Interdisciplinary Perspectives on Infectious Diseases The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Thailand Momentum on Policy and Practice in Local Legislation on Dengue Vector Control Tue, 01 Apr 2014 07:50:33 +0000 Over a past decade, an administrative decentralization model, adopted for local administration development in Thailand, is replacing the prior centralized (top-down) command system. The change offers challenges to local governmental agencies and other public health agencies at all the ministerial, regional, and provincial levels. A public health regulatory and legislative framework for dengue vector control by local governmental agencies is a national topic of interest because dengue control program has been integrated into healthcare services at the provincial level and also has been given priority in health plans of local governmental agencies. The enabling environments of local administrations are unique, so this critical review focuses on the authority of local governmental agencies responsible for disease prevention and control and on the functioning of local legislation with respect to dengue vector control and practices. Adisak Bhumiratana, Apiradee Intarapuk, Suriyo Chujun, Wuthichai Kaewwaen, Prapa Sorosjinda-Nunthawarasilp, and Surachart Koyadun Copyright © 2014 Adisak Bhumiratana et al. All rights reserved. Frequencies of Blood Group Systems MNS, Diego, and Duffy and Clinical Phases of Carrion’s Disease in Amazonas, Peru Mon, 31 Mar 2014 09:24:33 +0000 Carrion’s disease (CD), is a human bartonellosis, that is, endemic in the Andes of Peru, Ecuador, and Colombia. Bartonella bacilliformis, a native hemotrophic bacteria, is the causative agent of CD, and the interaction with the host could have produced changes in the gene frequencies of erythrocyte antigens. The goal here is to investigate the relationship between allele frequencies of blood group systems MNS, Diego, and Duffy and the clinical phases of CD, within a genetic context. In this associative and analytical study, 76 individuals from Bagua Grande, the province of Utcubamba, and the department of Amazonas in Peru, were enrolled. Forty of them resided in Tomocho-Collicate-Vista Hermosa area (high prevalence of cases in chronic phase, verrucous, or eruptive phase, without previous acute phase). Thirty-six individuals were from the area of Miraflores (high prevalence of cases in acute phase only) and were evaluated for blood group systems MNS, Diego, and Duffy. This study constitutes one of the first attempts at evaluating the genetic factors and clinical phases of CD. No significant statistical differences between allele frequencies of blood groups MNS, Diego, and Duffy and the prevalence of chronic and acute phases were detected in the two areas of Amazonas, Peru. Oscar Acosta, Luis Solano, Jorge Escobar, Miguel Fernandez, Carlos Solano, and Ricardo Fujita Copyright © 2014 Oscar Acosta et al. All rights reserved. A Multicenter Study of Beta-Lactamase Resistant Escherichia coli and Klebsiella pneumoniae Reveals High Level Chromosome Mediated Extended Spectrum β Lactamase Resistance in Ogun State, Nigeria Mon, 24 Mar 2014 12:02:15 +0000 As a result of the ever increasing problem of multiresistant bacteria, we instituted a surveillance program with the aim of identifying the basic molecular properties of ESBL in our environment. About 197 isolates of Escherichia coli and Klebsiella pneumoniae were selected and tested for ESBL production and antimicrobial susceptibility. Plasmid profiles were determined and curing ability was tested. ESBL prevalence was 26.4% for all isolates tested, with E. coli having a greater proportion. There was absolute resistance to ampicilin, tetracycline, and co-trimaxole among tested isolates. There was above average susceptibility to the 2nd and 3rd generation cephalosporins. Plasmid profiles of tested isolates ranged from 9 kbp to 26 kbp with average of  kbp for E. coli and  kbp K. pneumoniae, 9.6% of ESBL positive E. coli plasmids were cured, while 3.9% of K. pneumoniae plasmids were cured after treatment. The present study shows an upsurge in ESBL acquisition by gram negative bacteria and evidence of cocirculation of varying subtypes of ESBL with both plasmid transmissible and chromosome encoded subtypes. This calls for universal surveillance and more effort towards molecular epidemiology of this public health treatment. Folasoge A. Adeyankinnu, Babatunde O. Motayo, Akinniyi Akinduti, John Akinbo, Joseph I. Ogiogwa, Bukola W. Aboderin, and R. A. Agunlejika Copyright © 2014 Folasoge A. Adeyankinnu et al. All rights reserved. A Comparative Systematic Review of the Optimal CD4 Cell Count Threshold for HIV Treatment Initiation Thu, 20 Mar 2014 08:48:34 +0000 HIV infection is no longer characterized by high morbidity, rapid progression to AIDS, and death as when the infection was first identified. While anti-retroviral drugs have improved the outcome of AIDS patients, clinical research on the appropriate time to initiate therapy continues to evolve. Optimal therapy initiation would maximize the benefits of these drugs, while minimizing side effects and drug resistance. Recent 2013 WHO guidelines changed HIV therapy initiation from 350 cells/μL to 500 cells/μL. This systematic review provides an evidence-based comparison of starting treatment at >500 cells/μL with starting treatment at the range between 350 cells/μL and 500 cells/μL. An 11% increase in risk was detected from initiation therapy at the 350–500 cells/μL range (0.37 [0.26, 0.53]), when compared with starting treatment before 500 cells/μL (0.33 [0.22, 0.48]). Most individual study comparisons showed