and 5.1% of controls. In the post hoc analysis, discontinuing tenofovir disoproxil fumarate-based triple-drug antiretroviral therapy led to weight gain in people with (+2.7 kg) and without (+2.3 kg) prior dolutegravir use. Conclusions: In this nationwide clinical practice study, switching to dolutegravir/lamivudine was noninferior to continuing triple-drug antiretroviral therapy after 2 years of follow-up.

Germs doi: 10.3390/germs16030015

Authors: Isidoros Kougioumtzoglou Nikos Maniadakis Dimitrios Kouvelas Evangelia-Georgia Kostaki Nikos Selekos Areti-Dimitra Koulouvari Areti Lagiou

Background: Seasonal influenza remains a major public health challenge worldwide, causing significant morbidity each year and imposing substantial burdens on individuals, healthcare systems, and national economies. Vaccination is considered the most effective available strategy for prevention; however, uptake rates vary considerably across countries, with many failing to achieve the recommended coverage levels. The aim of this umbrella review is to systematically synthesize and critically appraise the existing evidence on healthcare professionals’ beliefs, attitudes, and behaviors regarding seasonal influenza vaccination. Methods: This umbrella review was conducted in accordance with the PRISMA 2020 statement. A literature search was conducted in PubMed, the Cochrane Library, and Google Scholar. The following search terms were used: beliefs, attitudes, behaviors, influenza vaccination, flu vaccine, healthcare professionals and primary healthcare. The inclusion criteria were as follows: (1) Reviews, (2) Published after 1 January 2000, (3) English language, (4) Healthcare professionals as the target-population. Results: Twenty-five studies met the selection criteria and were included in this review. Twelve out of 25 studies were systematic reviews. Globally, vaccination uptake remains below recommended levels, with reported coverage ranging from approximately 2% to 44% in several settings, while rates can exceed 90% in countries with mandatory vaccination policies. North America demonstrates the highest vaccination coverage, while the lowest coverage is reported in Africa and South America. Overall, low- and middle-income countries show significantly lower vaccination behavior compared with high-income countries. Attitudes and beliefs appear to shape vaccination behavior in high-income countries. The main driver of acceptance is perceived protection of oneself and family, whereas hesitancy is mainly driven by concerns about side effects and vaccine safety. Across studies, non-physician healthcare professionals consistently demonstrated lower influenza vaccine acceptance compared with physicians, while pediatricians and general practitioners were found to receive the influenza vaccine more frequently. In addition, younger physicians and those with fewer years of professional experience showed higher vaccination coverage and a greater likelihood of recommending influenza vaccination to patients. Conclusions: Vaccination coverage, worldwide, is lower than what is recommended by the World Health Organization. Healthcare professionals working in hospital settings tend to be vaccinated at a higher rate compared with those working in primary care or community-based healthcare settings. The recommendations that healthcare professionals give are influenced by whether they accept influenza vaccines themselves. Beliefs and attitudes seem to influence behavior in countries where structural barriers, such as limited access to primary healthcare and socio-economic status are absent.

Germs doi: 10.3390/germs16020014

Authors: Manuela Arbune Alina Plesea-Condratovici Anca Adriana Arbune Lavinia-Alexandra Moroianu Mariana Stuparu-Cretu Catalin Plesea-Condratovici

Background/Objectives: Obesity is an increasing challenge among people living with HIV (PLWH). This study aimed to assess the prevalence of general and abdominal obesity and its association with lifestyle in adult Romanian PLWH, providing the first national data. Methods: A single-center, cross-sectional study involved 106 adult PLWH. Eating behavior was assessed using the Rapid Eating Assessment for Participants—Short Version (REAP-S) and physical activity with the General Practice Physical Activity Questionnaire (GPPAQ), both standardized and validated. Anthropometric, clinical, and virological data were collected from medical records and direct measurement. Results: Median age was 36 years [IQR 33–42], 83.3% were male, and 73.6% lived in urban areas. Median time since HIV diagnosis was 11 years, and 60.4% had AIDS-defining illness. General obesity (BMI ≥ 30 kg/m2) occurred in 17.9%, overweight in 29.2%, and high-risk abdominal obesity in 22.6%. Physical inactivity was reported by 20.8%. Multivariable analysis showed that being moderately or physically active was the only independent predictor of abdominal obesity (OR 0.19; 95% CI, 0.07–0.51; p = 0.001). Conclusions: In this young Romanian cohort of PLWH, physical activity reduces the risk of abdominal obesity, underscoring the need to integrate such interventions into the standard of care to reduce metabolic risk associated with HIV.

Germs doi: 10.3390/germs16020013

Authors: Hind Muteb Albadrani

Introduction: Syphilis is a preventable sexually transmitted infection (STI) with severe health outcomes, yet it is not included in Saudi Arabia’s national premarital and antenatal STI screening programs. This study assessed knowledge, attitudes, and practices (KAP) toward syphilis in Saudi Arabia and identified predictors of acceptance for including syphilis testing in such programs. Methods: A cross-sectional online survey was conducted among 935 participants aged ≥20 years. Data included sociodemographic characteristics and measures of KAP and screening acceptance. Continuous variables were summarized as medians (IQR) and categorical variables as frequencies and percentages, with bivariate and multivariate logistic regression used to identify predictors of screening acceptance. Results: Knowledge and preventive practices were low, while attitudes were predominantly neutral (median attitude score: 34 IQR 32–38). Although intentions for personal testing were low (17%), support for syphilis testing in premarital (60.8%) and antenatal (48.9%) programs was considerable. Employment in the health sector, older age, and positive attitudes predicted acceptance of screening policies. Knowledge and practice showed a weak correlation (r = 0.14), whereas knowledge and attitude were moderately correlated (r = 0.55). Conclusion: KAP toward syphilis is influenced by specific sociodemographic factors. Although acceptance of screening is high at the policy level, individual-level preventive behaviors remain low.

Germs doi: 10.3390/germs16020012

Authors: Mudra Sikenis Bhavna Prajapati Ashutosh Kumar Singh Karmveer Yadav Ashish Kumar Vyas Narapity Pathirannehalage Sunil-Chandra Akansha Tandekar Surya Singh Tarun Patil Subhabrata Kar Rajnarayan R. Tiwari Ram Kumar Nema

Norovirus is the leading cause of acute infectious gastroenteritis in the world and accounts for a significant proportion of outbreaks at the food-borne and person-to-person levels. Due to their low infectious dose, persistence in the environment, and broad genetic diversity, they can quickly spread and reappear in even the most diverse populations. This review integrates current knowledge on the epidemiology of noroviruses, genomic organization, structural biology, virus–host interactions, and replication mechanisms, with a focus on factors that determine virus evolution and strain dominance. Literature has been systematically searched in the PubMed and Scopus databases to incorporate recent experimental and epidemiological findings. Analysis of global surveillance data indicates ongoing genetic diversification of circulating strains, with periodic replacement of major variants, particularly the GII.4 lineage. Variability of the capsid and recognition of histo-blood Group Antigens strongly affects the host’s susceptibility, viral attachment and immune escape. The capsid consists of most of the viral protein complexes. The structural proteins VP1 and VP2 are responsible for determining the contours of the capsid and antigenic specificity. Non-structural proteins are responsible for coordinating the genome replication and the modification of host cell pathways to favor the production of the virus. Eliminating these gaps by means of integrated genomic surveillance and functional studies will provide insight into the evolution of norovirus and help to develop broadly effective vaccines and antiviral strategies.

Germs doi: 10.3390/germs16020011

Authors: Terenzio Cosio

Infectious diseases have become increasingly dependent on diagnostic systems, whose reach have expanded, largely through advances in clinical microbiology, far more quickly than efforts to verify the reliability and accurate interpretation of their findings [...]

Germs doi: 10.3390/germs16020010

Authors: Jakub Młoźniak Adam Szymański Gabriela Stondzik Dagny Clea Krankowska Tomasz Mikuła Agnieszka Lembas Joanna Kozłowska Regina Podlasin Magdalena Thompson Grażyna Cholewińska Aleksandra Chylak-Nowosielska Anna Zabost Ewa Augustynowicz-Kopeć Alicja Wiercińska-Drapało

Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms capable of causing diverse clinical manifestations. Their epidemiology among people with HIV remains insufficiently characterized. This study examined the epidemiology of NTM among people with HIV admitted to the Hospital for Infectious Diseases in Warsaw between 2017 and 2023. Data on CD4+ T-cell counts, type of NTM involvement, species identification, and antimicrobial resistance were obtained from medical records. In the analyzed group the median of the CD4+ T-cell count was 25 cells/mm3 (IQR 65 cells/mm3). Late HIV diagnosis was observed in n = 45/50 (90.0%) patients. NTM colonization was identified in n = 20 (33.9%) patients, while n = 39 (66.1%) had active NTM disease, including pulmonary (53.9%), disseminated (41.0%), and extrapulmonary (5.1%) forms. Mycobacterium kansasii was the most common species among colonized patients, n = 7/24 (29.2%), whereas Mycobacterium avium predominated among patients with NTM disease, n = 30/42 (71.4%). Among patients with NTM disease, in vitro resistance to at least one antimicrobial agent was observed in 80.0% of M. avium isolates. High levels of resistance of M. avium were noted for ethambutol (n = 8/8, 100%), moxifloxacin (n = 16/22, 72.8%) and linezolid (n = 9/21, 42.9%). Proper identification of Mycobacterium species and its antibiotic resistance might be helpful in selecting effective antimicrobial therapy. Early HIV diagnosis is needed to prevent NTM disease.

Germs doi: 10.3390/germs16020009

Authors: Muhammad Amirul Amil Jun Hao Koo Xin Yun Yah Norizzati Adila Salam Muhammad Mawardi Zakaria

Introduction: The growing demand for traditional medicines and health supplements (TMHS) in Malaysia has raised concerns regarding microbial contamination in hard-shell capsule products. Despite regulatory oversight, recurring recalls highlight persistent non-compliance with Good Manufacturing Practice (GMP) standards. This study examines the risks of microbial contamination, recall patterns, and encapsulation practices among TMHS hard-shell capsule manufacturers in Malaysia. Methods: A cross-sectional approach was employed, comprising a review of regulatory guidelines, analysis of NPRA recall data from 2020 to 2024, and a structured survey of 86 TMHS manufacturers on equipment and production parameters. Results: Review of GMP guidance indicated that greater automation and reduced manual handling in capsule-filling processes help minimise microbial contamination. In line with this, TMHS products were recalled at a rate of 4.73%, more than 4 times the pharmaceutical recall rate (1.09%). Among the 245 TMHS recalls, 68 involved hard-shell capsule products that failed microbial testing, primarily total aerobic microbial count (73.53%). Additionally, manufacturers with 50–100 registered products had significantly higher odds of recall (OR = 10.0, 95% CI: 2.35–42.47). However, no significant associations were found between recall status and equipment type, capsule size, or production frequency. Conclusions: Microbial contamination remains a critical issue in TMHS hard-shell capsule products. Regulatory efforts should focus on medium-scale manufacturers and reinforce risk-based GMP adherence to enhance product safety and public health protection.

Germs doi: 10.3390/germs16010008

Authors: Oana Săndulescu Anca Streinu-Cercel Cătălina Poiană Viorel Jinga Beatrice Mahler Gheorghe Gindrovel Dumitra Sandra Adalgiza Alexiu Simona Negreș Cristina-Elena Zbârcea George-Sorin Țiplică Mihai Mitran Robert Stoica Mariana Mărdărescu Șerban Benea Adrian Gabriel Marinescu Victor Daniel Miron Elena Mătăsaru Odette Chirilă Sorin Petrea Iulian Petre Mihai Lixandru Adrian Streinu-Cercel

Background: Despite major advances in antiretroviral therapy, HIV transmission remains an important public health challenge. Pre-exposure prophylaxis (PrEP) is a highly effective prevention strategy, offering a significant opportunity to further reduce new HIV infections through expanded access and optimized implementation. Methods: A national multidisciplinary consensus process was conducted to define principles and operational pathways for PrEP referral and linkage in Romania. Experts from different medical fields, professional societies, academic institutions, and community-based organizations participated in structured discussions. Results: The consensus highlighted relevant knowledge gaps related to HIV prevention and PrEP among specialists working outside the field of infectious diseases, including difficulty recognizing risk factors for HIV, uncertainty about next steps after identifying risk factors, and uneasiness discussing sexual health. The consensus also emphasized a shared commitment of these professional societies to address these gaps through pragmatic, specialty-adapted training. Key priorities included improved HIV risk recognition in routine care, development of communication skills, and clear referral pathways to PrEP services. Existing barriers were also discussed, underscoring the importance of multidisciplinary networks and community engagement. Conclusions: This consensus provides a structured, context-adapted framework to support the upcoming nationwide implementation of PrEP in Romania. By strengthening provider education, clarifying clinical pathways, and fostering interdisciplinary collaboration, it offers a foundation for equitable and sustainable HIV prevention.

Germs doi: 10.3390/germs16010007

Authors: Ming-Ying Ai Wei-Lun Chang

Background: Stenotrophomonas maltophilia is a multidrug-resistant pathogen with limited therapeutic options that predominantly affects critically ill and immunocompromised patients. Trimethoprim–sulfamethoxazole (TMP/SMX) remains the conventional first-line therapy; however, emerging resistance and toxicity concerns necessitate alternative regimens. This study represents, to our knowledge, the first network meta-analysis (NMA) comparing the efficacy and safety of clearly defined monotherapy and combination antibiotic regimens for S. maltophilia infections. Materials and methods: A systematic search of PubMed, Cochrane Library, Web of Science, and ClinicalTrials.gov (inception to January 2026) identified eligible randomized-controlled studies and retrospective studies. Data were analyzed using a frequentist random-effects NMA with TMP/SMX as the reference. Evaluated regimens included TMP/SMX, fluoroquinolone (FQ), minocycline (MIN), TMP/SMX + FQ, TMP/SMX + MIN, FQ + MIN and FQ + other. Primary and secondary outcomes were all-cause mortality, clinical cure, and adverse effects. Results: Thirteen retrospective studies encompassing 2980 patients were included. Using TMP/SMX as the reference, network meta-analysis demonstrated heterogeneity in all-cause mortality across antimicrobial regimens. FQ and MIN monotherapies were associated with lower odds of mortality (effect sizes: 0.65, 95% CI: 0.49–0.85 and 0.50, 95% CI: 0.28–0.90), whereas combination therapy with TMP/SMX plus FQ was associated with higher mortality (effect size: 2.93, 95% CI: 1.18–7.31). Treatment ranking based on effect sizes suggested more favorable mortality profiles for MIN and FQ regimsens. No significant differences were observed in clinical cure, while FQ was associated with a lower incidence of adverse effects compared with TMP/SMX. Conclusions: This network meta-analysis suggests that FQ and MIN monotherapies may be associated with more favorable survival and tolerability compared with TMP/SMX monotherapy. No clear differences were observed for combination therapy relative to other active monotherapy options. Prospective randomized studies are required to validate these observations and to better inform the management of S. maltophilia infections.

