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Background To fulfill epidemiological data and investigate possible interspecies transmission, this study shall attempt to sequence representative HEV strains of human, swine and wild boar origin collected from 2010 to 2017 in Croatia. Methods In total, 174 anti-HEV antibody positive human sera samples; 1419 blood or faeces samples of swine, as well as 720 tissue and/or blood samples of wild boar originating from different counties (18 in total) in Croatia were tested for the presence of HEV RNA. Results HEV RNA was detected in 26 human sera samples (14.9%; 95% CI 10.4–21.0%). HEV RNA was detected in 216 tested swine (15.2%; 95% CI 13.5–17.1%), regardless of age, farm breeding system or geographical origin. Viral RNA was also detectable in faeces samples which prove that swine actively participate in shedding HEV into the environment. Of the total of 720 tested wild boar samples, 83 were HEV RNA positive (11.5, 95% CI 9.4–14.1%) originating from six counties. According to the sequence analysis all strains have shown to be members of Orthohepevirus A genotype HEV-3, regardless of host. The genotyping results confirm grouping of sequences into four subtypes of HEV strains of which subtypes 3a and 3c belong to the general cluster 3abchij, and were predominately detected during the study, while subtypes 3e and 3f fall within cluster 3efg. Strains within subtypes 3a and 3e were found in humans, swine and wild boars; subtype 3c strains were derived from humans and swine, whereas subtype 3f strains were found only in humans. Strains belonging to subtypes 3a and 3c were derived during the entire investigated period and may be considered endemic in Croatia, whereas strains within subtypes 3e and 3f were detected sporadically indicating the possibility of newly imported infections. Conclusions All detected strains show to be genetically highly related to strains found in humans and/or animals from other European Countries, indicating that trade of live animals or wild boar movement increases the risk of HEV infection spread. Furthermore, homologous strains found in different investigated species within this study indicate interspecies transmission of HEV and/or an existence of an accessible mutual source of infection.

Background:Candida auris has emerged globally as a multi-drug resistant yeast and is commonly associated with nosocomial outbreaks in ICUs. Methods: We conducted a retrospective observational multicentre study to determine the epidemiology of C. auris infections, its management strategies, patient outcomes, and infection prevention and control practices across 10 centres from five countries. Results: Significant risk factors for C. auris infection include the age group of 61–70 years (39%), recent history of ICU admission (63%), diabetes (63%), renal failure (52%), presence of CVC (91%) and previous history of antibiotic treatment (96%). C. auris was commonly isolated from blood (76%). Echinocandins were the most sensitive drugs. Most common antifungals used for treatment were caspofungin (40%), anidulafungin (28%) and micafungin (15%). The median duration of treatment was 20 days. Source removal was conductedin 74% patients. All-cause crude mortality rate after 30 days was 37%. Antifungal therapy was associated with a reduction in mortality (OR:0.27) and so was source removal (OR:0.74). Contact isolation precautions were followed in 87% patients. Conclusions:C. auris infection carries a high risk for associated mortality. The organism is mainly resistant to most azoles and even amphotericin-B. Targeted antifungal therapy, mainly an echinocandin, and source control are the prominent therapeutic approaches.

While the debate on the association between Enterobius vermicularis (E. vermicularis) and acute appendicitis has not been settled, a few case reports of this very rare encounter are beginning to come to light. E. vermicularis is one of the most common parasitic infections around the world, and acute appendicitis, on the other hand, is also a commonly encountered condition in general surgery. However, the association between these two conditions remains controversial. Here we present a case report of a young woman with appendicitis associated with E. vermicularis.

Antimicrobial resistance (AMR), a serious global public health challenge, may have accelerated development during the COVID-19 pandemic because antibiotics were prescribed for COVID-19. This study aimed to assess antibiotics use before and during the pandemic and correlate the results with the rate of resistant microorganisms detected in hospitalized patients during the study period. This single-center study looked retrospectively at four years of data (2018–2021) from Royal Hospital, Muscat, which is the biggest hospital in Oman with approximately 60,000 hospital admissions yearly. The consumption rate of ceftriaxone, piperacillin tazobactam, meropenem, and vancomycin was presented as the antibiotic consumption index, the ratio of defined daily dose (DDD) per 100 bed days. Analyses were performed using the nonparametric test for trend across the study period. Correlation between antibiotic consumption indexes and the isolated microorganisms in the four-year study period was performed using Spearman’s rank correlation coefficient. We compared data from the pre-COVID-19 to the COVID-19 period. Though more patients were admitted pre-COVID-19 (132,828 versus 119,191 during COVID-19), more antibiotics were consumed during the pandemic (7350 versus 7915); vancomycin and ceftriaxone had higher consumption during than before the pandemic (p-values 0.001 and 0.036, respectively). Vancomycin-resistant Enterococcus (VRE) and Candida auris were detected more during the COVID-19 period with p-values of 0.026 and 0.004, respectively. Carbapenem-resistant Enterobacterales (CRE), vancomycin-resistant Enterococcus spp., and C. auris were detected more often during the pandemic with p-values of 0.011, 0.002, and 0.03, respectively. Significant positive correlations between antibiotic consumption and drug-resistant isolates were noted. This study confirms that the overuse of antibiotics triggers the development of bacterial resistance; our results emphasize the importance of antibiotic control.