a benefit for starting treatment at 500 cells/μL in comparison with starting at the 350–500 cells/μL range with risks ranging from 19% to 300%, though a number of comparisons were not statistically significant. Overall, the study provides evidence based support for initiating anti retroviral therapy at cell counts >500 cells/μL wherever possible to prevent AIDS mortality and morbidity. Babatunde Olubajo, Kathryn Mitchell-Fearon, and Oluseye Ogunmoroti Copyright © 2014 Babatunde Olubajo et al. All rights reserved. Identification of Sphingomyelinase on the Surface of Chlamydia pneumoniae: Possible Role in the Entry into Its Host Cells Thu, 13 Mar 2014 12:28:23 +0000 We have recently suggested a novel mechanism, autoendocytosis, for the entry of certain microbes into their hosts, with a key role played by the sphingomyelinase-catalyzed topical conversion of sphingomyelin to ceramide, the differences in the biophysical properties of these two lipids providing the driving force. The only requirement for such microbes to utilize this mechanism is that they should have a catalytically active SMase on their outer surface while the target cells should expose sphingomyelin in the external leaflet of their plasma membrane. In pursuit of possible microbial candidates, which could utilize this putative mechanism, we conducted a sequence similarity search for SMase. Because of the intriguing cellular and biochemical characteristics of the poorly understood entry of Chlamydia into its host cells these microbes were of particular interest. SMase activity was measured in vitro from isolated C. pneumoniae elementary bodies (EB) and in the lysate from E. coli cells transfected with a plasmid expressing CPn0300 protein having sequence similarity to SMase. Finally, pretreatment of host cells with exogenous SMase resulting in loss plasma membrane sphingomyelin attenuated attachment of EB. Tuula A. Peñate Medina, Juha T. Korhonen, Riitta Lahesmaa, Mirja Puolakkainen, Oula Peñate Medina, and Paavo K. J. Kinnunen Copyright © 2014 Tuula A. Peñate Medina et al. All rights reserved. Serine Proteases of Malaria Parasite Plasmodium falciparum: Potential as Antimalarial Drug Targets Tue, 11 Mar 2014 11:36:44 +0000 Malaria is a major global parasitic disease and a cause of enormous mortality and morbidity. Widespread drug resistance against currently available antimalarials warrants the identification of novel drug targets and development of new drugs. Malarial proteases are a group of molecules that serve as potential drug targets because of their essentiality for parasite life cycle stages and feasibility of designing specific inhibitors against them. Proteases belonging to various mechanistic classes are found in P. falciparum, of which serine proteases are of particular interest due to their involvement in parasite-specific processes of egress and invasion. In P. falciparum, a number of serine proteases belonging to chymotrypsin, subtilisin, and rhomboid clans are found. This review focuses on the potential of P. falciparum serine proteases as antimalarial drug targets. Asrar Alam Copyright © 2014 Asrar Alam. All rights reserved. Multilocus Sequence Typing for Interpreting Blood Isolates of Staphylococcus epidermidis Sun, 02 Mar 2014 11:14:53 +0000 Staphylococcus epidermidis is an important cause of nosocomial infection and bacteremia. It is also a common contaminant of blood cultures and, as a result, there is frequently uncertainty as to its diagnostic significance when recovered in the clinical laboratory. One molecular strategy that might be of value in clarifying the interpretation of S. epidermidis identified in blood culture is multilocus sequence typing. Here, we examined 100 isolates of this species (50 blood isolates representing true bacteremia, 25 likely contaminant isolates, and 25 skin isolates) and the ability of sequence typing to differentiate them. Three machine learning algorithms (classification regression tree, support vector machine, and nearest neighbor) were employed. Genetic variability was substantial between isolates, with 44 sequence types found in 100 isolates. Sequence types 2 and 5 were most commonly identified. However, among the classification algorithms we employed, none were effective, with CART and SVM both yielding only 73% diagnostic accuracy and nearest neighbor analysis yielding only 53% accuracy. Our data mirror previous studies examining the presence or absence of pathogenic genes in that the overlap between truly significant organisms and contaminants appears to prevent the use of MLST in the clarification of blood cultures recovering S. epidermidis. Prannda Sharma, Ashley E. Satorius, Marika R. Raff, Adriana Rivera, Duane W. Newton, and John G. Younger Copyright © 2014 Prannda Sharma et al. All rights reserved. Steroids Decrease Prevalence of Positive Tuberculin Skin Test in Rheumatoid Arthritis: Implications on Anti-TNF Therapies Mon, 24 Feb 2014 11:38:03 +0000 Tuberculin skin test has been used as an indicator of latent tuberculosis in patients with Rheumatoid Arthritis (RA) before administration of biologicals. Effect of Disease modifying antirheumatic drugs (DMARDs) and steroids on the result of tuberculin skin test (TST) may have important implications in interpretation of results of this test. Objectives. To find the prevalence of positive TST in rheumatoid patients and the effect of standard treatment on the results of TST. Method. In this cross-sectional study two hundred and fifty patients of RA above 18 years of age, classified using 1987 ACR criteria for RA, were enrolled from rheumatology outdoor. Demographics, disease activity, disease duration, and