Germs doi: 10.3390/germs16010006

Authors: Blazej Rozplochowski Justyna D. Kowalska Arjan Harxhi Lukas Fleischhans Sergii Antoniak Deniz Gokengin Anna Vassilenko Kerstin Aimla Raimonda Matulionyte Antonios Papadopoulos Nino Rukhadze Botond Lakatos Dalibor Sedlacek Gordana Dragovic Marta Vasylyev David Jilich Anatonija Verhaz Nina Yancheva Josip Begovac Agata Skrzat-Klapaczynska Cristiana Oprea

Early in 2020, the WHO recommended that existing drugs be evaluated as a repurposed resource to fight the SARS-CoV-2 pandemic. Here, we investigate the trends of using repurposed and off-label drugs among people living with HIV in Central and Eastern Europe (CEE). From November 2020 to May 2021, data on the clinical outcomes of HIV-positive patients diagnosed with COVID-19 were collected on eCRFs (SurveyMonkey® platform, Inc. San Mateo, CA, USA). Factors associated with the off-label drugs available at this time (chloroquine, hydroxychloroquine, favipiravir, oseltamivir, and lopinavir/ritonavir) were identified using logistic regression models. Of the 557 HIV-positive patients assessed with COVID-19 disease, 67 (12.0%) received off-label drugs, as well as 11.6% (16/138) of hospitalized and 12.2% (51/419) of ambulatory patients (p = 0.8564). In the adjusted logistic regression model, higher odds of off-label drug use were found in patients who had their diagnoses confirmed by an RT PCR test (aOR 5.08 [95%CI 1.17–22.0], p = 0.0396), and who came from a non-EU region (aOR 6.79 [95%CI 3.51–13.1], p < 0.0001). The only factor decreasing the odds of off-label drug use was co-infection (aOR 0.31 [95%CI 0.10–0.94], p < 0.0395). In a cohort of HIV patients from the CEE, 12% were prescribed off-label drugs for COVID-19. Symptomatic patients with confirmed SARS-CoV-2 infection or who were from non-EU countries were more likely to receive a repurposed drug. Drug repurposing is an immediate solution to emerging pandemics. All data regarding the safety and effectiveness of such use should be monitored, reported, and publicly available. Access patterns within and outside the EU should be analyzed to prevent potential inequalities in access to care during epidemics in European settings.

Germs doi: 10.3390/germs16010005

Authors: Thida San Meiji Soe Aung Nan Aye Aye Oo Linn Linn Htun Myat Myint Zu Aung Lynn Waddy Nobumichi Kobayashi

Burkholderia cepacia complex (Bcc) consists of genetically diverse species having highly pathogenic potential to humans, causing nosocomial infections via environmental sources. In Myanmar, Bcc has been known as one of the common pathogens of infectious diseases, with relatively low prevalence. However, recently, an increase in isolation from bloodstream infections was noted in a pediatric hospital in Yangon. From December 2023 to June 2025, among the organisms isolated from blood samples (n = 586), Bcc was the most dominant species (n = 178, 30.4%), followed by Klebsiella pneumoniae (16.4%) and Candida spp. (12.7%). Species of Bcc and their genetic types were identified by sequence analysis of partial recA and gyrB genes. Based on the recA sequence, Bcc isolates were identified as B. cepacia (49%), B. cenocepacia (43%), and B. contaminans (7%), having 10, 3, and 2 recA-allelic types, respectively. Similarly, sequences of gyrB revealed the three Bcc species with multiple allelic types. Ceftazidime MIC > 32 mg/L and meropenem MIC > 16 mg/L were found in 38% and 34% of Bcc isolates, respectively. These findings indicated that Bcc, comprising three species with genetically diverse clones, has become the main cause of bloodstream infections in the pediatric hospital in Myanmar.

Germs doi: 10.3390/germs16010004

Authors: Philip Tenchev Emilia Naseva Nina Yancheva

Background/Objectives: While COVID-19 severity is strongly associated with older age, younger adults may also develop complications. This study investigated factors associated with transfer to ICU in hospitalized younger adults during May–December 2021. Materials and methods: Eighty-six consecutive patients aged ≥18 and <50 years were admitted to the University Multi-profile Hospital for Active Treatment of Infectious and Parasitic Diseases “Prof. Ivan Kirov”, Sofia, Bulgaria between 12 May 2021, and 7 December 2021. Results: Among 86 patients (median age 40 years; 55.8% female), common symptoms included fever (89.5%), cough (91.9%), headache (76.7%), and gastrointestinal symptoms (83.7%). Laboratory abnormalities were frequent: lymphopenia (median 0.94 × 109/L), elevated CRP (28.9 mg/L), LDH (333 U/L), and ferritin (198.5 µg/L). Severe andcritical disease occurred in 17.5% of cases, with 43% requiring oxygen therapy. In descriptive/univariate analyses, ICU transfer was more frequent among patients with hypoxemia (SaO2 < 90%) and higher CRP, D-dimer, vomiting and ferritin. In a Firth penalized logistic regression model (rare-event setting), endocrine/metabolic comorbidity showed a directionally consistent association with ICU transfer; gastrointestinal comorbidity signals were not interpretable because of extremely small cell counts. Conclusions: Younger adults usually present with mild to moderate COVID-19; however, a substantial minority develop severe illness. Hypoxemia and elevated inflammatory and coagulation markers were consistently associated with worse outcomes. Endocrine/metabolic comorbidity showed the most consistent association with transfer to ICU in this cohort, although all comorbidity estimates should be interpreted cautiously, given the small number of events.

Germs doi: 10.3390/germs16010003

Authors: Ioana Arbanaș Gabriela Coja Vlad Monescu Bianca Elena Popovici Ileana-Raluca Lixandru Oana Falup-Pecurariu

Background/Objectives: Viral gastroenteritis leads to a broad range of hospitalization costs globally in children, depending on the region. To our knowledge, no recent studies have examined the hospitalization cost associated with viral gastroenteritis in Romania. The aim of this study is to determine the direct hospitalization cost of community-acquired viral gastroenteritis (rotavirus, adenovirus and norovirus) in children admitted to Children’s Clinical Hospital of Brașov, Romania, for one year. Methods: All children aged 0–60 months hospitalized for a stool sample positive for rotavirus, adenovirus or norovirus during January 2023 and December 2023 were included in this study. Hospital-acquired gastroenteritis, gastrointestinal coinfections or children with acute coinfection were excluded. The stool specimens were tested using the immunochromatography method. Results: Out of the total of 282 children, 218 children presented rotavirus gastroenteritis, 35 children presented adenovirus gastroenteritis and 29 children presented norovirus gastroenteritis. Regarding patient characteristics, a higher proportion of boys than girls was observed in all three comparison groups, the average age for children with rotavirus was 22.2 months vs. norovirus and adenovirus, and children presented an average age of 16.4 months. Average hospitalization length of stay for rotavirus was 4.64 (±1.95) days, for adenovirus it was 4.54 (±1.52) days and for norovirus it was 4.75 (±1.93) days. Direct hospitalization costs did not differ between rotavirus, adenovirus, and norovirus infections (Kruskal–Wallis H(2) = 0.145, p = 0.930). Conclusions: In this single-center study, rotavirus remained the most frequent cause of viral gastroenteritis requiring hospitalization in young children, followed by adenovirus and norovirus. Although the average length of stay was similar across groups, hospitalization costs varied, with rotavirus-associated cases showing the highest mean expenses and widest cost variability.

Germs doi: 10.3390/germs16010002

Authors: Amber Consul Mohamad Mubder Samrawit Misiker Shadaba Asad Kimberly D. Leuthner Chia-Dan Kang Yassin Shams Eldien Naga Chad L. Cross Ernesto Abel-Santos

Objective: Although Las Vegas is a major tourist hub, it is not among the counties that are under CDC surveillance for Clostridioides difficile infection (CDI), a major nosocomial infection. To determine the distribution of C. difficile ribotypes in the Las Vegas area, we collected stool samples from CDI-positive patients at the University Medical Center (UMC). Methods: We included adult patients diagnosed with CDI and provided informed consent. C. difficile was isolated from the stool samples and ribotyped. Demographic information was also obtained and analyzed. All information was compared to the surveillance data from the CDC. Results: We identified more frequently in male patients than in the CDC data. Less than half of the patients used antibiotics prior to the infection. We observed several comorbidities in our patient sample pool, with cardiovascular disease and diabetes being the most prevalent comorbidities. Hypervirulent C. difficile strain 027 was the most prevalent ribotype. Except for two samples of ribotype 076, all other samples represented unique singlet ribotypes. Four of these ribotypes (160, 302, 363, and 813) have not been explicitly reported in humans. Conclusions: Due to the unique environment created by the tourism industry in Las Vegas, this population is exposed to national and international visitors. This study shows the pre-COVID landscape of C. difficile ribotypes in Las Vegas and offers valuable insights into the varieties of C. difficile that are currently infecting this community.

Germs doi: 10.3390/germs16010001

Authors: Carmen-Ecaterina Leferman Lacramioara Ochiuz Laura Stoica Liliana Georgeta Foia Bogdan Minea Cezar Ilie Foia Victor Constantinescu Oana Olariu Alin Dumitru Ciubotaru Bogdan Alexandru Stoica

Background: Thiabendazole (TBZ), a benzimidazole with established antifungal and anthelmintic properties, has also been reported to exert antiangiogenic effects relevant to tissue remodeling and chronic inflammatory microenvironments. The present study examined how manganese coordination and cyclodextrin modify the dissolution behavior and endothelial activity of TBZ. Methods: Antiangiogenic potential was assessed through a human umbilical vein endothelial cells (HUVECs) scratch-wound migration assay. Dissolution profiles of TBZ, manganese–thiabendazole (MnTBZ), and MnTBZ/monochlorotriazynil-β-cyclodextrin (MCT-β-CD) formulation were evaluated under biorelevant pH conditions (1.2, 4.5, 6.8, 7.4) using the paddle method. Results: TBZ displayed a more rapid and extensive dissolution at pH 1.2, compared to MnTBZ. Partial dissociation at pH 4.5 modestly improved TBZ availability, while dissolution remained minimal at neutral pH. MCT-β-CD enhanced the solubility of MnTBZ at pH ≥ 6.8. In agreement with these profiles, TBZ exerted the strongest inhibition of endothelial migration, followed by MnTBZ/MCT-β-CD and MnTBZ. Conclusions: Manganese coordination and cyclodextrin formulation modulate both the dissolution behavior and endothelial migration-inhibitory activity of TBZ, suggesting that such formulation approaches may influence the delivery-related and functional properties of benzimidazole derivatives.

Germs doi: 10.3390/germs15040006

Authors: Yavor Kornovski Stoyan Kostov Yonka Ivanova Stanislav Slavchev Angel Yordanov Eva Tsoneva

Background: Pelvic inflammatory disease (PID) is a common and potentially severe infection of the upper genital tract. Complications such as tubo-ovarian abscess (TOA), sepsis, and diffuse peritonitis contribute significantly to reproductive morbidity, particularly when diagnosis or treatment is delayed. Aim: The aim of this review is to present an updated, clinically relevant synthesis of the current evidence on the epidemiology, microbiology, diagnostic approach, imaging modalities, and management of PID, with a focus on severe forms including TOA, sepsis, and peritonitis. Content: PID is most frequently initiated by sexually transmitted pathogens—primarily Chlamydia trachomatis and Neisseria gonorrhoeae—which rapidly progresses to a polymicrobial infection involving anaerobic and enteric organisms. Diagnosis is predominantly clinical, supported by nucleic acid amplification tests, inflammatory markers, and imaging. Transvaginal ultrasonography remains the first-line diagnostic approach for suspected TOA, while CT or MRI is reserved for unclear cases or to assess rupture. Mild to moderate disease is managed with broad-spectrum combination antibiotics, whereas severe PID or TOA requires hospitalization, parenteral therapy, and timely source control through image-guided drainage or surgery. Ruptured abscesses and PID-associated sepsis demand urgent surgical intervention and multidisciplinary supportive care. Tailored approaches are necessary in pregnancy, adolescence, and immunosuppressed and postmenopausal patients. Conclusions: Prompt recognition, a low threshold for empiric antimicrobial therapy, the appropriate use of imaging, and decisive escalation to drainage or surgery are essential to limit morbidity and preserve reproductive health. Integrating guideline-based practice with structured clinical pathways may improve outcomes and reduce long-term sequelae of PID.

Germs doi: 10.3390/germs15040005

Authors: Iulian Buzincu Mihaela Blaj Eliza Isabela Buzincu Adi-Ionuț Ciumanghel Irina Gîrleanu Irina Ciumanghel Ana-Maria Trofin Vlad Nuțu Alexandru Năstase Ramona Cadar Vlad Carp Beatrice Cobzaru George Mălureanu Corina Lupașcu Ursulescu Cristian Dumitru Lupașcu

Early bacterial infections (EBI) remain a major cause of morbidity and mortality after liver transplantation (LT). This study aimed to characterize their incidence, microbiological spectrum, risk factors, and clinical impact in an Eastern European cohort. We retrospectively analyzed 64 adult LT recipients from a tertiary center, focusing on perioperative parameters, infection profiles, and postoperative outcomes. EBI, defined as infections occurring within 30 days after transplantation and diagnosed according to CDC/NHSN criteria, occurred in 48.4% of patients. Gram-negative bacilli predominated (73.7%), mainly Pseudomonas aeruginosa (34.2%) and Klebsiella pneumoniae (15.8%), while Clostridioides difficile (CDI) accounted for 18.4% of confirmed cases diagnosed by stool toxin assay. Infected patients had greater intraoperative blood loss (median 6500 mL vs. 5000 mL, p = 0.036) and required more transfusions. The higher infection rate in our cohort may also be related to longer surgical duration. All deaths within the first postoperative year occurred among infected recipients, yet overall 30-day (7.8%) and 1-year (14.1%) mortality rates remained within the range reported internationally, suggesting that timely diagnosis and adequate management limited the impact of infections on survival. These findings emphasize the importance of infection prevention, optimized transfusion and bleeding control, and tailored antibiotic prophylaxis based on local microbiological patterns after LT.

Germs doi: 10.3390/germs15040004

Authors: Mihaela-Camelia Vasile Catalin Plesea-Condratovici Mariana Stuparu-Cretu Anca-Adriana Arbune Claudiu-Ionut Vasile Manuela Arbune

Background: COVID-19 has been associated with neurological and psychiatric manifestations, both at disease onset and during post-infectious sequelae, such as anxiety, depression, and sleep disturbances. Previous pandemics suggest potential for long-term neuropsychiatric consequences. Materials and Methods: We conducted a prospective longitudinal study in patients hospitalized with non-critical COVID-19, evaluating symptoms using validated psychometric instruments at discharge and after 3–6 and 12 months post-infection. Additionally, a four-year follow-up was performed through telephone interviews to document newly diagnosed psychiatric disorders and mortality. Results: At baseline, 22% of patients reported anxiety, 8% depression, and 16% poor sleep. Most symptoms improved within the first year, particularly during the first 3–6 months. At four-year follow-up, mortality reached 5%, while clinician-diagnosed psychiatric disorders increased to 6% for anxiety, 11% for depression, and 3% for mixed disorders. Anxiety and poor sleep—but not depression—were associated with the severity of the acute episode. Conclusions: Overall, post-COVID-19 anxiety, depression, and sleep disturbances were more prevalent than in the general population, though the rates were lower than those reported in other studies. Most symptoms resolved within the first year. However, new-onset cases of depression and other psychiatric disorders emerged during long-term follow-up, suggesting distinct trajectories of post-COVID-19 psychiatric morbidity.