West Nile virus (WNV) infections are a mosquito-borne virus of the Flaviviridae family. The clinical feature of the virus varies between individuals from being asymptomatic in most of the cases to severe central nervous system disease manifested as meningitis, encephalitis, and paralysis. Diabetic nephropathy patient with microvascular and macrovascular complications, who received a kidney transplant a year ago on immunosuppressive therapy, presented with a three-day history of upper respiratory tract infection and fever. He lived in an endemic area of brucella infection. He underwent a thorough and full evaluation with various laboratory and radiological evaluations. The patient was started empirically on ceftriaxone and acyclovir for a presumptive diagnosis of herpes encephalitis and covering also Listeria with ampicillin. The patient did not improve with the initial management, so a T2-weighted magnetic resonance imaging of the brain executed that showed nonspecific hyper-intensity in the left frontal area suggestive of microangiopathic changes. WNV-neutralizing antibodies were positive with a high titer >1:640, whereas WNV RNA was not detected in the plasma sample. In the serum sample, WNV IgM and IgG were both positive. WNV IgM antibodies were detected with 6.55 and 5.97 antibody index and were done by a semiquantitative ELISA. Furthermore, WNV-neutralizing antibodies were positive as well as with a titer of 1:80. As there is no specific antiviral treatment available, the patient management was supportive; reduction in immunosuppressive agents and the use of IV IgG. This is the first reported case of one-year post renal transplant who developed WNV encephalitis and neuropathy with significant response to immunoglobulin after 18 days of infections.

Aim As Coronavirus Disease-2019 (COVID-19) pandemic continues to evolve, the search for safe and effective therapeutic interventions remain essential. Methods We conducted a retrospective cohort study on patients hospitalized with laboratory confirmed severe acute respiratory syndrome coronavirus-2 infection, comparing standard of care along with Convalescent Plasma with or without Tocilizumab (CP vs. CPT). Results A total of 110 patients were enrolled with an overall mean age of 50 ± 16 years. Patients on CPT were more likely to have had acute respiratory distress syndrome (77% vs. 42%; p < 0.001), sepsis (9.7% vs. 0; p = 0.036), chest X-ray abnormalities (71% vs. 44%; p = 0.004), intensive care unit admission (84% vs. 56%; p = 0.001) as well as being on mechanical ventilation (79% vs. 48%; p = 0.001). After CPT treatment, all measured inflammatory markers, except interleukine-6, showed an overall steady decline over time (all p -values <0.05) and the ventilatory parameters showed significant improvement of PaO 2 /FiO 2 ratio from 127 to 188 within 7 days ( p < 0.001). Additionally, 52% (32/62) of the patients had favorable outcome, either as improvement of ventilatory parameters or extubation within 14 days of hospitalization. However, mortality rate in those on CPT was higher than those who received CP alone (24% vs. 8.3%; p = 0.041). Conclusion In patients with severe COVID-19 infection, using tocilizumab with convalescent plasma is associated with improvement in inflammatory and ventilatory parameters but no effect on mortality. These findings require validation from randomized clinical trials.

In recent years, several European countries reported cases of imported chikungunya infection. We present the first imported clinically manifested chikungunya fever in Croatia. A 27-year-old woman returned to Croatia on 21 March 2016, after she stayed in Costa Rica for two months where she had noticed a mosquito bite on her left forearm. Five days after the mosquito bite she developed severe arthralgias, fever and erythematous papular rash. In next few days symptoms gradually subsided. After ten days she felt better, but arthralgias re-appeared accompanied with morning stiffness. Two weeks after the onset of the disease she visited the infectious diseases outpatient department. The physical examination revealed rash on the trunk, extremities, palms and soles. Laboratory findings showed slightly elevated liver transaminases. Serological tests performed on day 20 after disease onset showed a high titer of chikungunya virus (CHIKV) IgM and IgG antibodies which indicated CHIKV infection. CHIKV-RNA was not detected. Serology to dengue and Zika virus was negative. The patient was treated with nonsteroid anti-inflammatory drugs and paracetamol. Her symptoms ameliorated, however, three months later she still complaint of arthralgias. The presented case highlights the need for inclusion of CHIKV in the differential diagnosis of arthralgia in all travelers returning from countries with documented CHIKV transmission.

BACKGROUND: Lyme borreliosis is the most prevalent tick-borne disease in Europe. Ixodes ricinus also carries other pathogenic bacteria, but corresponding human diseases are rarely reported. Here, we compared the exposure to Rickettsia helvetica and Rickettsia monacensis with that to Lyme borreliosis spirochetes. We assumed that their exposure corresponds to their infection rate in questing I. ricinus. FINDINGS: Three Rickettsia species were detected in ticks with a total prevalence of 7.9%, of which the majority was R. helvetica (78%) and R. monacensis (21%). From the same geographic area, skin biopsies of erythema migrans patients were investigated for possible co-infections with Rickettsia spp.. Forty-seven out of 67 skin biopsies were PCR positive for Borrelia burgdorferi s.l. and one sample was positive for R. monacensis. The Borrelia genospecies from the R. monacensis positive patient was identified as Borrelia afzelii. The patient did not show any symptoms associated with rickettsiosis. CONCLUSIONS: Co-infections of I. ricinus with Rickettsia spp. and B. burgdorferi s.l. were as high as expected from the individual prevalence of both pathogens. Co-infection rate in erythema migrans patients corresponded well with tick infection rates. To our knowledge, this is the first reported co-infection of B. afzelii and R. monacensis.