therapy were recorded. All patients underwent TST. Results. Fifty-one (20.4%) patients were found to be tuberculin positive. Tuberculin positivity was not affected by MTX intake but it was significantly low in patients with recent steroid intake as compared to patients who had not taken steroids in last 3 months (3% versus 25%, P = 0.002). Conclusion. Prevalence of tuberculin positivity in patients with RA was found to be low. Results were not affected by methotrexate; however tuberculin skin test results in patients with recent use of steroids are likely to be negative. Shweta Agarwal, Siddharth Kumar Das, Girdhar G. Agarwal, and Ragini Srivastava Copyright © 2014 Shweta Agarwal et al. All rights reserved. Level of CD8 T Lymphocytes Activation in HIV-Infected Pregnant Women: In the Context of CD38 and HLA-DR Activation Markers Wed, 22 Jan 2014 10:06:08 +0000 Background. To date the effect of pregnancy on the immune activation of CD8 T cells that may affect HIV disease progression has not been well studied and remains unclear. Objective. To determine the effect of pregnancy on CD8 T lymphocyte activation and its relationship with CD4 count in HIV infected pregnant women. Study Design. Case control. Study Site. AMPATH and MTRH in Eldoret, Kenya. Study Subjects. Newly diagnosed asymptomatic HIV positive pregnant and nonpregnant women with no prior receipt of antiretroviral medications. Study Methods. Blood samples were collected from the study participants and levels of activated CD8 T lymphocytes (CD38 and HLA-DR) were determined using flow cytometer and correlated with CD4 counts of the study participants. The descriptive data focusing on frequencies, correlation, and cross-tabulations was statistically determined. Significance of the results was set at . Results. HIV positive pregnant women had lower activated CD8 T lymphocyte counts than nonpregnant HIV positive women. Activated CD8 T lymphocyte counts were also noted to decrease in the second and third trimesters of pregnancy. Conclusion. Pregnancy has a significant suppression on CD8+ T lymphocyte immune activation during HIV infections. Follow-up studies with more control arms could confirm the present study results. Stanslaus Musyoki, Simeon Mining, and Paul Nyongesa Copyright © 2014 Stanslaus Musyoki et al. All rights reserved. Control of a Clonal Outbreak of Multidrug-Resistant Acinetobacter baumannii in a Hospital of the Basque Country after the Introduction of Environmental Cleaning Led by the Systematic Sampling from Environmental Objects Mon, 30 Dec 2013 15:18:19 +0000 Background. Between July 2009 and September 2010, an outbreak of multidrug-resistant (MDR) Acinetobacter baumannii was detected in one critical care unit of a tertiary hospital in the Basque Country, involving 49 infected and 16 colonized patients. The aim was to evaluate the impact of environmental cleaning and systematic sampling from environmental objects on the risk of infection by MDR A. baumannii. Methods. After systematic sampling from environmental objects and molecular typing of all new MDR A. baumannii strains from patients and environmental isolates, we analyzed the correlation (Pearson’s r) between new infected cases and positive environmental samples. The risk ratio (RR) of infection was estimated with Poisson regression. Results. The risk increased significantly with the number of positive samples in common areas (RR = 1.40; 95%CI = 0.99–1.94) and positive samples in boxes (RR = 1.19; 95%CI = 1.01–1.40). The number of cases also positively correlated with positive samples in boxes (; ) and common areas (; ). Conclusion. Once conventional measures have failed, environmental cleaning, guided by systematic sampling from environmental objects, provided the objective risk reduction of new cases and enabled the full control of the outbreak. Jesús Delgado Naranjo, José Ignacio Villate Navarro, Mercedes Sota Busselo, Alberto Martínez Ruíz, José María Hernández Hernández, María Pilar Torres Garmendia, and María Isabel Urcelay López Copyright © 2013 Jesús Delgado Naranjo et al. All rights reserved. Utility of Serum Neopterin and Serum IL-2 Receptor Levels to Predict Absolute CD4 T Lymphocyte Count in HIV Infected Cases Thu, 05 Dec 2013 14:49:53 +0000 A prospective study was carried out to evaluate the efficacy of serum neopterin and soluble IL-2 receptor (sIL-2R) concentrations in comparison to CD4 count to study the progression of HIV disease and monitor response to ART in HIV cases. One hundred newly diagnosed HIV seropositive subjects were recruited. CD4 counts were determined by FACS system. Serum neopterin and sIL-2R levels were measured using enzyme immunoassay. In our study, levels of neopterin and sIL-2R were significantly higher in subjects with CD4 200 cells/μL (with S. neopterin levels of 25.1 nmol/L and sIL-2R levels of 47.1 pM as cutoff values for CD4 200 cells/μL) compared to those in subjects with CD4 200 cells/μL at baseline which indicate that these markers can be utilized for initiation of ART in HIV cases. The levels of these markers decreased significantly after initiation of ART. In patients with CD4 200 cells/μL, these markers are helpful in predicting disease progression. Sanjim Chadha, Preena Bhalla, Hitender Gautam, Anita Chakravarti, Sanjeev Saini, S. Anuradha, and Richa Dewan Copyright © 2013 Sanjim Chadha et al. All rights reserved. The Importance of IgG Avidity and the Polymerase Chain Reaction in Treating Toxoplasmosis during Pregnancy: Current Knowledge Thu, 26 Sep 2013 13:52:13 +0000 A brief report on the nature and epidemiology of T. gondii infection is firstly presented. The importance of the specific IgG