Germs doi: 10.3390/germs15040003

Authors: Ekaterina Lyutsova Teodora Stoyanova Andi Isidro Iliyan Todorov Diana Radkova

Background: Typhoid fever (TF) is a systemic infection caused by Salmonella enterica serovar Typhi, typically associated with regions where sanitation and access to clean water are inadequate. Although rare in non-endemic countries, TF remains a diagnostic consideration in travelers returning from endemic areas with febrile illness. Case report: We present the case of an 18-year-old female who developed TF following recent travel to Nigeria. The initial clinical presentation, including fever, dysuria, and abdominal pain, led to a misdiagnosis of acute pyelonephritis. Malaria, arboviral infections, acute viral hepatitis, and parasitic diseases were systematically ruled out through clinical evaluation, serological testing, and parasitological analysis. The clinical course was marked by fever, abdominal pain, somnolence, and hematological and hepatic abnormalities. Blood cultures confirmed the diagnosis, with the isolate verified and serotyped by the National Center of Infectious and Parasitic Diseases. Targeted antimicrobial treatment with ceftriaxone and levofloxacin resulted in full recovery, with no evidence of relapse or chronic carriage over a three-month follow-up period. Conclusions: This case highlights the critical importance of a structured differential diagnostic approach and microbiological confirmation in febrile patients with relevant travel history. In non-endemic settings, where TF may be underrecognized, early recognition, pathogen identification, and appropriate antimicrobial therapy remain essential to favorable outcomes and public health safety.

Germs doi: 10.3390/germs15040002

Authors: Oana Săndulescu

It is with both gratitude and anticipation that I write these words, looking back on almost 15 years of continued publication and marking the transition of Germs into a new chapter through our collaboration with MDPI [...]

Germs doi: 10.3390/germs15040001

Authors: Clàudia Aunós

We are pleased to announce that, beginning with Volume 15, Issue 4 (2025), Germs (ISSN: 2248-2997) will now be published by MDPI [...]

Germs doi: 10.18683/germs.2025.1469

Authors: Marko Markovic Jovan Ranin Aleksa Despotovic Ivan Rajkovic Jovana Ranin Milan Tanasijevic Nikola Mitrovic Natasa Nikolic Ivana Milosevic Ivana Gmizic

Introduction: Doravirine/lamivudine/tenofovir disoproxil fumarate (DOR/3TC/TDF) is recommended for both ART initiation and switch in virologically suppressed patients. We report early real-world outcomes after DOR/3TC/TDF introduction in Belgrade, Serbia. Methods: We conducted a single-center retrospective study at the Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, including all adults who initiated or switched to DOR/3TC/TDF between May 2024 and April 2025. Demographics, comorbidities, prior ART, adverse events, and laboratory data (CD4, HIV-1 RNA, triglycerides, total and LDL cholesterol) were abstracted from electronic records. Results: Of 260 participants, 75 were treatment-naïve and 185 switched regimens; median follow-up was 7 months (IQR: 1-11 months). In naïve patients, CD4 counts increased (458.2±312.0 to 580.7±262.8 cells/µL; p=0.007) and viral load fell to undetectable in 82.8% (24/29; p=0.002). In switch patients, CD4 counts remained stable (665.0±317.5 to 660.5±268.0; p=0.891) and suppression was maintained, with rates of undetectable viral load rising from 83.2% to 93.1% (p=0.013). No significant short-term changes were observed in triglycerides, total cholesterol, or LDL. No virological failures occurred; one discontinuation due to rash was recorded. Conclusions: In routine care in Belgrade, once-daily DOR/3TC/TDF was well tolerated and effective: naïve patients achieved rapid suppression with CD4 gains, and switch patients maintained high rates of undetectable viral load without adverse lipid shifts. These findings support DOR/3TC/TDF as a practical option in the Serbian setting.

Germs doi: 10.18683/germs.2025.1470

Authors: Oana Săndulescu Anca Streinu-Cercel Mariana Mărdărescu Cristiana Oprea Maria Dorobanţu Gener Ismail Aura Diana Reghina Odette Chirilă Extended Consensus Group Adrian Streinu-Cercel

Owing to significant advances in HIV treatment and the resultant increase in life expectancy, the number of aging individuals living with HIV and associated comorbidities continues to rise. Consequently, the management of people living with HIV is no longer solely the responsibility of infectious disease or HIV specialists, but requires an integrated and multidisciplinary approach that addresses the prevention, as well as the monitoring and treatment needs of associated conditions. The care of people living with HIV in Romania is largely aligned with international guidelines, particularly those of the European AIDS Clinical Society (EACS). However, guideline implementation requires adaptation to local clinical realities and collaboration across medical specialties. In response to this need, a team of experts in infectious diseases, cardiology, nephrology, diabetes, metabolic disorders, and clinical psychology, convened to develop a national consensus for the interdisciplinary management of people living with HIV. The consensus provides clear and practical recommendations addressed to both infectious disease specialists and healthcare providers from other specialties involved in the care of people living with HIV. Its goal is to offer a unified, up-to-date, and applicable framework to support patient-centered care, facilitate interdisciplinary collaboration, and contribute to improving the quality of life of people living with HIV in Romania.

Germs doi: 10.18683/germs.2025.1471

Authors: Ioana Luca Elena Diana Andone Ioana Arbanas Laura Bleotu Oana Falup Pecurariu

Influenza remains a common cause of hospitalization among children, bringing substantial morbidity and mortality rates. Despite its soaring prevalence, a significant gap in therapeutic interventions persists, especially for the pediatric population. We present a literature review detailing clinical trials or case reports published in the last six years (since 2019) that discuss the prevention or treatment of influenza in children. We used search engines such as PubMed or Cochrane Library. All studies/case reports are written in English, and all the clinical trials are finished. In Europe, oseltamivir, zanamivir, and baloxavir marboxil are recommended for the treatment or prophylaxis of influenza in adults and children, while the Food and Drug Administration added intravenous peramivir to the list of anti-influenza drugs. Oseltamivir remains the first line of treatment and chemoprophylaxis. However, there are still discussions related to the duration of prophylaxis, with shorter periods of administration being explored, or the most efficient treatment dosage program (whether it is the conventional dosage of 3 mg/kg/dose for children <40 kg or 75 mg for adults, twice daily, compared to a double dosage administration program). When faced with an old disease, it is essential to constantly assess the efficacy of conventional molecules and dosages, along with new antivirals or complementary medication.

Germs doi: 10.18683/germs.2025.1472

Authors: Oana Săndulescu Mojca Matičič Federico Garcia Marianne Alanko Blomé Mario U Mondelli William Irving Snjezana Zidovec-Lepej Anders Widell Gülşen Özkaya Şahin

Viral hepatitis remains a global health concern, with growing recognition of the impact of hepatitis A virus (HAV), hepatitis E virus (HEV), and herpesvirus-associated hepatitis, particularly in vulnerable groups. This narrative review from the ESCMID Study Group for Viral Hepatitis (ESGVH) summarizes recent advances and expert perspectives. For HAV, insights into viral evolution, epidemiology, and risk groups underline the preventable nature of severe disease. HEV is increasingly recognized as both a hepatotropic and a systemic pathogen, with expanding knowledge on natural and vaccine-induced immunity. Herpesvirus-associated hepatitis, while rare, poses significant challenges, especially in patients with immunosuppression or during pregnancy, where early suspicion and empirical antiviral therapy can be lifesaving. Collectively, these evolving insights highlight the importance of strengthened diagnostics, targeted prevention, and tailored management strategies to mitigate the burden of these underappreciated but clinically significant causes of viral hepatitis.

Germs doi: 10.18683/germs.2025.1473

Authors: Oana Săndulescu Mojca Matičič Federico Garcia Marianne Alanko Blomé Mario U Mondelli William Irving Snjezana Zidovec-Lepej Anders Widell Gülşen Özkaya Şahin

Hepatitis B virus (HBV), hepatitis delta virus (HDV), and hepatitis C virus (HCV) remain leading drivers of chronic viral hepatitis, cirrhosis, hepatocellular carcinoma, and liver-related mortality. This ESCMID Study Group for Viral Hepatitis (ESGVH) narrative review summarizes recent advances and expert perspectives in the field. For HBV, emerging biomarkers such as quantitative HBs antigen, HBV RNA, and hepatitis B core-related antigen offer opportunities to refine monitoring and to individualize treatment. HDV epidemiology is evolving, and is being increasingly studied; in parallel, the approval of bulevirtide represents a major breakthrough in therapy, with further agents in the HDV pipeline. For HCV, direct-acting antivirals provide curative therapy and have made elimination a realistic goal, while identifying remaining gaps in diagnosis, linkage-to-care, and equitable access offers clear opportunities to accelerate progress. Together, these advances bring the goal of a hepatitis-free future closer than ever.

Germs doi: 10.18683/germs.2025.1474

Authors: Maria-Elena Vodarici Nicola-Maria Militaru Lucia Zekra Nicoleta Chipăilă Oana-Elena Ioniţă Andra-Elena Petcu Roxana-Carmen Cernat Bogdan Florentin Niţu Simona Claudia Cambrea Irina-Magdalena Dumitru

Introduction: Brain abscess is defined as a suppurative collection resulting from hematogenous dissemination as an extension from otorhinolaryngologic infectious foci, or secondary to cranial trauma and neurosurgical procedures. Its evolution follows four histopathological stages, the most severe complication being intraventricular rupture, which is associated with extremely high mortality. Central nervous system infections caused by multidrug-resistant (MDR/XDR) Acinetobacter baumannii are rare but severe, significantly limiting therapeutic options due to the reduced penetration of the blood-brain barrier by active antimicrobial agents. Case report: We report the case of a 48-year-old patient with a history of hemorrhagic stroke treated surgically, who was admitted for fever, severe headache, and vomiting. On admission, lumbar puncture confirmed bacterial meningitis, with isolation of A. baumannii susceptible only to colistin. Brain magnetic resonance imaging revealed a postoperative cerebellar abscess. Initial empirical therapy consisted of meropenem and vancomycin, subsequently adjusted according to the susceptibility profile to cefiderocol, intravenous and intrathecal colistin, combined with ampicillin/sulbactam and minocycline. The clinical course was favorable with regard to meningitis, with partial regression of the cerebellar abscess. Follow-up lumbar punctures were sterile, and the patient’s neurological condition stabilized, allowing avoidance of neurosurgical drainage. Conclusions: Meningitis and brain abscess caused by MDRA. baumannii represent rare clinical entities with potentially severe outcomes. Intrathecal administration of colistin, in combination with systemic multidrug therapy, proved decisive in controlling the infection. An interdisciplinary approach and individualized antimicrobial regimens are essential to achieving a favorable prognosis in such complex cases.

Germs doi: 10.18683/germs.2025.1475

Authors: Florin-Dumitru Mihălţan Ruxandra Ulmeanu Roxana-Maria Nemeş Sorin Petrea Anca Streinu-Cercel Oana Săndulescu

Respiratory syncytial virus (RSV) continues to be a predominant cause of lower respiratory tract infections among infants and toddlers, posing a substantial burden on pediatric health and healthcare systems worldwide.

Germs doi: 10.18683/germs.2025.1468

Authors: Mihai Octavian Dan Dragoş Florea Alexandru Rafila Mihai Turcitu Dan Florin Turcitu Daniela Tălăpan

Introduction: Antimicrobial resistance is a significant public health issue worldwide, associated with limited treatment options and with major consequences for healthcare systems. Our study aims to assess rates and patterns of resistance to five last-resort antimicrobials in a cohort of carbapenemase-producing Klebsiella pneumoniae strains, isolated over a one-year interval. Additionally, we have tested two potentially synergistic combinations for in vitro efficacy. Methods: This prospective observational study evaluated Klebsiella pneumoniae strains with diminished carbapenem susceptibility from patients admitted to the National Institute for Infectious Diseases “Prof. Dr. Matei Balș” in Bucharest between August 2023 and July 2024. Strains presenting a minimum inhibitory concentration to meropenem of >0.125 μg/mL underwent phenotypic enzyme production testing, followed by synergistic testing to identify antimicrobial salvage therapy options. A subset of these strains was analysed for the detection of plasmid-mediated resistance genes, using a custom workflow for DNA extraction and amplification/detection. Results: A total of 139 non-duplicate strains were isolated, with 129 (92.8%) being carbapenemase producers. These 129 strains were phenotypically diverse: 29 (22.5%) were NDM, 12 (9.3%) OXA-48 type, 8 (6.2%) KPC, while most of them (62.0%) were double carbapenemase producers: 79 (61.2%) NDM and OXA-48-type, and one strain was NDM and KPC. Forty-six strains were resistant to cefiderocol (35.7%), 108 (83.7%) to ceftazidime/avibactam, 127 (98.4%) to ceftolozane/tazobactam, 116 (90.0%) to imipenem/relebactam and 127 (98.4%) to aztreonam. The association of aztreonam with ceftazidime/avibactam demonstrated a synergistic effect in 127 (98.5%) strains, while aztreonam with imipenem/relebactam was efficient in vitro against 103 (79.8%) strains. Conclusions: Antimicrobial resistance remains a concerning phenomenon among Enterobacterales, especially when considering the increasing resistance rates even against salvage therapy antimicrobials.

Germs doi: 10.18683/germs.2025.1466

Authors: Razieh Dehbanipour Vala Taghi Zadeh Maleki Zohreh Ghalavand

The heteroresistance phenotype refers to the presence of bacterial subpopulations with reduced antibiotic susceptibility compared with the main population. Mathematical modelling and computer simulations suggest that heteroresistance can lead to negative treatment outcomes and finally, treatment failure. Due to the low frequency and resistance level of resistant subpopulations, detection of heteroresistance phenotype in the diagnostic laboratory is problematic. Routine laboratory tests do not have the ability to accurately detect heteroresistance, but on the other hand, specific methods are time consuming and expensive. The emergence of colistin heteroresistance is a public health concern that threatens human health. Colistin heteroresistance to date has been reported in eight pathogens including Acinetobacter spp., Klebsiella spp., Enterobacter spp., Pseudomonas spp., Escherichia coli, Salmonella enterica serovar Typhimurium (referred to as Salmonella Typhimurium), Neisseria meningitidis and Stenotrophomonas maltophilia. The growing emergence of colistin heteroresistance worldwide underscores the crucial need for coordinated global action to combat it. Understanding the mechanisms of colistin heteroresistance can help to provide better guidelines for reducing antibiotic resistance and to achieve new therapeutic approaches. Our review showed that the prevalence of colistin heteroresistance strains varies in different countries. It seems that the use of different treatment strategies, especially combination therapy, can be effective in reducing the incidence of resistant subpopulations. Also, the use of new generation diagnostic methods can have a significant impact on treatment. Our findings in this review are needed to raise the awareness of microbiologists and specialists to the colistin heteroresistance mechanisms and to achieve effective treatment.

Germs doi: 10.18683/germs.2025.1467

Authors: Diego Fernando Severiche-Bueno Silvia J Galvis-Blanco Jacqueline Mugnier

Introduction: Co-infection with Histoplasma capsulatum and Pneumocystis jirovecii is rarely documented in HIV-negative immunocompromised patients and poses significant diagnostic challenges due to overlapping radiological patterns and limited access to advanced mycological testing. Case report: A 58-year-old woman with systemic lupus erythematosus and lupus nephritis, under treatment with corticosteroids and cyclophosphamide, presented with fever and hypoxemia. Chest computed tomography demonstrated bilateral micronodules, ground-glass opacities, and mediastinal lymphadenopathy. HIV testing and initial cultures were negative. Bronchoalveolar lavage revealed P. jirovecii, prompting the initiation of trimethoprim-sulfamethoxazole. Despite targeted therapy, the patient developed progressive respiratory failure, requiring intensive care. Transbronchial biopsy later confirmed coinfection with H. capsulatum. Antifungal therapy with liposomal amphotericin B and itraconazole was initiated; however, the clinical course was marked by progressive deterioration, culminating in death. Conclusions: This case highlights the need for high clinical suspicion of dual opportunistic infections in non-HIV immunocompromised patients. Diagnostic delays, particularly in resource-limited settings without fungal PCR, may adversely affect outcomes. In such complex hosts, early invasive diagnostics and broader access to rapid molecular testing are critical to improving prognosis in this vulnerable population.