avidity test and polymerase chain reaction (PCR) for toxoplasmosis is discussed, along with their significance and importance as auxiliary methods for determining the most likely time for the initial infection by this coccidian and for defining the therapeutic strategy. Lastly, practical comments are made in relation to the classical therapeutic regimens, with special attention to the indications for fetal treatment, when this is necessary. João Bortoletti Filho, Edward Araujo Júnior, Natália da Silva Carvalho, Talita Micheletti Helfer, Priscila de Oliveira Nogueira Serni, Luciano Marcondes Machado Nardozza, and Antonio Fernandes Moron Copyright © 2013 João Bortoletti Filho et al. All rights reserved. Prospective Trial of a Novel Nomogram to Achieve Updated Vancomycin Trough Concentrations Thu, 12 Sep 2013 15:06:37 +0000 Purpose. To determine if the use of a novel vancomycin nomogram predicts dosing regimens that achieve target trough concentrations equal to or more accurate than dosing regimens calculated using traditional pharmacokinetic calculations, evaluate the incidence of subtherapeutic and supratherapeutic troughs, and assess pharmacist's impressions of the nomogram. Methods. Prospective, open-label study in 473 patients who had a new order for vancomycin and were >18 years of age and ≤120 kg. Patients were randomized to the active group, dosed using the nomogram, or to the control group, dosed using traditional pharmacokinetic calculations already in place at our institution. Results. Patients dosed via nomogram were within the appropriate trough range in 44% of cases compared to 33% in the control group (). Vancomycin troughs less than 10 mcg/mL were significantly decreased with the use of nomogram (). Incidence of supratherapeutic troughs, greater than 20 mcg/mL, was not significantly different between groups (), and pharmacists agreed that the nomogram was easy to use and saved their time. Conclusions. A novel vancomycin nomogram was prospectively validated and found to be more effective than traditional pharmacokinetic dosing. The nomogram is being implemented as the standard dosing protocol at our institution. Amber R. Wesner, Marcia L. Brackbill, Larissa L. Coyle, and Robert S. Kidd Copyright © 2013 Amber R. Wesner et al. All rights reserved. Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit Wed, 28 Aug 2013 15:11:51 +0000 Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/μL (mean 205.7, range 2.0–694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20–367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU. Jose Orsini, Noeen Ahmad, Ashvin Butala, Rosemarie Flores, Truc Tran, Alfonso Llosa, and Edward Fishkin Copyright © 2013 Jose Orsini et al. All rights reserved. Antimicrobial Property of Extracts of Indian Lichen against Human Pathogenic Bacteria Sun, 25 Aug 2013 09:16:07 +0000 Context. Usnea ghattensis G. Awasthi (Usneaceae) endemic fruticose lichen found growing luxuriantly in Northern Western Ghats of India, it also contains Usnic acid as a major chemical and tested against some human pathogenic bacteria. Objective. To explore antimicrobial properties of Usnea ghattensis against some human pathogenic bacteria. Materials and Methods. The lichen was extracted in acetone, methanol, and ethanol. In vitro antimicrobial activity was tested initially by Kirby-Bauer technique of disc diffusion method and was confirmed by minimum inhibitory concentration using Broth microdilution method according to the NCCLS guidelines. Results. Ethanol extract was most effective against Bacillus cereus and Pseudomonas aeruginosa with a zone of inhibition 29.8 ± 0.6 mm and 12.3 ± 0.5 mm diameters at a concentration of 0.2 mg/mL. Acetone and methanol extract demonstrated almost similar activity against Staphylococcus aureus and the zone of inhibition was 24.6 ± 0.5 and 24.7 ± 0.4 mm. Only methanol extract was showing activity against Streptococcus faecalis with a 13.5 ± 0.8 mm zone. MIC value noted against Staphylococcus aureus and Streptococcus faecalis was 6.25 μg/mL and 25 μg/mL, whereas against Bacillus cereus and Pseudomonas aeruginosa, MIC calculated was 3.125 μg/mL and 200 μg/mL, respectively. Conclusion. The present study demonstrates the relatively higher activity of this lichen against not only gram (+) but significantly also against gram (−) bacteria. This indicates that this lichen might be a rich source of effective antimicrobial agents. Priya Srivastava, D. K. Upreti, T. N. Dhole, Apurva K. Srivastava, and Meghanand T. Nayak Copyright © 2013 Priya Srivastava et al. All rights reserved. Risk Factors Associated with Vancomycin-Resistant Enterococcus in Intensive Care Unit Settings in Saudi Arabia Tue, 20 Aug 2013 11:15:43 +0000 Background. Vancomycin-resistant enterococci (VRE) are significant nosocomial pathogens worldwide. There is one report about the epidemiology of VRE in Saudi Arabia. Objective. To determine the risk factors associated with VRE infection or colonization in intensive care unit (ICU) settings. Design. This is a descriptive, epidemiologic hospital-based case-control study of patients with VRE from February 2006 to March 2010 in ICU in a tertiary hospital in Saudi Arabia. Methods. Data were collected from hospital records of patients with VRE. The main outcome measure was the adjusted odds ratio estimates of potential risk factors for VRE. Results. Factors associated with VRE included ICU admission for multiorgan failure, chronic renal failure, prior use of antimicrobial agents in the past three months and before ICU admission, gastrointestinal oral contrast procedure, and hemodialysis. Being located in a high risk room (roommate of patients colonized or infected with VRE) was found to be protective. Conclusions. Factors associated with VRE acquisition are often complex and may be confounded by local variables. Mahmoud Shorman and Jaffar A. Al-Tawfiq Copyright © 2013 Mahmoud Shorman and Jaffar A. Al-Tawfiq. All rights reserved. Periprosthetic Joint Infections Mon, 19 Aug 2013 11:45:46 +0000 Implantation of joint prostheses is becoming increasingly common, especially for the hip and knee. Infection is considered to be the most devastating of prosthesis-related complications, leading to prolonged hospitalization, repeated surgical intervention, and even definitive loss of the implant. The main risk factors to periprosthetic joint infections (PJIs) are advanced age, malnutrition, obesity, diabetes mellitus, HIV infection at an advanced stage, presence of distant infectious foci, and antecedents of arthroscopy or infection in previous arthroplasty. Joint prostheses can become infected through three different routes: direct implantation, hematogenic infection, and reactivation of latent infection. Gram-positive bacteria predominate in cases of PJI, mainly Staphylococcus aureus and Staphylococcus epidermidis. PJIs present characteristic signs that can be divided into acute and chronic manifestations. The main imaging method used in diagnosing joint prosthesis infections is X-ray. Computed tomography (CT) scan may assist in distinguishing between septic and aseptic loosening. Three-phase bone scintigraphy using technetium has high sensitivity, but low specificity. Positron emission tomography using fluorodeoxyglucose (FDG-PET) presents very divergent results in the literature. Definitive diagnosis of infection should be made by isolating the microorganism through cultures on material obtained from joint fluid puncturing, surgical wound secretions, surgical debridement procedures, or sonication fluid. Success in treating PJI depends on extensive surgical debridement and adequate and effective antibiotic therapy. Treatment in two stages using a spacer is recommended for most chronic infections in arthroplasty cases. Treatment in a single procedure is appropriate in carefully selected cases. Ana Lucia L. Lima, Priscila R. Oliveira, Vladimir C. Carvalho, Eduardo S. Saconi, Henrique B. Cabrita, and Marcelo B. Rodrigues Copyright © 2013 Ana Lucia L. Lima et al. All rights reserved. Atherosclerosis Induced by Chlamydophila pneumoniae: A Controversial Theory Wed, 17 Jul 2013 09:31:14 +0000 More than a century ago, inflammation and infection were considered to have atherogenic effects. The old idea that coronary heart disease (CHD) possibly has an infectious etiology has only reemerged in recent years. Atherosclerosis is the main pathological process involved in CHD and is, logically, the first place to look for infectious etiology. The process of atherosclerosis itself provides the first hints of potential infectious cause. Smooth muscle proliferation, with subsequent intimal thickening, luminal narrowing, and endothelial degeneration, constitutes the natural history of atherosclerosis, being with the severity and speed of these changes. Both viral and bacterial pathogens have been proposed to be associated with the inflammatory changes found in atherosclerosis. Recently, Chlamydophila pneumoniae (C. pneumoniae) has been implicated as a possible etiologic agent of coronary artery disease and atherosclerosis. New evidence which supports a role for C. pneumoniae in the pathogenesis of atherosclerosis has emerged. C. pneumoniae has been detected in atherosclerotic arteries by several techniques, and the organism has been isolated from both coronary and carotid atheromas. Recent animal models have suggested that C. pneumoniae is capable of inducing atherosclerosis in both rabbit and mouse models of atherosclerosis. Furthermore, human clinical treatment studies which examined the use of antichlamydial macrolide antibiotics in patients with coronary atherosclerosis have been carried out. The causal relationship has not yet been proven, but ongoing large intervention trials and research on pathogenetic mechanisms may lead to the use of antimicrobial agents in the treatment of CHD in the future. Hamidreza Honarmand Copyright © 2013 Hamidreza Honarmand. All rights reserved. Entry, Retention, and Virological Suppression in an HIV Cohort Study in India: Description of the Cascade of Care and Implications for Reducing HIV-Related Mortality in Low- and Middle-Income Countries Wed, 10 Jul 2013 13:11:36 +0000 HIV treatment, care, and support programmes in low- and middle-income countries have traditionally focused more on patients remaining in care after the initiation of antiretroviral therapy (ART) than on earlier stages of care. This study describes the cumulative retention from HIV diagnosis to the achievement of virological suppression after ART initiation in an HIV cohort study in India. Of all patients diagnosed with HIV, 70% entered into care within three months. 65% of patients ineligible for ART at the first assessment were retained in pre-ART care. 67% of those eligible for ART initiated treatment within three months. 