Germs doi: 10.18683/germs.2025.1465

Authors: Leonard Năstase Silvia-Maria Stoicescu Nicolae Suciu Laurenţiu Camil Bohîlţea Eugenia Panaitescu Adina-Brânduşa Baciu

Introduction: The effects of drug addiction in pregnancy are associated with multiple maternal, fetal and neonatal risks in the short and long term. Methods: This was a retrospective descriptive study conducted in the National Institute for Maternal and Child Health "Alessandrescu-Rusescu" Bucharest, Romania - "Polizu" Hospital of Obstetrics and Gynecology (higher level maternity hospital), includes newborns from the last 22 years (2002–2024) from mothers who used illicit drugs before and during pregnancy. Results: The incidence of newborns born to mothers with drug addiction has steadily increased over the period studied, especially in the last 12 years. Neonatal morbidity was marked by: withdrawal syndrome (61.2% of cases), risk of congenital/perinatal infections through maternal infections (58.16%), prematurity (43.87%), birth weight ≤2500 g (55.10%), intrauterine growth restriction. Conclusions: Illicit drug use in pregnancy, associated with prematurity, intrauterine growth restriction, neonatal withdrawal syndrome, risk of congenital/perinatal infections through maternal infections, is an important risk factor for neonatal morbidity and mortality.

Germs doi: 10.18683/germs.2025.1464

Authors: Agata Skrzat-Klapaczyńska Sergii Antoniak Svitlana Antonyak Konstantinos Protopapas Antonios Papadopoulos Daniela Maric Botond Lakatos Antonija Verhaz Milan Zlamal Zofia Bartovska Milena Stefanovikj Gordana Dragovic Arjan Harxhi David Jilich Kerstin Aimla Lilia Cojuhari Justyna Kowalska Josip Begovac

Introduction: The implementation of nationwide viral hepatitis C elimination programs is challenging in Central and Eastern European countries (CEEC). It is reasonable to start by targeting specific populations, such as people living with HIV (PLWH), who are at higher risk of acquiring HCV or developing HCV-related complications. Methods: Euroguidelines in Central and Eastern Europe Network Group consists of experts in the field of infectious diseases from 26 countries in the region. Between April 26th and June 23rd 2023, the group performed an on-line survey consisting of 32 questions. The questionnaire assessed the status of HCV micro-elimination in 2022. Results: Twelve HIV centers from 11 countries responded: Albania, Bosnia and Herzegovina, Croatia, Czech Republic, Estonia, Greece, Hungary, Macedonia, Moldova, Serbia and Ukraine. All centers screen for HCV antibody all PLWH at entry into care. The seroprevalence of anti-HCV was <5% in 5 centers (Albania, Croatia, Serbia, North Macedonia and Hungary), 30.2% in Estonia and 29% in Ukraine, Greece and Moldova had high seroprevalence as well, 15.3% and 15.6% respectively. The prevalence of HCV viremia in antibody-positive PLWH was very high in Greece (85%), while in most other treatment centers it ranged from 4.2% to 38.2%. There is also a screening policy of annual HCV-testing of HCV-antibody negative persons in all centers by either testing all PLWH or those considered at risk. Direct-acting antiviral agents (DAA) were not available in one country (Albania). Among PLWH who entered care in 2022, nine out of 12 ECEE centers reported cases of HCV/HIV coinfection, with five centers indicating that at least 50% of these individuals were HCV-viremic. Conclusions: HCV screening in PLWH followed by access to DAA treatments were available in all but one center. Microelimination of HCV in PLWH in the majority of surveyed HIV treatment centers in CEEC has not been achieved and efforts to reach this goal need to be strengthened.

Germs doi: 10.18683/germs.2025.1463

Authors: Hannah Sinks Caitlin Waters Alejandro Alvarez Gary L. Goldberg David W. Rosenthal Elizabeth O. Schmidt

Introduction: This study aimed to better understand patient-reported human papillomavirus (HPV) vaccination rates and barriers to vaccination among transgender patients receiving care at a gender-affirming clinic in urban New York. Methods: All patients with arrived appointments at the Center for Transgender Care at Northwell Health from 1 January 2020 through 14 July 2021, aged 14 and up, were invited to participate. Participants were sent an online consent form followed by a survey that assessed HPV knowledge, personal vaccination history, and reasons for or against vaccination. Data were collected in RedCap and analyzed using descriptive and basic inferential statistics. We received 79 completed consent forms and 70 completed surveys. Results: At least 68 of the 70 participants identified as transgender or gender diverse. Only 61.4% (43/70) of participants reported ever being offered the HPV vaccine and 55.7% (39/70) reported ever receiving at least one dose. Common reasons in favor of vaccination included doctor recommendation and decreasing cancer risk. Common reasons mentioned against HPV vaccination included sexual inactivity, concern over side effects, and assumption of low-risk HPV status. Of unvaccinated participants, 58.1% (18/31) reported they were more likely to get vaccinated after completing the survey. Conclusions: The HPV vaccination rate in this study was higher than the rates seen in previous studies involving sexual and gender minority participants. Provider recommendation was found to be important in promoting vaccination.

Germs doi: 10.18683/germs.2025.1462

Authors: Filis Demirgean Simona Albu Maria-Magdalena Constantin Adrian Streinu-Cercel

Labiaplasty, the surgical modification of the labia minora, has gained popularity lately due to increasing functional and aesthetic concerns. We examine the preoperative considerations, postoperative outcomes, and potential complications associated with this intervention, while describing our center’s protocol for laser labiaplasty. The use of laser technology appears to enhance surgical outcomes, by minimizing tissue trauma and expediting recovery. This paper highlights the importance of individualized patient care, surgeon expertise, and adherence to best practices to optimize safety and results. As labiaplasty techniques continue to evolve, further studies are necessary to evaluate their benefits, risks and long-term outcomes.

Germs doi: 10.18683/germs.2025.1461

Authors: Filis Demirgean Simona Albu Maria-Magdalena Constantin Adrian Streinu-Cercel

Introduction: Genitourinary syndrome of menopause (GSM) and vulvovaginal atrophy (VVA) significantly impact women’s quality of life, leading to symptoms such as vaginal dryness, irritation, dyspareunia, and urinary incontinence. While traditional treatments include hormonal therapy and surgical interventions, these approaches may not be suitable for all patients. Laser vaginal rejuvenation has emerged as a promising, minimally invasive alternative that enhances vaginal tissue health with minimal downtime. Methods: This retrospective study analyzes data from 53 patients who underwent internal, external, or combined laser vaginal rejuvenation. Patient demographics, medical and gynecological history, treatment indications, procedural details, and post-treatment outcomes were assessed. Results: The most common reasons for seeking treatment included vaginal laxity (69.8%), urinary incontinence (47.2%), and vaginal discomfort (15.1%). The majority (90.6%) opted for combined internal and external treatment, with most undergoing three sessions. Post-procedure symptoms were minimal, limited to transient discomfort and minor, self-limiting bleeding in three patients. No patients developed wound infections; this finding is reflected in the postoperative reevaluation, using genital cultures. Conclusions: Findings suggest laser vaginal rejuvenation is well-tolerated, with high adherence and satisfaction rates. While our study is limited by its descriptive nature and single-center design, results align with existing literature, supporting the procedure’s safety and efficacy.

Germs doi: 10.18683/germs.2025.1460

Authors: Ilinca Savulescu-Fiedler Teodora Deaconu Roxana Siliste Corina Homentcovschi Adriana Gurghean Ioana Toader Serban Benea

Introduction: Inflammation may induce dysautonomia, which is revealed by the decrease in heart rate variability (HRV) parameters. Our pilot study compares changes in HRV and the association between HRV and inflammatory markers in three RNA viral infections: acute (SARS-CoV-2, measles) and chronic (HIV). Methods: We evaluated 25 patients with viral infections and 8 control patients without viral disease, with similar mean age and comorbidities. Patients with measles and COVID-19 were hospitalized for mild to moderate respiratory symptoms, while those with HIV were assessed during follow-up visits. HRV parameters were assessed in time and spectral domains, under standardized conditions. Results: Significant differences were identified between measles and COVID-19 patients regarding SDNN (p = 0.016), rMSSD (p = 0.002), and between COVID-19 and HIV patients, both for SDNN (p = 0.029) and rMSSD (p = 0.017). SDNN and rMSSD had the highest value in COVID-19 group and the lowest value (lower than in the control group) in HIV and measles patients. All frequency-domain parameters reached their highest values in COVID-19 patients, whereas they were consistently lower in those with HIV and measles. A significant correlation of LF/HF ratio with serum fibrinogen was observed only in patients with measles and HIV infection (r = 0.793, p = 0.011, respectively r = 0.955, p < 0.001). Conclusions: Our study showed a significant decrease in HRV parameters in measles and HIV patients, with a more stable autonomic response in mild-moderate COVID-19 forms. A correlation between inflammation and markers of sympathetic dominance was found in patients with measles and HIV but not in COVID-19. Further studies may assess the relation between inflammation in viral infections and subtle changes in HRV parameters

Germs doi: 10.18683/germs.2025.1457

Authors: Gheorghiţă Jugulete Bianca Borcoş Mădălina Maria Merişescu

Introduction: This case highlights a rare and significant complication of Chlamydia pneumoniae infection: optic neuritis (ON). Acute Chlamydia pneumoniae infection in children typically presents with respiratory tract symptoms and may occasionally lead to complications or sequelae. ON is a condition most commonly associated with viral infections or other demyelinating diseases. Case report: The patient, a 10-year-old girl, initially presented with the typical systemic symptoms of Chlamydia pneumoniae infection, including fever, chills, and headache, in addition to an atypical symptom—chromatic deficit, or visual disturbances. This prompted further investigation into potential neurological complications, ultimately leading to a diagnosis of ON. The case underscores the importance of a comprehensive diagnostic workup, including serological testing (IgM ELISA) and PCR analysis of nasopharyngeal specimens, to confirm the underlying infection. Additionally, imaging studies (CT, MRI) and consultations with specialists in neurology and ophthalmology were critical for excluding other potential causes and assessing the extent of complications. The rapid and favorable response to treatment highlights the importance of early diagnosis and appropriate management. Conclusions: Although ON is a rare complication of Chlamydia pneumoniae infection, it should be considered in pediatric patients with unexplained visual symptoms, particularly when the clinical course does not improve or worsens despite treatment for the primary infection. This case further emphasizes the importance of interdisciplinary collaboration in managing complex cases and the need for vigilant monitoring of potential neurological complications in children with respiratory infections.

Germs doi: 10.18683/germs.2025.1451

Authors: Clement Meseko Uwem Okon Edet Okoroiwu Henshaw Nicodemus Mkpuma Kayode Abraham Olawuyi Charles Archibong

Introduction: Despite decades of research on highly pathogenic avian influenza, especially H5N1, an understanding of the impact of research outputs on policy, the impact of funding and policies, collaboration between authors, and other bibliometric measurable indices is elusive. Methods: H5N1 research data were retrieved from the PubMed database using “H5N1”, “highly pathogenic”, and “influenza” as keywords, and combined with the Boolean operator, “OR”. The evaluated growth pattern of H5N1 research was analysed using Microsoft Excel, while the VOS viewer window version 1.6.15 was utilized in analyzing the keywords, authors’ inputs, and collaborations amongst research institutes/universities involved in H5N1 research. Results: A total of 8411 articles published within 2003 and 2023 were retrieved. The trend of the published articles indicates that 2003 to 2004 had the lowest number of articles, while the highest were observed for 2009 and 2010. Since then, there has been a gradual decline. The most dominant article type was original research article (89.80%), followed by reviews with 7.54%. The most productive countries were Japan, the United States of America, China, and Egypt in Africa. The top 15 authors accounted for 12.40% of the total published data. Keywords analysis revealed the emergence of newer keywords such as H5N8, wild birds, mammals, and Nigeria; however, as expected, influenza virus avian H5N1 subtype was the dominant keyword. Research institutes with backgrounds in agriculture and veterinary medicine dominated the top 15 organizations involved in H5N1 research. Conclusions: Our findings suggest that research aimed at developing therapeutics and vaccines, as well as continuous surveillance in high-risk areas is urgently needed. Furthermore, the findings provide baseline data for all the stakeholders involved in H5N1 research, which could inform future research, funding, and policies.

Germs doi: 10.18683/germs.2025.1452

Authors: Amany Gamal Thabit Magda Nasser Sediek Mona Sallam Embarek Mohamed

Introduction: Pseudomonas aeruginosa produces many exotoxins which are essential for the bacterial pathogenesis. The aim of this study was to identify Pseudomonas aeruginosa from clinical specimens, detect the sensitivity pattern, biofilm production, and the frequency of exogenes. Methods: Pseudomonas aeruginosa clinical isolates were identified by conventional and genotypic methods. Antibiotic susceptibility patterns and biofilm production were performed. Molecular detection of exotoxin genes exoS, exoT, exoU, and exoY in Pseudomonas aeruginosa isolates was performed by PCR. Results: Seventy-five Pseudomonas aeruginosa were identified in 400 clinical specimens. Sixty-six (88%) isolates were carbapenem-resistant. A total of 25 (33.3%) isolates were extensively drug resistant, 18 (24%) were multidrug resistant, and 11 (14.7%) were pandrug resistant. Sixty-three (84%) isolates were biofilm producers. Biofilm formation was detected in 56 (85%) of carbapenem-resistant isolates. Totally, 70 (93.3%) isolates carried exoS, 68 (90.7%) carried exoY, 65 (86.7%) carried exoT, and 28 (37.3%) carried exoU. Exogenes were highly expressed in carbapenem-resistant isolates. Coexistence of more than one gene was detected in nearly all isolates. Conclusions: Pseudomonas aeruginosa clinical isolates were resistant to many anti-pseudomonal antibiotics. Most of isolates were biofilm-producers. The genes exoT, exoS and exoY were identified in almost all P. aeruginosa strains and are considered an inevitable component of P. aeruginosa virulence.

Germs doi: 10.18683/germs.2025.1453

Authors: Gheorghe Gindrovel Dumitra Carmen-Adriana Dogaru Sandra Adalgiza Alexiu Dorica Sănduţu Cosmina Berbecel Monica Curelea Cristina Vasilica Barbu Anca Deleanu Adrian Grom Maria Lup Ioana Budiu Mădălina Vesa Florin Proşa Daniela Ştefănescu Roxana Surugiu Ştefana Oana Popescu Anca Lăcătuş Mihaela Adela Iancu Adina Turcu-Stiolica

Introduction: Human papilloma virus (HPV) vaccination is a key strategy for preventing HPV-related cancers, yet vaccine hesitancy remains a challenge due to persistent myths and misconceptions. This study aimed to identify the most frequently encountered HPV vaccine-related myths in clinical practice from the perspective of family doctors and to assess differences in their prevalence between urban and rural populations. Methods: A cross-sectional study was conducted among family doctors in Romania who reported common myths encountered when discussing HPV vaccination with parents and women eligible for catch-up vaccination. The analysis focused on identifying the most prevalent perceived myths and assessing differences between urban and rural settings, age groups and genders, using Kruskal-Wallis test, followed by post-hoc Dunn’s tests with Holm correction to account for multiple comparisons, as well as Chi-square tests. Results: The most frequently reported myths overall were “The HPV vaccine is only for girls” (mean score ± SD, 2.91 ± 1.27), “The HPV vaccine has severe and long-term side effects” (mean score ± SD, 2.83 ± 1.27), and “There are too many new vaccines” (mean score ± SD, 2.77 ± 1.3). Rural respondents reported significantly higher belief in concerns related to vaccine safety, effectiveness, increasing number of vaccines, necessity in monogamous individuals, fear of injections, and concerns about promiscuity, particularly in their perception of parents of adolescent girls. Conclusions: Family doctors consider that persistent myths continue to fuel vaccine hesitancy, especially in rural areas. Strengthening family doctors' communication skills through motivational interviewing and evidence-based counseling is essential. Public health efforts should focus on targeted educational interventions and social prescription tools to improve vaccine acceptance and reduce the burden of HPV-related diseases.