30% of patients who initiated ART died or were lost to followup, and 82% achieved virological suppression in the last viral load determination. Most attrition occurred the in pre-ART stages of care, and it was estimated that only 31% of patients diagnosed with HIV engaged in care and achieved virological suppression after ART initiation. The total mortality attributable to pre-ART attrition was considerably higher than the mortality for not achieving virological suppression. This study indicates that early entry into pre-ART care along with timely initiation of ART is more likely to reduce HIV-related mortality compared to achieving virological suppression. Gerardo Alvarez-Uria, Raghavakalyan Pakam, Manoranjan Midde, and Praveen Kumar Naik Copyright © 2013 Gerardo Alvarez-Uria et al. All rights reserved. Knowledge of and Adherence to Hygiene Guidelines among Medical Students in Austria Thu, 11 Apr 2013 10:38:58 +0000 Background. Adherence to hygiene guidelines is of utmost importance for healthcare professionals. The aim of this study was to evaluate the knowledge on and the adherence to hygiene guidelines among medical students in Austria. Additionally, a possible difference between female and male students was investigated. Methods. An open paper-based survey among third-year medical students at the Medical University of Graz was conducted. The questionnaire consisted of 20 single-choice questions covering compliance with basic hygiene standards, self-rated knowledge of hygiene guidelines, and satisfaction with current hygiene education, equipment, and quality standards. Results. Of 192 medical students, 70% judged their knowledge of hygiene standards as “excellent” or “good”; however, only 49% reported adherence to hygiene guidelines and only 43% performed hygienic hand disinfection according to WHO guidelines. Of the respondents, 79% voted for a mandatory course on hygiene standards in medical education. No significant gender differences were observed. Conclusion. While the knowledge on hygiene guidelines appears to be good among medical students, adherence is limited and requires improvement. The need for an optimum education in hygiene is high. Verena G. Herbert, Paul Schlumm, Harald H. Kessler, and Andreas Frings Copyright © 2013 Verena G. Herbert et al. All rights reserved. Changing Behavior among Nurses to Track Indwelling Urinary Catheters in Hospitalized Patients Wed, 06 Mar 2013 13:37:05 +0000 Catheter-associated urinary tract infections (CAUTIs) are preventable complications of hospitalization. An interdisciplinary team developed a curriculum to increase awareness of the presence of indwelling urinary catheters (IUCs) in hospitalized patients, addressed practical, primarily nurse-controlled inpatient risk-reduction interventions, and promoted the use of the IUC labels (“tags”). Five thirty-minute educational sessions were cycled over three daily nursing shifts on two inpatient medical floors over a 1-year period; participants were surveyed to elicit feedback and provide real-time insight on the learning objectives. Nurse self-reported IUC tagging was early and sustained; after the IUC tag was introduced, there was a significant increase in tagging reported by the end of the block of educational sessions (from 46.2% to 84.6%, ). Early engagement combined with a targeted educational initiative led to increased knowledge, changes in behavior, and renewed CAUTI awareness in hospitalized patients with IUCs. The processes employed in this small-scale project can be applied to broader, hospitalwide initiatives and to large-scale initiatives for healthcare interventions. As first-line providers with responsibility for the placement and daily maintenance of IUCs, nurses are ideally positioned to implement efforts addressing CAUTIs in the hospital setting. Bona Yoon, Samantha D. McIntosh, Leslie Rodriguez, Alma Holley, Charles J. Faselis, and Angelike P. Liappis Copyright © 2013 Bona Yoon et al. All rights reserved. Immunological Aspects of Candida and Aspergillus Systemic Fungal Infections Mon, 21 Jan 2013 14:05:54 +0000 Patients with allogeneic stem cell transplantation (SCT) have a high risk of invasive fungal infections (IFIs) even after neutrophil regeneration. Immunological aspects might play a very important role in the IFI development in these patients. Some data are available supporting the identification of high-risk patients with IFI for example patients receiving stem cells from TLR4 haplotype S4 positive donors. Key defense mechanisms against IFI include the activation of neutrophils, the phagocytosis of germinating conidia by dendritic cells, and the fight of the cells of the innate immunity such as monocytes and natural killer cells against germlings and hyphae. Furthermore, immunosuppressive drugs interact with immune effector cells influencing the specific fungal immune defense and antimycotic drugs might interact with immune response. Based on the current knowledge on immunological mechanism in Aspergillus fumigatus, the first approaches of an immunotherapy using human T cells are in development. This might be an option for the future of aspergillosis patients having a poor prognosis with conventional treatment. Christoph Mueller-Loebnitz, Helmut Ostermann, Anke Franzke, Juergen Loeffler, Lutz Uharek, Max Topp, and Hermann Einsele Copyright © 2013 Christoph Mueller-Loebnitz et al. All rights reserved. Serological Evidence of Exposure to Leptospira spp. in Veterinary Students and Other University Students in Trinidad and Tobago Wed, 09 Jan 2013 09:57:46 +0000 The study compared the serological evidence of leptospirosis in 212 students in four schools (veterinary, dental, advanced nursing education and pharmacy) of the University of the West Indies (UWI), by testing for IgG immunoglobulins to Leptospira spp. using the enzyme-linked immunosorbent assay (ELISA) and the microscopic agglutination test (MAT). Overall, of 212 students tested by the ELISA, 12 (5.7%) and 31 (14.6%) were positive and borderline, respectively. Amongst the 113 veterinary students 11 (9.7%) and 19 (16.8%) were seropositive and borderline respectively compared with nonveterinary students with corresponding values of 1 (1.0%) and 12 (12.1%). The frequency of serological evidence of leptospirosis by the ELISA was statistically significantly (; ) higher in veterinary students, 26.5% (30 of 113) than in nonveterinary students, 13.1% (13 of 99). By the MAT, the seropositivity for leptospirosis was similar for veterinary students, 7.1% (8 of 113) and nonveterinary students, 7.1% (7 of 99). For veterinary students, the prevalent infecting serovar was Icterohaemorrhagiae Copenhageni while amongst nonveterinary students, the prevalent serovar was Australis Rachmati. Being a veterinary student was the only risk factor that was significantly associated with Leptospira infection indicating that veterinary students need to be cognizant and to practise preventive measures for leptospirosis. Ambrose James, Kingsley Siele, Neeka Harry, Sharianne Suepaul, Alva Stewart-Johnson, and Abiodun Adesiyun Copyright © 2013 Ambrose James et al. All rights reserved. Neglected Infectious Diseases: Mechanism of Pathogenesis, Diagnosis, and Immune Response Thu, 27 Dec 2012 10:21:09 +0000 Eliete Caló Romero, Fabiana Pimenta, and Décio Diament Copyright © 2012 Eliete Caló Romero et al. All rights reserved. Analysis of Kinetoplast DNA from Mexican Isolates of Leishmania (L.) mexicana Tue, 25 Dec 2012 13:05:30 +0000 This study analyzed DNA minicircles of Mexican isolates of L. (Leishmania) mexicana to look for genetic differences between strains isolated from patients with diffuse cutaneous (DCL) and localized (LCL) leishmaniasis. The kDNA was analyzed using polymerase chain reaction (PCR), restriction fragment polymorphism analysis of the PCR products (PCR-RFLP) and the PCR products were sequenced. In the PCR with primers specific for the subgenus Leishmania, the Mexican isolates gave higher amplification products than the other L. mexicana complex strains and with specific primers for the L. mexicana complex they were poorly amplified. In the PCR-RFLP analysis with the Eco RV, Hae III, and Mbo I endonucleases, the Mexican isolates displayed similar restriction patterns, but different from the patterns of the other members of the L. mexicana complex. In the phylogenetic tree constructed, the kDNA sequences of the Mexican clones formed two groups including sequences of LCD or LCL clones, apart from the other L. mexicana complex members. These results suggest that the kDNA minicircles of the Mexican isolates are more polymorphic than the kDNA of other members of the L. mexicana complex and have different recognition sites for the restriction enzymes used in this study. Omar Hernández-Montes, Saúl González Guzmán, Federico Martínez Gómez, Douglas C. Barker, and Amalia Monroy-Ostria Copyright © 2012 Omar Hernández-Montes et al. All rights reserved. Natural History and Factors Associated with Early and Delayed Mortality in HIV-Infected Patients Treated of Tuberculosis under Directly Observed Treatment Short-Course Strategy: A Prospective Cohort Study in India Tue, 18 Dec 2012 09:21:20 +0000 Despite the impressive global results of DOTS in India, the effectiveness of DOTS for the treatment of tuberculosis in HIV-infected patients is not well known. This is an observational prospective cohort study performed in Anantapur District, Andhra Pradesh, India. The study included 1000 DOTS antituberculosis treatment (ATT) episodes and 840 person-years. CD4 lymphocyte count was below 200 cells/mm3 in 77% of the cases, and 21% were retreatments. Two thirds were presented with extrapulmonary tuberculosis, and the most common form of extrapulmonary tuberculosis was tuberculous meningitis followed by pleuritis, abdominal tuberculosis, and lymphadenitis. Cumulative incidence of mortality was 16%, 26%, 39%, and 46% at 1, 3, 12, and 24 months, respectively. Factors associated with three-month (early) mortality were being homeless, having low CD4+ lymphocyte count, having tuberculous meningitis, belonging to a socially disadvantaged community, having more than 35 years, and being on an antiretroviral therapy at the moment of initiating the ATT. Factors associated with delayed mortality were having low CD4+ lymphocyte count, belonging to a socially disadvantaged community, receiving a category II ATT because of a previous episode of ATT and having acid fast bacilli in sputum before the ATT initiation. These findings indicate that there is an urgent need to improve the treatment of tuberculosis in HIV-infected patients in India. Gerardo Alvarez-Uria, Praveen Kumar Naik, Raghavakalyan Pakam, Lakshminaryana Bachu, and Manoranjan Midde Copyright © 2012 Gerardo Alvarez-Uria et al. All rights reserved. A 5-Year Retrospective Review of Fungal Keratitis at Hospital Universiti Sains Malaysia Sun, 16 Dec 2012 17:21:21 +0000 Background. Corneal blindness from healed infected keratitis is one of the most preventable causes of monocular blindness in developing countries, including Malaysia. Our objectives were to identify the causative fungi, predisposing risk factors, the proportion of correct clinical diagnosis, and visual outcome of patients treated in our hospital. Methods. A retrospective review of medical and microbiology records was conducted for all patients who were treated for fungal keratitis at Hospital Universiti Sains Malaysia from January 2007 until December 2011. Results. Forty-seven patients (47/186, 25.27%) were treated for fungal keratitis during the study period. This demonstrated that the incidence of fungal keratitis has increased each year from 2007 to 2011 by 12.50%, 17.65%, 21.21%, 26.83%, and 28.57%, respectively. The most common predisposing factors were injury to the eye followed by use of topical