Germs doi: 10.18683/germs.2025.1454

Authors: Mădălina Maria Merişescu Gheorghiţă Jugulete Irina Dijmărescu Andreea Mihaela Băluţă Anca Oana Dragomirescu

Introduction: The objective of this study was to identify and analyze cases of pertussis hospitalized in 2024 that met the clinical criteria, epidemiological context, and laboratory confirmation through polymerase chain reaction (PCR) or serological testing for Bordetella pertussis. This study aimed to assess the age distribution of cases, vaccination rates, identify severe cases, and associated complications such as apnea, acute respiratory failure, and acute pneumonia. The findings aim to provide valuable data to enhance diagnostic and therapeutic strategies for managing pertussis in the pediatric population. Methods: We conducted a retrospective study from January to November 2024, involving pediatric patients admitted to the Pediatric Departments of the National Institute of Infectious Diseases “Prof. Dr. Matei Balş,” Bucharest, Romania, diagnosed with pertussis. The diagnosis was established based on epidemiological and clinical criteria and confirmed through laboratory tests, including serology or PCR testing. The selection criteria focused on hospitalized patients presenting clinical signs suggestive of pertussis, with laboratory confirmation. Results: Among the hospitalized patients, a significant proportion, 56.9%, were unvaccinated, while 12.5% had incomplete vaccination status. Common comorbidities contributing to increased hospitalization risk included prematurity, malnutrition, and asthma. Co-infections were identified in 32% of cases, with common pathogens such as measles, SARS-CoV-2, rhinovirus, and adenovirus. Respiratory complications were frequent, with apnea occurring in 51% of cases, pneumonia in 60%, and respiratory failure in 13.2%. Despite these complications, no fatalities were reported. Conclusions: This study highlights significant concerns related to low vaccination coverage in the pediatric population, emphasizing the importance of improving vaccination rates to prevent severe pertussis cases. The study also identifies the frequent occurrence of severe complications, including respiratory failure, apnea, and pneumonia, underlining the need for early intervention and effective management. Co-infections with respiratory pathogens further complicate diagnosis and treatment, underscoring the importance of comprehensive clinical evaluation in suspected cases of pertussis.

Germs doi: 10.18683/germs.2025.1455

Authors: Ana-Maria Slănină Adorata Elena Coman Antoneta-Dacia Petroaie Carmen Liliana Barbacariu Otilia Novac Elena Popa Mihaela Manole Agnes Iacinta Bacuşcă Adriana Cosmescu

Introduction: A major area of pathology in primary care practice is represented by respiratory infections, from common colds to severe lower respiratory tract illness. Our aim was to evaluate the incidence of Mycoplasma pneumoniae and Chlamydia pneumoniae pneumonia among the patients with suspected atypical pneumonia from a family medicine urban setting in Iaşi, Romania, to study serological retrospective diagnosis, the therapeutic outcome and the modified immunologic parameters in a subgroup of patients. Methods: We enrolled 93 patients with suspected atypical community-acquired pneumonia (CAP); enzyme-linked immunosorbent assay (ELISA) testing for Mycoplasma pneumoniae and Chlamydia pneumoniae was performed, both immunoglobulins M and G being determined. Considering the systemic inflammation associated to atypical germs infections, in a subgroup of 13 patients, with positive results for Mycoplasma and Chlamydia pneumoniae, interleukin 5, interleukin 8, tumor necrosis factor α and interferon γ levels were determined, using chemiluminescence method (EI-CLA). Results: Positive IgM serology for atypical germs was recorded in 25.8% of patients. Mycoplasma pneumoniae infection was confirmed in 10.8% of patients, Chlamydia pneumoniae infection in 6.5% of patients, and co-infection (both Mycoplasma pneumoniae and Chlamydia pneumoniae) in 8.6% of patients. A number of 41 patients (44.0%) presented chronic cough/bronchial hyperreactivity despite the treatment. Modified values were recorded for all immunological parameters tested, confirming the role in chronic airway inflammation. Conclusions: Mycoplasma and Chlamydia pneumoniae CAP, frequent among young adults, is successfully treated with macrolides, still, the residual symptoms and the modified immunologic parameters need further studies regarding chronic inflammation.

Germs doi: 10.18683/germs.2025.1456

Authors: Maud Foissac Lucas Balloy Guillaume Wartel Anne-Gaёlle Leroy Marie-Pierre Moiton

Introduction: Solid organ transplant recipients are particularly prone to infections, and many germs can be involved, including opportunistic pathogens. Regarding catheter-related infections however, the number of causative microorganisms is most often limited to germs of the skin flora, rare enterobacteria and Pseudomonas aeruginosa. Case report: We present here a case of venous catheter-related cutaneous infection in a man with immunosuppression, which was surprisingly caused by a rare environmental fungus, named Nigrograna chromolaenae. The therapeutic strategy combining posaconazole and removal surgery appears to have been effective, with no relapse more than 2 months after surgery. Conclusions: Due to advances in molecular biology techniques, it is possible that infections with Nigrograna spp. will be increasingly described. At the moment the reported cases are few in number, and the treatment is not yet standardized, which is why we thought this new case could support the literature about these opportunistic pathogens.

Germs doi: 10.18683/germs.2025.1458

Authors: Saurabh RamBihariLal Shrivastava Prateek Sudhakar Bobhate

Ebola virus disease (EVD) is a rare infectious tropical disease, which is a serious illness among humans, and is often fatal [...]

Germs doi: 10.18683/germs.2024.1449

Authors: Katarina Maksimovic Sandra Šipetić-Grujičić Jelena Ilić Živojinović Milena Tomanić Isidora Vujčić

Efforts to reduce the spread of COVID-19 led to the temporary closing of schools, colleges, and restrictions on freedom of movement [...]

Germs doi: 10.18683/germs.2024.1448

Authors: Khadijeh Bamneshin Mohsen Poudineh Roya Haji Alibabaei Mohammad Reza Jabbari Amiri Zahra Sadat Fateminasab Zahra Ghorbani Reyhaneh Maleki Azad Khaledi

We evaluated the gene prevalence of the icaADBC operon, its correlation with biofilm formation and antibiotic resistance through a global meta-analysis. We searched for articles that reported the prevalence of icaADBC operon, biofilm, and antibiotic resistance in S. aureus from 2000 up to 1st March 2024. The search was done in scientific databases such as PubMed, Scopus, Google Scholar, EMBASE, and Web of Science. The MESH keywords were: icaADBC operon, biofilm, methicillin-resistant Staphylococcus aureus, antibiotic resistance. Comprehensive Meta-Analysis Software was used for data analysis. The estimation of the combined prevalence of each desired variable was performed by depicting a forest plot through the random-effects model with a 95% confidence interval. Data heterogeneity was estimated by Q and I2 indices, and p-value <0.05 was reflected as statistically significant heterogeneity. Fifteen articles were eligible for inclusion. The prevalence of ica operon genes varied between 28–51.5%. The prevalence of total ica operon genes in S. aureus was reported at 42.4% (95%CI: 29.4–56.5). Biofilm formation prevalence of S. aureus isolates in different studies was reported between 10-100%. The rate of total biofilm in S. aureus was 95.8%. The rate of total strong, moderate, and weak biofilm in S. aureus was reported at 35.4%, 35.3%, and 23.9%, respectively. Most reviewed studies reported a correlation between ica genes and biofilm. We found that many studies reported a correlation between the high prevalence of ica operon genes, phenotypic biofilm production, and antibiotic resistance. Also, regardless of whether the strains were MRSA or not, the high biofilm formation ability was reported at 95.8% by most studies.

Germs doi: 10.18683/germs.2024.1442

Authors: Oana Săndulescu İmran Hasanoğlu Mojca Matičič on behalf of ESGVH

In 2024, the global fight against viral hepatitis has made steady strides, marking yet another important year in the effort to eliminate this significant public health challenge.[...]

Germs doi: 10.18683/germs.2024.1447

Authors: Wijesundara Mudiyanselage Thilini Nimansala Senaratne Jayaweera Arachchige Asela Sampath Jayaweera

Many microorganisms are used to produce antibiotics, vaccines, and medicines for various diseases, and preserving these microorganisms and viruses can ensure that the development process is streamlined. We have reviewed the short-term and long-term microbial and viral preservation methods including novel and emerging technologies. Short-term preservation methods of microorganisms are designed to maintain the viability of the organisms for periods ranging from a few days up to one year. The novel microfluid systems allow for the creation of microenvironments that support the growth and proliferation of specific microorganisms and the isolation of individual cells or small populations of microorganisms for studying microbial behavior and interactions. Long-term preservation involves storing the organisms for an extended period, ranging from months to decades, while retaining their viability and genetic stability. The mineral oil or liquid paraffin storage, storage in distilled water, storage in sterile soil, lyophilization, and cryopreservation are well known, and encapsulation of nanoparticles to preserve microorganisms, electrospinning, and electro spraying and supercooling are novel and emerging methods. Each short and long-term microbial and viral preservation method has advantages and disadvantages, and, based on the requirement, the appropriate method can be chosen.

Germs doi: 10.18683/germs.2024.1443

Authors: Marta Vasylyev Hanne Lamberink Ivanna Svyst Oksana Khlypnyach Oleksandra Sluzhynska Maryana Sluzhynska Iryna Shtoiko Oleksandra Hrushynska Dmytro Demianenko Casper Rokx

Introduction: Armed conflicts exacerbate the spread of infectious diseases. We assessed the impact of the 2022 armed conflict in Ukraine on common sexually, bloodborne, and respiratory-transmitted infectious diseases in internally displaced people (IDP) in Ukraine. Methods: A cross-sectional study (#aware.id) was conducted in Lviv, Ukraine, from 3 May 2023 to 24 June 2024, including IDP seeking care for HIV, hepatitis B and C, COVID-19, tuberculosis, and sexually transmitted infections. After medical screening to evaluate disease risk, we used rapid point-of-care tests followed by confirmatory standard of care testing. The main endpoints were the infectious disease case positivity rate in IDP compared to a local at-risk population, the association with war related risk factors including shelter use and experienced violence, and linkage to care. Results: Among 695 enrolled participants (250 IDP and 445 locals), the median age was 37 years (IQR 30-45) and 58.7% were women. Both groups disclosed a high HIV and viral hepatitis disease risk. Among IDP, rates of HIV (4.8% in IDP vs. 7.1% in local at-risk population), hepatitis C (33.9% vs. 40.0%) and syphilis (4.7% vs. 2.7%) were comparable with the local at-risk controls (all p>0.05), while the hepatitis B rate was lower in IDP (6.3% vs. 26.9%, p0.05). Despite higher war-related risk factors, we found no clear association with infectious disease burden in IDP disclosing these factors. All those diagnosed were linked to care within 4 weeks. Conclusions: The undiagnosed infectious disease burden in IDP was high and comparable to a high-risk local population.

Germs doi: 10.18683/germs.2024.1444

Authors: Cristina Nicoleta Ciurea Anca Delia Mare Mihai Mareş Felicia Toma Irina-Bianca Kosovski Anca Cighir Adrian Man

Introduction: Intercellular communication helps regulate the cell density and the virulence traits in yeasts and bacteria. The study aims to identify the effects of quorum sensing molecules (QSMs) like farnesol and tyrosol on Candida spp. virulence traits. Methods: The effects of farnesol and tyrosol were studied on the growth rate of Candida albicans, Candida parapsilosis, Candida krusei, Candida auris, and Candida guilliermondii at different time points, on a 48 hours incubation period. The growth rate was assessed spectrophotometrically. The biofilm formation abilities of Candida spp. were assessed by crystal violet staining technique. Moreover, the expression of C. albicans virulence genes (ALS3, HSP70, SAP2) was analyzed as a response to 100 μM farnesol and tyrosol, by RT-PCR. Results: Generally, farnesol was found to inhibit the growth rate and biofilm formation mostly in non-albicans species, while tyrosol exerted a non-consistent response on the different Candida species. The expression of ALS3 and HSP70 in C. albicans was upregulated by the QSMs. Conclusions: Both farnesol and tyrosol are involved in the regulation of Candida spp. virulence mechanisms, dependent on the used concentration and exposure time and in a species-dependent manner.

Germs doi: 10.18683/germs.2024.1445

Authors: Ahlam Almulhim Amer Alomar Ibrahim Alhabib Lamya Zohair Yamani Nasreldin Elhadi

Introduction: Shiga toxin-producing Escherichia coli (STEC), particularly E. coli O157:H7, is a major contributor to foodborne outbreaks globally. Both E. coli O157 and non-O157 strains can lead to severe health issues, including hemolytic colitis and hemolytic uremic syndrome, which can result in kidney failure. Methods: Two hundred and one frozen beef samples were purchased from various supermarkets located in the Eastern Province of Saudi Arabia and subsequently enriched in tryptic soy broth (TSB). From the enriched samples in TSB, 1 mL portion was mixed with immunomagnetic beads (IMB) coated with specific antibodies targeting the E. coli O157 O antigen. The beads, which contained the captured bacteria, were then streaked onto CHROMagar O157 and Sorbitol MacConkey (SMAC) agar. The DNA extracted from these samples was examined using multiplex PCR to identify potential virulence gene markers, specifically stx-1, stx-2, and eae. Results: Of the 201 examined samples, 88 (43.8%) and 106 (52.7%) were positive for E. coli and produced colorless and mauve colonies on SMAC agar and CHROMagar O157, respectively. Out of 298 isolates in total, 174 isolates of E. coli were isolated with IMB enrichment. The highest detection rate of virulence gene markers was found among isolates that had been isolated using IMB enrichment, where 25 (8.4%), 2 (0.7%) and 12 (4%) isolates tested positive for stx1, stx2, and eae genes respectively. Among 42 isolates harboring potential virulence gene markers, 11 isolates were identified as E. coli O157 (stx1+/eae+ or stx2+/eae+). ERIC-PCR genotyping was able to determine the genetic relatedness among 42 isolates of E. coli O157 and E. coli non-O157 into 10 types with four identical related clusters and a genetic similarity rate above 90% homology from the identified isolates. Conclusions: The present study gives a clear perspective on STEC contamination in imported frozen beef marketed in Saudi Arabia. Because of the many possibilities of STEC contamination in imported frozen beef, further studies on the spread of STEC at various levels of imported frozen meat are needed on a long-term basis.

Germs doi: 10.18683/germs.2024.1446

Authors: Gheorghe Gindrovel Dumitra Sandra Adalgiza Alexiu Dorica Sănduţu Cosmina Berbecel Monica Curelea Cristina Vasilica Barbu Anca Deleanu Adrian Grom Maria Lup Ioana Budiu Mădălina Vesa Roxana Surugiu Anca Lăcătuş Adina Turcu-Stiolica

Introduction: Vaccine hesitancy remains a significant public health challenge, particularly in rural populations where geographic and socioeconomic barriers exacerbate the issue. This study aimed to examine the factors influencing vaccine hesitancy, focusing on influenza vaccinations in rural and urban communities in Romania. Methods: The study was conducted between October 4 and October 30, 2024, across 16 family medicine practices, including seven in rural and nine in urban areas from Romania. A 13-item vaccine hesitancy questionnaire, assessing factors such as fear of adverse effects, distrust in vaccines, and perceived necessity included 272 responses. Latent Class Analysis (LCA) was used to identify distinct subgroups of hesitancy, while Chi-square and odds ratio analyses assessed geographic differences. We performed logistic regression for the most observed root attitudes on influenza vaccination refusal. Results: Rural residents were significantly more likely to refuse influenza vaccination compared to urban residents. The LCA revealed three distinct latent classes, characterized by varying levels of agreement with key hesitancy items. Class 1 demonstrated low hesitancy, Class 2 exhibited high hesitancy driven by beliefs in natural immunity and perceived lack of necessity, and Class 3 showed intermediate hesitancy, influenced by distrust in vaccines and past negative experiences. Among the key significant triggers underlying vaccine refusal were fear of adverse effects, parental status, chronic diseases, and previous vaccination experiences, while factors such as age and gender showed limited impact. Conclusions: Vaccine hesitancy persists as a complex, multidimensional issue, with rural populations disproportionately affected. Targeted, context-specific interventions addressing key drivers such as distorted risk perception, fear of adverse effects and distrust in vaccines are critical for improving vaccination rates These findings underscore the importance of tailored public health strategies to promote equitable vaccine uptake.

Germs doi: 10.18683/germs.2024.1441

Authors: George Kassianos Rok Civljak Gerrit Adrianus van Essen Oana Falup Pecurariu Filipe Froes Andrey Galev Kadri Kõivumägi Zuzana Kristufkova Ernest Kuchar Jan Kyncl Helena C. Maltezou Miloš Marković Anne Mosnier Raúl Ortiz de Lejarazu Y Leonardo Alessandro Rossi Jörg Schelling

High quality research is critical for evidence-based decision making in public health and fundamental to maintain progress and trust in immunization programs in Europe. In 2024 the European Centre for Disease Prevention and Control (ECDC) conducted an update of the 2020 systematic review to capture more recent evidence on of the efficacy, effectiveness of influenza vaccines in individuals aged 18 years and older in the prevention of laboratory-confirmed influenza. While this report was highly anticipated due to the strength of the protocol and processes put in place, during our assessment, we expressed two chief concerns. We are concerned by the grading of the evidence certainty applied and being unable to reproduce some data extracted in the report from the primary sources. While the systematic review benefited of strong methods and processes, the execution of the research protocol warrants revision due to the issues discussed. We encourage the ECDC to work towards an updated review within a reasonable time frame to avoid misinterpretation by decision-making bodies across Europe.

Germs doi: 10.18683/germs.2024.1438

Authors: Naufal Arif Ismail Jamaluddin Haikhah Evania Tasnim Fauziah Muhammad Adam Prabasunu Fadila Husnia Rahma Siswanto Siswanto Vita Widyasari

Introduction: Dengue infection poses a serious threat to global public health, including Indonesia. The rapid spread and significant economic impact are crucial concerns for control efforts. Investigating risk factors of dengue virus infection is necessary to formulate effective strategies, particularly at the household level. This study aims to investigate contributing risk factors to dengue virus transmission in the Borobudur Subdistrict, Magelang, Indonesia, an area with persistently high dengue infection mortality rates. Methods: This study adopted a case-control design and utilized secondary data collected from six villages in the Borobudur Subdistrict. A total of 111 households (37 cases and 74 controls) participated in the study and completed a questionnaire encompassing: (1) Sociodemographic data; (2) Healthy housing components; (3) Sanitation and behavioral components; and (4) Dengue infection prevention practices. Data were analyzed bivariately using statistical software to identify differences in group proportions. Results: The findings of this study indicate that the presence of stagnant water (odds ratio [OR]: 5.02) and mosquito larvae (OR: 4.80) around the house, morning sleep habits (OR: 6.97), and lack of participation in anti-dengue programs (OR: 3.23) are significant risk factors (p0.05) were found in healthy housing components between the case and control groups. Conclusions: This study has identified contributing risk factors to dengue virus transmission in the Borobudur Subdistrict. These results can serve as a foundation for designing more effective intervention programs for dengue infection and future prevention efforts.

Germs doi: 10.18683/germs.2024.1439

Authors: Ivan Mihanovic Relja Beck Marin Petric Natasa Males Raskovic Ana Dunatov Huljev Dijana Perkovic Mirela Pavicic Ivelja

Introduction: Alveolar echinococcosis is one of the most pathogenic zoonoses caused by the larval forms of Echinococcus multilocularis. It is endemic in central Europe, but from 2001 to 2018, eight European countries reported their first cases of alveolar echinococcosis. These numbers testify to unprecedented spread of the infection. Case report: We report the first case of alveolar echinococcosis from southern Croatia that was incidentally found in an immunocompromised 70-year-old male patient. He was admitted to the hospital due to macrohematuria and renal insufficiency. Diagnostic assessment of kidney impairment revealed a large liver infiltration whose radiographic appearance was suspicious of a cancer. Nevertheless, histopathological and molecular analysis of the liver biopsy confirmed alveolar echinococcosis. The lesion was irresectable due to expansion along the major liver vessels. Therefore, conservative treatment with albendazole was started and the existing immunosuppressive therapy was modulated. The control imaging following 11 months of albendazole treatment showed regression of the lesions. Conclusions: It is not clear whether this case was imported or autochthonous, but it is evident that the incidence of alveolar echinococcosis is rising in Europe. Due to its rareness and malignant nature of the disease, it is often misdiagnosed or diagnosed late when radical surgical treatment is impossible to perform. Clinicians should be aware of this emerging parasitic disease, especially in immunocompromised patients, because every delay in reaching the diagnosis seriously hampers therapeutic efficacy. Better therapeutic options and standardized guidelines on the modulation of immunosuppressive therapy in these patients are highly needed.

Germs doi: 10.18683/germs.2024.1440

Authors: Andrei Bunea Dan Lăptoiu Isabela Târcomnicu Dan Oţelea Gheorghe Popescu Rodica Marinescu

Introduction: This paper examines the use of local antibiotic therapy in one-stage septic revision surgery for late periprosthetic joint infections (PJIs). This case study suggests that morselized bone allografts impregnated with antibiotics in powder form are a preferable alternative to polymethyl methacrylate (PMMA) because they can generate higher local antibiotic concentrations. Current research also recommends using vancomycin and aminoglycosides as the preferred choice of antibiotics, as they may have low diffusion in tissues when administered intravenously, but are effective when administered locally. The article emphasizes the importance of achieving high local antibiotic concentrations to eradicate bacterial biofilms and provides guidelines for the preparation of bone allografts. Case report: The paper assesses the case study of a 68-year-old male patient who underwent two-stage total revision surgery for a late septic failure of the endoprosthesis (approximatively one year after implantation). The first stage involved removing the implant, debridement, lavage, and setting a fixed spacer manually made from polymethyl methacrylate impregnated with 4 g of vancomycin. The second stage of revision surgery utilized a morselized bone allograft impregnated with 4 g of vancomycin as a means of local antibiotic therapy and bone defect coverage. Systemic levels of vancomycin were measured at 4, 8, 12 and 24 hours respectively after surgery. During this period, no systemic vancomycin was administered. After the second stage was carried out and the testing was carried out, systemic vancomycin therapy was initiated and the plasma levels of the drug were assessed and subsequently therapeutic doses were adjusted. Conclusions: Vancomycin loaded bone allograft achieved higher systemic concentrations that its polymethyl methacrylate counterpart, when being manually loaded with the same amount of antibiotic. Nonetheless, the levels were well below nephrotoxic levels, indicating that this may be a valuable tool for local means of antibiotic therapy in selected patients that could not endure such a systemic therapeutic regiment. For septic revisions, antibiotic loaded bone allograft holds a valuable place in the surgical arsenal of local antimicrobial treatment, by far exceeding that of the polymethyl methacrylate.

Germs doi: 10.18683/germs.2024.1435

Authors: Laura Constantin Anca Ungurianu Isabela Ţârcomnicu Ema Bălulescu Denisa Margină

Introduction: The COVID-19 pandemic has promoted an intensive investigation into the pathophysiological mechanisms of SARS-CoV-2 infection, risk factors, and its impact on disease severity. Vitamin D has generated significant attention for its potential role in viral prevention and immune defense due to its pleiotropic functions, including immunomodulation and antimicrobial effects. This study aimed to assess serum 25(OH)D3 levels in patients with COVID-19 compared to those with other viral respiratory infections and to evaluate associations of vitamin D levels with symptomatology, clinical characteristics, presence of comorbidities and laboratory investigation. Methods: The study included 78 patients admitted to a hospital with COVID-19 (52 patients) or other viral respiratory infections (26 patients). Routine blood biomarkers, markers of inflammation, markers of endothelial dysfunction, serum 25(OH)D3 were analyzed, and patients were classified according to vitamin D levels and presence of comorbidities. Results: Most patients had vitamin D levels <30 ng/mL and there was no significant difference in 25(OH)D3 levels between patients with and without COVID-19 (p=0.768). Aging and comorbidity prevalence were significantly increased in the COVID-19 than in the non-COVID-19 group (p<0.001; p=0.049). A significant positive correlation was determined between endocan level and serum ferritin concentration in patients with COVID-19 and vitamin D deficiency. A borderline significantly elevated NLR was observed in patients with COVID-19 who were also vitamin D deficient, compared with the similar non-COVID-19 subgroup (p=0.05). In patients with COVID-19 and insufficient vitamin D, levels of 25(OH)D negatively correlated with endocan. Interestingly, COVID-19 patients with diabetes exhibited significantly lower 25(OH)D3 levels compared to non-diabetic patients (p=0.003), along with higher ferritin levels, suggesting a potential association between vitamin D deficiency and diabetes in COVID-19. Conclusions: These findings contribute to the understanding of the complex interplay between vitamin D status, comorbidities, and COVID-19 outcomes, emphasizing the need for further research to elucidate their underlying mechanisms and clinical implications.

Germs doi: 10.18683/germs.2024.1436

Authors: Nguyen Bao Vy Tran Thuc Quyen Huynh Hong Loan Ngo Ngoc Hoa Binh Nguyen Thi Hiep Nguyen Thi Hang Tong Thi Truc Ly Trinh Van Dung Nguyen Le Nhat Minh Pham Prem Prakash Das Teck Kwang Lim Qingsong Lin Thi Thu Hoai Nguyen

Introduction: The emergence of colistin resistance threatens the treatment of Pseudomonas aeruginosa infections. Methods: In this study, in vitro development of colistin resistance was investigated using comparative phenotypic and proteomic analysis of P. aeruginosa ATCC 9027, its 14-day colistin sub-MIC exposed strain (Col-E1), and 10-day antibiotic-free cultured Col-E1 strain (Col-E2). Antibiotic susceptibility, morphology, virulence factors, and proteomic changes were assessed using disc-diffusion, agar-based, spectrophotometry, SEM, and iTRAQ-LC-MS/MS methods. Results: Colistin-exposed strains decreased susceptibility to colistin while remaining susceptible to other antibiotics. Col-E1 reduced the cell lengths by 17.67% and the colony size by 36.16% compared to the initial strain. The reduction remained in Col-E2. The pyocyanin production was reduced in Col-E1 (p=0.025, Tukey HSD) and increased again in Col-E2 (p=0.005, Tukey HSD). In contrast, no significant changes in elastase, protease, rhamnolipid, pyoverdine, and biofilm production were observed (p>0.05, Tukey HSD). In Col-E1, the proteome analysis showed 135 differentially expressed proteins (DEPs) of which 94 DEPs (69.23%) maintained their expression change in Col-E2. Among DEPs, 82 were involved in metabolism and protein synthesis. Some DEPs (6/135) played a role in stress response such as GrpE (fold change: 14.93) and Hmp (fold change: 12.08). In particular, membrane proteins like OprD, DdlB, and OprI showed significant colistin response with fold change of -8.47, 6.43 and 6.19, respectively. Conclusions: In summary, colistin response in P. aeruginosa seemed to affect morphology, production of pyocyanin, and proteins of metabolism, protein synthesis, stress response and membrane.

Germs doi: 10.18683/germs.2024.1437

Authors: Konstantinos Alexakis Petros Ioannou George Sourvinos Diamantis P. Kofteridis

Introduction: Central nervous system (CNS) infection due to the varicella zoster virus (VZV) can complicate the primary infection or the reactivation, leading to significant mortality and morbidity. This study aimed to describe the clinical, laboratory, and radiological characteristics of patients with confirmed VZV CNS infection in a tertiary hospital in Greece. Methods: Data about patients hospitalized from January 2018 to September 2023 with CNS infection by VZV, confirmed by a syndromic polymerase chain reaction in the cerebrospinal fluid (CSF), were retrospectively collected and evaluated. Results: In total, 14 patients were recorded. The median age was 49 years, and 35.7% were male. Headache was present in 71.4%, a rash in 57.1%, and fevers, nausea or vomiting, and disorientation in 35.7%. The CSF showed lymphocytic pleocytosis in all patients. Brain magnetic resonance imaging was performed in 53.8%. Empirical antivirals were given in 69.2%, and intravenous acyclovir was given to all patients after identification of VZV in the CSF. Only 7.1% (1 patient) required intensive care unit admission, and 7.1% (1 patient) died. Patients presenting without a rash may be slightly younger, have a slightly lower Charlson comorbidity index, be more likely to present with photophobia or phonophobia, and have lower serum CRP. Conclusions: Patients presenting with VZV CNS infection have lymphocytic pleocytosis in the CSF and usually have a favorable outcome with antiviral treatment. Those presenting without a rash may have a different overall clinical phenotype from those with a rash; however, this must be evaluated in larger studies in the future.

Germs doi: 10.18683/germs.2024.1429

Authors: Mansoor Khaledi Ahdiyeh Saghabashi Hossein Ghahramanpour

Although Pseudomonas aeruginosa (PA) hasn’t been considered as a recognized agent of diarrhea, this organism is able to cause community-acquired diarrhea accompanied by fever and sepsis, as well as antibiotic-associated diarrhea (AAD). Antibiotic resistance rates in stool isolates of PA are generally lower compared to other infection sites, but in patients with AAD, there are reports of resistance to most of the antibiotic classes in these isolates. PA, along with other opportunistic pathogens like Clostridioides difficile, can cause AAD. Therefore, it is suggested to examine stool samples of patients with predisposing factors such as intensive care unit (ICU) admission and long-time antibiotic treatment, especially with cephalosporins, for both C. difficile and PA.

Germs doi: 10.18683/germs.2024.1430

Authors: Mihaela Cristina Olariu Mihai Hristu Olariu Adela Mihaela Iancu Oana Săndulescu Anca Streinu-Cercel Ecaterina Constanţa Barbu Gülşen Özkaya Şahin Alina Maria Borcan Miruna Maria Cruceru Mădălina Simoiu on behalf of ESCMID Study Group for Viral Hepatitis (ESGVH)

Esophageal lesions are common findings in disorders of the digestive tract in patients living with HIV, the most typical symptoms being odynophagia and/or dysphagia. This article provides a narrative review of the spectrum of esophagitis in patients living with HIV, focusing on fungal, viral, bacterial and non-infectious etiologies, as well as co-infections with viral hepatitis viruses. The article provides a comprehensive approach to the strategy of diagnosis and the role of upper digestive endoscopy and histopathological examination in the evaluation of esophageal pathology in patients living with HIV.