steroid, and preexisting ocular surface disease. Fusarium species were the most common fungal isolated, followed by Candida species. Clinical diagnosis of fungal keratitis was made in 26 of the 41 (63.41%) cases of positive isolates. Of these, in eleven cases (23.40%) patients required surgical intervention. Clinical outcome of healed scar was achieved in 34 (72.34%) cases. Conclusions. The percentage of positive fungal isolated has steadily increased and the trend of common fungal isolated has changed. The latest review regarding fungal keratitis is important for us to improve patients' outcome in the future. Fadzillah Mohd-Tahir, A. Norhayati, Ishak Siti-Raihan, and M. Ibrahim Copyright © 2012 Fadzillah Mohd-Tahir et al. All rights reserved. Influence of Triatoma dimidiata in Modulating the Virulence of Trypanosoma cruzi Mexican Strains Mon, 03 Dec 2012 07:33:41 +0000 The epidemiology of Chagas disease is complex. There are different vectors and reservoirs and different clinical manifestations. In order to assess whether the biological behavior of three strains isolated in southeastern Mexico (H4 isolated from human, Z17 isolated from Didelphis sp., and V isolated from T. dimidiata) could be modified during passage through the vector T. dimidiata, the parasitemia curve, the amount of amastigote nests, and mortality of BALB/c infected with blood trypomastigotes of T. cruzi were evaluated. Strains were maintained in continuous passage from mouse to mouse and in animals infected with metacyclic trypomastigotes. The parasitemia curves were significantly different () between mice to mice and triatoma to mice groups in strains H4 and Z17, and was also observed fewer amastigote nests in cardiac tissue ( strain H4 with higher number versus all groups and Z17 between mice to mice and triatoma to mice) 45 days after inoculation. It is concluded that T. dimidiata influences in modulating the virulence of strains of T. cruzi in the region. Further studies of the intestinal tract of the insect in search for some protein molecules involved in regulating may clarify the virulence of the parasite. E. Guzman-Marin, M. Jimenez-Coello, M. Puerto-Solis, A. Ortega-Pacheco, and K. Y. Acosta-Viana Copyright © 2012 E. Guzman-Marin et al. All rights reserved. Q Fever: An Old but Still a Poorly Understood Disease Mon, 19 Nov 2012 09:42:50 +0000 Q fever is a bacterial infection affecting mainly the lungs, liver, and heart. It is found around the world and is caused by the bacteria Coxiella burnetii. The bacteria affects sheep, goats, cattle, dogs, cats, birds, rodents, and ticks. Infected animals shed this bacteria in birth products, feces, milk, and urine. Humans usually get Q fever by breathing in contaminated droplets released by infected animals and drinking raw milk. People at highest risk for this infection are farmers, laboratory workers, sheep and dairy workers, and veterinarians. Chronic Q fever develops in people who have been infected for more than 6 months. It usually takes about 20 days after exposure to the bacteria for symptoms to occur. Most cases are mild, yet some severe cases have been reported. Symptoms of acute Q fever may include: chest pain with breathing, cough, fever, headache, jaundice, muscle pains, and shortness of breath. Symptoms of chronic Q fever may include chills, fatigue, night sweats, prolonged fever, and shortness of breath. Q fever is diagnosed with a blood antibody test. The main treatment for the disease is with antibiotics. For acute Q fever, doxycycline is recommended. For chronic Q fever, a combination of doxycycline and hydroxychloroquine is often used long term. Complications are cirrhosis, hepatitis, encephalitis, endocarditis, pericarditis, myocarditis, interstitial pulmonary fibrosis, meningitis, and pneumonia. People at risk should always: carefully dispose of animal products that may be infected, disinfect any contaminated areas, and thoroughly wash their hands. Pasteurizing milk can also help prevent Q fever. Hamidreza Honarmand Copyright © 2012 Hamidreza Honarmand. All rights reserved. Experimental Evaluation of the Pathogenicity of Different Strains of Schistosoma mansoni Wed, 07 Nov 2012 16:07:12 +0000 The pathogenesis of three different Schistosoma mansoni strains from the Brazilian states of Minas Gerais (BH strain) and São Paulo (SJ and SD strains) was evaluated in experimentally infected mice. Observations of the most severe clinical cases among local patients treated (SD strain) in the city of Campinas (São Paulo, Brazil) formed the basis of this study. Mice were used as definitive hosts and were infected with cercariae from Biomphalaria tenagophila (SJ and SD strains) and Biomphalaria glabrata (BH strains). The parameters analyzed were as follows: number of S. mansoni eggs in mice feces; number of granulomas per tissue area in liver, spleen, lungs, pancreas, and ascending colon; measurements of hepatic and intestinal granulomas; number of adult worms; and measurements of trematode eggs. The comparison among the three strains indicated that the SD strain, isolated in Campinas, presented a higher worm recovery relative to the number of penetrating cercariae. In addition, when compared to the SJ and BH strains, the SD strain demonstrated similar pathogenicity to the BH strain, with a greater quantity of granulomas in the viscera, as well as larger granulomas and eggs. Furthermore, a greater quantity of trematode eggs was also shed in the feces. Antônio Aurélio Euzébio Jr., Nádia Regina Borim Zuim, Arício Xavier Linhares, Luiz Augusto Magalhães, and Eliana Maria Zanotti-Magalhães Copyright © 2012 Antônio Aurélio Euzébio et al. All rights reserved.