Germs doi: 10.18683/germs.2024.1427

Authors: Konstantinos Pitsikakis Michail Skandalakis Konstantinos Fragkiadakis Stella Baliou Petros Ioannou

Introduction: Infective endocarditis (IE) is a disease that may frequently lead to significant morbidity and is associated with high mortality rates. Even though IE is classically caused by Gram-positive bacteria, Gram-negative bacteria may seldom cause IE. Antimicrobial resistance (AMR) may pose significant problems in treating IE, especially for carbapenem-resistant pathogens. This study aimed to review all cases of IE by carbapenem-resistant Gram-negative bacteria in a systematic way and present information on epidemiology, clinical findings, treatment, and outcomes. Methods: A systematic review of PubMed, Cochrane Library, and Scopus (all published studies up to 6 August 2023) for published studies providing information on epidemiology, clinical findings, treatment, and outcomes of IE by carbapenem-resistant Gram-negative bacteria was performed. Results: A total of 24 studies containing data from 26 patients were included. Among all patients, 53.9% were male, and the median age was 66 years. Among all patients, 38.5% had a history of a prosthetic valve. The most commonly affected valve was the aortic, followed by the mitral valve. Fever, sepsis, emboli, and shock were the most frequent clinical findings. The most commonly isolated pathogens were Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Aminoglycosides, colistin, cephalosporins, and carbapenems were the most commonly used antimicrobials. Surgery was performed in 53.8% of patients. Mortality was 38.5%. Conclusions: The development of infection control measures and antimicrobial stewardship interventions is needed to reduce the spread of AMR and the likelihood of this fatal infection.

Germs doi: 10.18683/germs.2024.1428

Authors: Basil Alawyia Sarah Fathima Nikolaos Spernovasilis Danny Alon-Ellenbogen

Introduction: Antimicrobial resistance (AMR) is among the greatest threats to global healthcare. The World Health Organization (WHO) estimates that by 2050 ten million deaths will be attributed to AMR annually. In response, the WHO has implemented antibiotic stewardship programs which focus on optimizing antibiotic use and raise, amongst others, the issue of the preferred method of intravenous antibiotic administration. Various studies have attempted to answer this question with conflicting results. Review: This review examined several studies assessing extended/continuous infusion compared to intermittent infusion of three beta-lactams: piperacillin-tazobactam, cefepime, and meropenem. The findings and conclusions of each study were summarized and compared to one another to provide a general overview of the current evidence. Conclusions: We conclude that continuous/extended infusion showed a greater clinical benefit in highly critical cases, namely sepsis and febrile neutropenia, compared to intermittent infusion. Additionally, in cases where a pathogen was identified, continuous/extended infusion showed superiority. Nonetheless, high-quality studies with larger samples are needed to demonstrate the difference between these two modes of infusion in a way that would better inform guidelines and policies, aiding in the fight against AMR.

Germs doi: 10.18683/germs.2024.1433

Authors: Alina Maria Borcan Mihaela Cristina Olariu Elena Liliana Costea Georgiana Radu Mădălina Simoiu

Introduction: Aggregatibacter (Actinobacillus) actinomycetemcomitans is a commensal bacterial pathogen in the human oral cavity. It can, however, represent the source of local or systemic infections with serious evolution, in particular infective endocarditis. We present a particular case of an adult male patient with infective endocarditis with A. actinomycetemcomitans and patent ductus arteriosus (PDA). Case report: A 37-year-old patient, chronic ethanol user, is hospitalized for altered general condition, persistent cough, left chest pain, headache and dizziness, symptoms evolving for about 3 weeks. The clinical examination revealed crackling pulmonary rales present basally bilaterally, as well as numerous cavities and dental abscesses. Chest radiography showed mixed left hiliobasal pneumonia. Chest CT depicted pulmonary abscess and two filling defects in the pulmonary artery trunk, possible thrombotic/vegetative images/mediastinal thrombotic/adenopathic images. Broad spectrum antibiotic treatment was initiated. Transthoracic ultrasonography visualized persistence of ductus arteriosus and an echodense formation attached to the lateral wall of the pulmonary artery trunk. Following positive blood cultures for Aggregatibacter actinomycetemcomitans, the diagnosis of infective endocarditis was established and antibiotic treatment was de-escalated to ceftriaxone according to the antibiogram. The clinical course under treatment was slowly favorable, the patient was discharged on request on day 44 with continued treatment at home. Conclusions: Infective endocarditis caused by Aggregatibacter actinomycetemcomitans should be considered in patients with altered general condition and congenital cardiovascular defects. In the present case, the patient presented two risk factors, namely poor dental hygiene and PDA.

Germs doi: 10.18683/germs.2024.1432

Authors: Gheorghiţă Jugulete Maria Mădălina Merişescu Carmen Pavelescu Monica Luminiţa Luminos

Introduction: Streptococcus pneumoniae is one of the associated bacteria that can cause the rare but high mortality hematological pathology known as purpura fulminans (PF) in both adults and children. Pediatric patients with PF can progress quickly to sepsis and multiorgan failure, especially immunocompromised individuals and young children. Due to the thrombotic blockage of blood arteries in PF, there is diffuse intravascular thrombosis and hemorrhagic infarction of the skin, which evolves from ecchymosis to skin necrosis, risk of limb sequelae, sepsis and fatality. Case report: We present a case of a previously healthy 1-year and 9-months old female who was admitted to the Intensive Care Unit of the National Institute of Infectious Diseases "Prof. Dr. Matei Balş"- Bucharest, Romania. On physical examination, she was febrile, hypotensive, tachycardic, and had erythematous patches on her left upper limb and trunk. Initial blood work was significant for creatinine 4.45 mg/dL, aspartate aminotransferase 112 U/L, alanine aminotransferase 130 U/L and fibrinogen 596 mg/dL. Hematological workup showed a white blood cells count of 34 × 109/L, hemoglobin 9.7 g/dL, platelets 23,000/L, D-dimers 89,000 μg/L, and elevated PT and aPTT. Broad-spectrum antibiotics vancomycin and ceftriaxone were administrated. A lumbar puncture was performed for cerebrospinal fluid (CSF) analysis and culture grew Streptococcus pneumoniae serotype 1A. She required peritoneal dialysis due to acute kidney injury (AKI) and surgeries for affected skin areas. After multiple organ system failures, our patient evolved rapidly to irreversible tissue necrosis and death. Conclusions: We aim to report a rare case of PF associated with pneumococcal meningoencephalitis in an immunocompetent child, to better appreciate the risk of fatal evolution when managing this disease in children.

Germs doi: 10.18683/germs.2024.1431

Authors: Prakrati Yadav Durga Shankar Meena Deepak Kumar Nikhil John Navneet Kaur Sarika Kombade Gopal Krishana Bohra Sarvesh Tiwari Vijaylaxmi Nag

Introduction: Non-tuberculous mycobacterial (NTM) disease is an underdiagnosed condition that usually manifests as pulmonary infection. Extrapulmonary manifestations are rare and can be easily overlooked or misdiagnosed as tuberculosis or malignancy. Case report: Herein, we present four cases of extrapulmonary NTM disease in immunocompetent patients. Patient 1 had bone marrow suppression secondary to NTM infection. Patient 2 was diagnosed with Mycobacterium abscessus meningitis, brain abscess and arachnoiditis. Patient 3 had pleural effusion, and fluid cytology revealed Mycobacterium fortuitum. Patient 4 was a 30-year-old male with cervical lymphadenopathy due to NTM. Two patients (case 2 and case 4) were initially diagnosed with tuberculosis but showed no response to anti-tubercular drugs. One patient (case 3) died within seven days of initiation of treatment. The rest of the patients (cases 1 and 2) showed clinical improvement with antimicrobial therapy for NTM species. Case 4 responded well to surgical excision without the need for antibiotics. Conclusions: Clinicians should be vigilant about the possibility of NTM disease. Early diagnosis is vital to prevent poor outcomes, particularly in the setting of disseminated infections.

Germs doi: 10.18683/germs.2024.1425

Authors: Robert Hohan Ovidiu Vlaicu Leontina Bănică Andreea Ioana Tudor Anca Negru Simona Paraschiv Dan Oţelea

Introduction: To better understand the factors which influence the spread of monkeypox (mpox) infection, the patients that tested positive for mpox virus by real-time PCR in one of the main infectious diseases centers in Bucharest were analyzed in this study, amounting to one third of the confirmed cases in Romania. Methods: Clinical data and laboratory tests were used to build the patient profiles. In the case of positive mpox results, next-generation sequencing of the viral genome was also performed to better comprehend the epidemiology of the infections and the evolutionary path of this virus. Results: Among 47 patients with clinical suspicion of infection, 18 cases tested positive for mpox by real-time PCR (RT-PCR). Patients were mainly men who have sex with men (MSM), often coinfected with HIV-1 (half of the cases) and presenting with other sexually transmitted infections (STIs). Phylogenetic analysis was performed on 20 samples (15 patients) and indicated that mpox cases in Romania were the result of multiple importing events followed by local spread. A few sequences from European countries (Germany, Italy, France) and USA were found to be closely related to the Romanian sequences. Intra-host evolution was observed and documented in one patient with HIV-1 infection with uncontrolled viremia, showing slightly different mutation profiles in two body compartments. Conclusions: This study showed that the mpox cases from Romania presented similar clinical, epidemiological and mutational features with those reported by other European countries.

Germs doi: 10.18683/germs.2024.1426

Authors: Jayalaxmi Wangkheimayum Tuhina Banerjee Somorita Baishya Swati Sharma Manabendra Dutta Choudhury Monjur Ahmed Laskar Amitabha Bhattacharjee

Introduction: The rise in antimicrobial resistance among bacterial pathogens is a global concern, and anti-virulence therapy may be an alternative strategy to address the issue. Multidrug resistant (MDR) hypervirulent Klebsiella pneumoniae (HvKp) is known to be associated with healthcare associated infections. These are often challenging to treat and here anti-virulence therapy may be a treatment option. The study of anti-virulence compounds against HvKp by in-silico prediction, in-vitro experiments and in-vivo assay enables to determine which anti-virulence compounds are suitable for an alternative approach MDR HvKp. Methods: Modeling of the proteins, ligand binding and molecular docking were performed targeting different hypervirulence genes viz., rmpA, rmpA2 and, iroC by in-silico analysis using different bioinformatics tool and software. Minimum inhibitory concentration (MIC) was determined for six anti-virulence compounds; curcumin, eugenol, reserpine, linoleic acid, Ɛ-anethole, and α-thujone by standard protocol. Quantitative real-time PCR was performed selecting two isolates harboring rmpA, rmpA2 and iroC genes. Galleria mellonella larva killing assay was used for in-vivo experiment. Results: In-silico analysis observed that linoleic acid could be the best fit in comparison with the other compounds. None of the anti-virulence compounds showed any inhibitory activity and upon transcriptional expression analysis of the hypervirulence genes; rmpA was marginally increased for both the isolates when linoleic acid exposure was given. Conclusions: In-vivo study revealed that linoleic acid and reserpine showed anti-virulence activity.

Germs doi: 10.18683/germs.2024.1421

Authors: Petros Ioannou Sofia Maraki Emmanuel Velivasakis Diamantis P Kofteridis

Introduction: Pseudoglutamicibacter cumminsii (formerly Arthrobacter cumminsii) is a microorganism rarely reported as a cause of infection. It is a Gram-positive, non-motile, and non-spore-forming bacterium belonging to the Micrococcaceae family. It is known for its environmental ubiquity, being frequently found in soil, water, and other ecological niches. Case report: A 39-year-old woman with a history of glucose-6-phosphate dehydrogenase deficiency and multiple surgeries at the left lower extremity for osteomyelitis at the left tibia presented with a relapse of chronic osteomyelitis of the left tibia. She underwent surgical debridement, and cultures grew Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella oxytoca, Proteus mirabilis, and Pseudoglutamicibacter cumminsii, according to identification with matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Targeted antimicrobial treatment with ciprofloxacin and amoxicillin-clavulanate for six weeks led to patient recovery. Conclusions: Accurate identification by advanced diagnostic techniques is essential for effectively managing rare pathogens. Further research and reporting of cases are needed to understand better the epidemiology, pathogenesis, optimal treatment, and improved clinical outcomes associated with P. cumminsii infections.

Germs doi: 10.18683/germs.2024.1412

Authors: Mihnea Ioan Nicolescu Alexandra Maria Bălănici

We share the world we live in with millions of microbial species, some of them having no interest in harming various parts of our body, while others discover new ways of harnessing resources from human cells and tissues, for which newer and more powerful antibiotics must be developed and prescribed to people in need.[...]

Germs doi: 10.18683/germs.2024.1420

Authors: Fatemeh Janani Pouria Azami Mohammad Ghenaatpisheh Sanani Khadijeh Bamneshin

Introduction: We aimed to conduct a systematic review of the epidemiology of Escherichia coli in bloodstream infections (BSI) of hematopoietic stem cell transplantation patients. Methods: For a comprehensive search of studies that reported the prevalence of E. coli and antibiotic resistance in bloodstream infections from 2000 to January 1, 2024, databases such as PubMed, EMBASE, Google Scholar, Scopus, and Web of Science were searched. The main keywords used were: Escherichia coli, epidemiology, bloodstream infection, microbial resistance, antibiotic resistance, hematopoietic malignancy, hematopoietic stem cell transplantation. After applying eligibility criteria, and quality assessment of studies, data analysis was done by comprehensive meta-analysis (CMA) software. Results: The prevalence of bacterial bloodstream infections amongst different studies varied between 8–51%. Also, bloodstream infections caused by E. coli varied between 2.5–57%. Prevalence of extended-spectrum β-lactamases (ESBLs) of Escherichia coli in bloodstream infections varied between 15–80%. As well, the mortality rate caused by Escherichia coli strains in bloodstream infection varied between 6.7–27.3%. Resistance to ciprofloxacin, cefepime, third- and fourth-generation cephalosporins, was reported to be the highest (prevalence of 100%), and the lowest was against amikacin, with a prevalence between 13-38%. Conclusions: The high prevalence of Escherichia coli-related BSI, and subsequent mortality, especially by multidrug resistance and ESBL strains, in patients undergoing hematopoietic stem cell transplantation, requires essential measures to prevent the spread of microbial resistance.

Germs doi: 10.18683/germs.2024.1419

Authors: Gabriel-Petre Gorecki Dana-Rodica Tomescu Liana Pleș Anca-Maria Panaitescu Șerban Dragosloveanu Cristian Scheau Romina-Marina Sima Ionuț-Simion Coman Valentin-Titus Grigorean Daniel Cochior

Introduction: Sepsis and septic shock represent severe pathological states, characterized by the systemic response to infection, which can lead to organ dysfunction and high mortality. Early diagnosis and rapid intervention are crucial for improving survival chances. However, the diagnosis of sepsis is complex due to its nonspecific symptoms and the variability of patient responses to infections. Methods: The objective of this research was to analyze the implications of using artificial intelligence (AI) in the diagnosis of sepsis and septic shock. The research method applied in the analysis of the implications of using artificial intelligence (AI) in the diagnosis of sepsis and septic shock is the literature review. Results: Among the benefits of using AI in the diagnosis of sepsis, it is noted that artificial intelligence can rapidly analyze large volumes of clinical data to identify early signs of sepsis, sometimes even before symptoms become evident to medical staff. AI models can use predictive algorithms to assess the risk of sepsis in patients, allowing for early interventions that can save lives. AI can contribute to the development of personalized treatment plans, adapting to the specific needs of each patient based on their medical history and response to treatment. The use of patient data to train AI models raises concerns regarding data privacy and security. Conclusions: Artificial intelligence has the potential to revolutionize the diagnosis and treatment of sepsis, offering powerful tools for early identification and management of this critical condition. However, to realize this potential, close collaboration between researchers, clinicians, and technology developers is necessary, as well as addressing ethical and implementation challenges.

Germs doi: 10.18683/germs.2024.1418

Authors: Maria Alexandra Junghetu Elena Bălăşescu Laurenţiu Mihăiţă Stratan Daniela Adriana Ion

Introduction: SARS-CoV-2 represents one of the most extensively researched pathogens in the last decade due to its major impact on humanity. Not only does this viral infection cause respiratory disturbances, but it also generates cardiovascular injury. Cardiac arrhythmias represent one of the main consequences of SARS-CoV-2 infection, but they can also occur in the context of antiviral treatment. Furthermore, arrhythmias do not always seem to be correlated with the severity of the lung injury. However, they represent a poor prognostic factor in terms of mortality, increasing the need for intensive care and the length of hospitalization. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Statement, from September 2022 to October 2023, we conducted this study by examining the literature through the PubMed database using the following keywords: COVID-19, cardiac arrhythmias, and, in terms of study design, observational studies. Results: We initially identified 266 studies across PubMed. After applying the inclusion/exclusion criteria, we managed to include 22 studies in our review. Conclusions: Deducing the pathophysiological mechanisms behind SARS-CoV-2's ability to disrupt the electrical activity of the heart, as well as identifying associated risk factors in patients with SARS-CoV-2 infection, could allow targeted therapeutic interventions to decrease the risk of mortality in hospitalized patients.

Germs doi: 10.18683/germs.2024.1417

Authors: Hamid Sadeghi Saeideh Gholamzadeh Khoei Sara Shahsavari Masoumeh Aslanimehr Farhad Nikkhahi Abouzar Babaei Nematollah Gheibi Behzad Bizhani

Introduction: Crimean-Congo hemorrhagic fever (CCHF) is the widest emerging severe viral tick-borne disease affecting humans. Crimean-Congo haemorrhagic fever virus (CCHFV) circulates by routine enzootic tick-vertebrate hosts-tick transmission cycles. We aimed to evaluate the molecular prevalence of CCHFV in ticks on a global scale. Methods: A systematic procedure was used to perform this review and meta-analysis using PubMed, Google Scholar, and Web of Science databases from 1 January 2000 through 12 April 2023. Of the 2310 papers identified, 43 articles met the inclusion criteria for this study. Results: The overall prevalence of CCHFV was 4.0% (95%CI: 2.7–6.0%) in ticks on the global scale, with heterogeneity (I2 = 96.387; p = 0.0001). The genus Hyalomma was shown as the most frequent tick infected with CCHFV 5.4% (95%CI: 3.3–8.7%). We found that the pooled prevalence of CCHFV was higher in Hyalomma aegyptium 27.6% (95%CI: 22.7–33.2%). The pooled prevalence was higher in Asia 5.1% (95%CI: 3.3–7.7%), and Spain 21.0% (95%CI: 3.4–66.9). The locations with annual rainfall of 401-1000 mm 6.1% (95%CI: 2.6–13.5%) and latitude of 31-40° 6.0% (95%CI: 4.1–8.9%) were associated with the greatest pooled prevalence of CCHFV in ticks. Conclusions: Surveillance of CCHFV in ticks will give a better comprehension for the future implementation of public health interventions. The question of whether Hyalomma aegyptium is a plausible or certain vector should be the subject of further investigation.

Germs doi: 10.18683/germs.2024.1416

Authors: Vlad Ștefan Pleșca Adrian Gabriel Marinescu Cătălina Voiosu Anca Cristina Drăgănescu Anca Streinu-Cercel Alexandra Vilaia Răzvan Hainăroșie Doina Anca Pleșca Oana Săndulescu

Introduction: Acute otitis and sinusitis are common complications in patients with influenza and are responsible for increased hospitalization rates. Methods: A five-year retrospective study (2018–2023) was conducted including all patients hospitalized for influenza (etiologic diagnosis by RT-PCR) to identify the incidence and characteristics of cases complicated with otitis and/or sinusitis. Cases associated with other viral co-infections were excluded from the analysis. Results: We identified a cumulative rate of 20.6% (324 cases) of acute otitis (AO) and acute sinusitis (AS) among patients with influenza. Of these, 62.3% had AO, 28.1% AS, and 9.6% concomitant AO and AS. Cases of AO were predominant in the pediatric population (97.0%), while cases of AS were more common in adults (56.1%). Influenza A viruses were identified in 67.2% of patients. The infection with influenza B viruses increased the risk of acute congestive otitis media 2.1-fold (p = 0.020), and influenza A viruses increased the risk of acute maxillary sinusitis 2.7-fold (p = 0.029). Late presentation to the hospital, with a median of 4 days from the onset of influenza symptoms, was identified as a factor in the occurrence of AO and AS. Conclusions: The risk of AO and AS is increased in patients with influenza, especially in the pediatric population and in late hospital presentations. These findings highlight the importance of proper monitoring and management of patients with influenza to prevent the development of complications, as well as the need to better understand the mechanisms whereby influenza viruses contribute to these secondary conditions.

Germs doi: 10.18683/germs.2024.1415

Authors: Laura Iosif Ana Maria Cristina Țâncu Oana Elena Amza Bogdan Dimitriu Ana Ispas Mihaela Pantea Marina Imre

Introduction: Assessment of the denture plaque can provide a valuable report regarding the oral health of geriatric patients and the oral hygiene habits in this population group. Focusing on the current research gap on this topic in Romania, our research aims to highlight the microbial plaque on the different surfaces and types of removable poly(methyl methacrylate) (PMMA) prostheses to qualitatively evaluate the microbial species, and to assess the combined effect of mechanical and chemical cleaning of dentures on the prosthetic microbiome. Methods: The prosthetic plaque from four denture wearers was identified with a UV activated fluorescent revealer and digitally photographed. Swab samples according to a certain hygiene protocol were cultured on three different growth media such as blood agar (BA), bromothymol blue lactose agar (AABTL) and Sabouraud dextrose agar (SDA). Results: Denture plaque was variably distributed on the surface of the prostheses. Regardless of the denture type (conventional complete denture, tooth or implant supported overdenture, removable partial denture) the microbial plaque was identified at the retentive areas, especially at interdental spaces. The main plaque deposition areas were the vestibular incline of the labial flange of the maxillary denture and the lingual incline of the posterior lingual flange of the mandibular denture. The prosthetic microbiome consisted of pathogenic Gram-positive aerobes (Streptococcus spp. and coagulase-negative Staphylococcus spp.), Gram-positive anaerobes (Actinomyces spp. and Klebsiella spp.) as well as subspecies of fungi of the genus Candida. Conclusions: Despite its poor variety, the denture microbiome in the investigated cases hosts colonies with high pathogenic potential. Some areas of the prostheses are more likely to accumulate dental plaque. Dentists should insist through more regular checks of the patients and their caregivers on ensuring the biocontrol of the dentures, especially in frail geriatric patients exposed to greater risks related to general health.

Germs doi: 10.18683/germs.2024.1414

Authors: Amit K Rai Ragini Tilak Punit Tiwari Pooja Meena Ashok Kumar Atul K Tiwari Munesh K Gupta

Introduction: Neonatal candidemia is a life-threatening event in babies requiring ICU admission. Prompt diagnosis and appropriate treatment reduce mortality and morbidity. Worldwide, there is an emergence of drug-resistant rare Candida species causing neonatal sepsis that necessitates antifungal susceptibility testing in each case. Methods: We did a prospective study to isolate Candida species causing neonatal sepsis and to determine the predisposing risk factors and time to positivity for flagged positivity. We also determined fluconazole, itraconazole and amphotericin B minimum inhibitory concentration (MIC) against isolated Candida species by broth microdilution method using CLSI M27-A3 guidelines. Results: A total of 107 neonatal candidemia events were noted. Prematurity was the most common predisposing risk factor. Most isolates were non-albicans Candida. Candida utilis, C. pelliculosa, C. tropicalis and K. ohmeri were the predominant fungi causing neonatal candidemia. A varied antifungal MIC against isolated Candida species was noted. However, 90% of the isolated Candida strains had <8 µg/mL fluconazole MIC. Moreover, ≥8 and ≥2 µg/mL MIC for fluconazole and amphotericin B respectively were also noted. Conclusions: Rare Candida species having varied fluconazole and amphotericin B MIC cause neonatal candidemia. Therefore, culture isolation and antifungal susceptibility testing should be done in each case of neonatal candidemia.

Germs doi: 10.18683/germs.2024.1413

Authors: Amira M. Sultan Noha Mostafa Mahmoud

Introduction: Integrons are genetic systems that may confer antibiotic resistance to Pseudomonas aeruginosa. Biofilm formation can facilitate gene exchange and can accelerate the development of antibiotic resistance. The aim of this work was to assess the distribution of resistance integrons including class 1, 2 and 3 among biofilm- and non-biofilm producing clinical strains of P. aeruginosa. We also aimed to investigate the relationship between the existence of these integrons and the isolates’ resistance patterns. Methods: Specimens were obtained from patients showing evidence of infection. P. aeruginosa isolates were identified using conventional techniques, while disk diffusion test was used to detect their antimicrobial susceptibilities. Biofilm formation was detected by the tissue culture plate technique, while classes of integrons were detected by polymerase chain reaction. Results: Out of 106 P. aeruginosa isolates, 55.7% were class 1 integron-positive while 19.8% were class 2 integron-positive. However, class 3 integrons were not detected. Significant associations were found between class 1 integrons and resistance toward amikacin, gentamicin, cefepime, ceftazidime and ciprofloxacin. Class 2 integrons were associated with amikacin, ceftazidime and cefepime resistance. Of pseudomonal isolates, 61.3% were biofilm producing. Biofilm production was associated significantly with the existence of class 1 integrons (p < 0.001) and class 2 integrons (p = 0.039). Conclusions: About two thirds of isolated strains harbored resistance integrons, which emphasized their significance in our locality. The frequencies of class 1 and 2 integrons were significantly higher among biofilm forming isolates. Ongoing surveillance and infection control strategies are necessary to limit spread of integrons.

Germs doi: 10.18683/germs.2024.1423

Authors: Santiago Gómez-Jordan Samuel Jarava Yuliana Ascencio-Guzmán Diego Viasus

Introduction: Urogenital tuberculosis (UGTB) is a frequent presentation of extrapulmonary tuberculosis. Recognizing this condition is paramount for healthcare providers, especially in patients living with human immunodeficiency virus (HIV), as it significantly influences both mortality and quality of life. Case report: This report presents the case of a 57-year-old male patient diagnosed with de novo HIV infection who presented with respiratory and urinary symptoms, and prostate abscess in a computed tomography. He was ultimately diagnosed with a tuberculous prostate abscess through real-time polymerase chain reaction. Conclusions: This case underscores the importance of utilizing molecular diagnostic tools in identifying UGTB, shedding light on their invaluable role in timely diagnosis.

Germs doi: 10.18683/germs.2024.1422

Authors: Jayaweera Arachchige Asela Sampath Jayaweera Gerard Ranasinghe

Introduction: Actinotignum schaalii is a Gram-positive coccobacillus, and a member of the normal human microbiota. A. schaalii is considered as an emerging pathogen causing urinary tract infections among the elderly. Because of an anaerobic growth requirement and lack of knowledge on pathogenic potential following conventional microbiology laboratory techniques, A. schaalii is difficult to identify. Case report: A previously well 24-year-old male presented to a tertiary care unit with fever, left flank pain, and dysuria for two days. He was initially treated with empiric oral ciprofloxacin by the general practitioner. Following admission, blood cultures and urine cultures were done, and empirical intra-venous piperacillin-tazobactam was started. X-ray of the pelvis revealed left-sided pyelonephritis and left ureteric calculi. A nephrostomy tube was inserted to relieve the obstruction which drained pus and was sent to microbiology laboratory in aerobic and anaerobic blood culture bottles. Two days later blood culture flagged positive for Gram-positive bacilli from the anaerobic bottle, and the pus from enriched anaerobic culture grew A. schaalii. The urine culture remained negative. By VITEK 2 anaerobic card and MALDI-TOF analysis, it was identified as A. schaalii. Following clinical improvement, he was discharged with oral doxycycline. Ureteric calculus was removed and remained sterile following 16s DNA analysis. Conclusions: The urine Gram staining may have a role in detecting and considering anaerobic media to isolate A. schaalii. The novel diagnostic platforms are important to speciate the pathogen. Also, the lack of pathogen-specific breakpoints for antimicrobial susceptibilities made it a problem to decide on appropriate therapy.

Germs doi: 10.18683/germs.2023.1405

Authors: Mihai Săndulescu Valentin Daniel Sîrbu Ion Alexandru Popovici

Peri-implantitis is a pathological condition in dental medicine that manifests as an inflammatory process affecting the tissues surrounding dental implants. Peri-implantitis occurs when the soft and hard tissues surrounding these implants become inflamed, leading to progressive destruction of the supporting bone. The etiology of peri-implantitis is multifactorial, involving microbial, host-related, and environmental factors. Microbial involvement in peri-implantitis can be explained either by direct in-situ virulence activation leading to pathogenicity, or by induction of low-grade chronic immune activation, leading to long-term persistence of a pro-inflammatory status. Understanding peri-implantitis is pivotal in maintaining the long-term success of dental implants and improving patient outcomes in implant-supported restorations. Recognizing the etiological factors, including particular bacterial species, genetic predispositions, and environmental influences, is very important for devising effective preventive strategies and targeted interventions.

Germs doi: 10.18683/germs.2023.1411

Authors: Lusiana Lis Surachmiati Siti Rizny Fitriana Saldi Trah Lusianingtyas Kusmarinah Bramono

Erratum on: Lusiana, Surachmiati L, Saldi SRF, Lusianingtyas T, Bramono K. [...]

Germs doi: 10.18683/germs.2023.1410

Authors: Giorgio Novelli Mattia Moretti Maria Costanza Meazzini Davide Paolo Bernasconi Sergio Maria Ivano Malandrin Monica Raggi Cristina Maria Angela Cassé Luca Arturo Pavesi Davide Sozzi

COVID-19 (coronavirus disease-2019), caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) [...]

Germs doi: 10.18683/germs.2023.1409

Authors: Aris P. Agouridis Spyridon A. Karageorgos Constantinos Tsioutis

We thank Dr. Mungmunpuntipantip and Dr. Wiwanitkit for their comment on our article [...]

Germs doi: 10.18683/germs.2023.1408

Authors: Ricardo Campos Monteiro Rogerio Caldeira Rodrigues Malta Geovana Lacerda Rodrigues Gustavo Luis de Paiva Anciens Ramos Janaína dos Santos Nascimento

Acinetobacter baumannii causes a series of infections in healthcare settings and the community, the main ones highlighted in Figure 1 [...]

Germs doi: 10.18683/germs.2023.1407

Authors: Alexandru Gliga Mihai Săndulescu Oana Amza Ruxandra Stănescu Marina Imre

Dental pathologies of endodontic origin are varied in nature, and include infectious and non-infectious causes. Through this review, we aim to provide a deeper understanding of the role of bacterial involvement and in the pathogenesis of endodontic pathologies, by reviewing the relevant literature on the most common bacterial species involved, and their capacity to organize as biofilms. Furthermore, we focus on the most important recent updates in the management of endodontic infections, from a multidisciplinary perspective.