Antimicrobial Resistance and Sports: The Scope of the Problem, Implications for Athletes' Health and Avenues for Collaborative Public Health Action

Antimicrobial resistance (AMR) poses a global threat, leading to increased mortality and necessitating urgent action-however, its impact on athletes and the world of sports has hitherto been neglected. Sports environments (including athletic and aquatic) exhibit high levels of microbial contamination, potentially contributing to the spread of resistant microorganisms during physical activities. Moreover, the literature suggests that travel for sports events may lead to changes in athletes' gut microbiomes and potentially impact their antibiotic resistance profiles, raising questions about the broader implications for individual and public/global health. The prevalence of Staphylococcus aureus (S. aureus) among athletes (particularly those engaged in contact or collision sports) ranges between 22.4% and 68.6%, with MRSA strains being isolated in up to 34.9% of tested individuals. Factors such as training frequency, equipment sharing, delayed post-training showers, and a history of certain medical conditions are linked to higher colonization rates. Moreover, MRSA outbreaks have been documented in sports teams previously, highlighting the importance of implementing preventive measures and hygiene protocols in athletic settings. In light of the growing threat of AMR, there is a critical need for evidence-based treatment guidelines tailored to athletes' unique physiological demands to ensure responsible antibiotic use and mitigate potential health risks. While various initiatives-such as incorporating AMR awareness into major sporting events-aim to leverage the broad audience of sports to communicate the importance of addressing AMR, proactive measures (including improved AMR surveillance during large sporting events) will be indispensable for enhancing preparedness and safeguarding both athletes' and the general public's health. This narrative review thoroughly assesses the existing literature on AMR and antibiotic usage in the context of sports, aiming to illuminate areas where information may be lacking and underscoring the significance of promoting global awareness about AMR through sports.

Emergence of Echinococcus multilocularis in Central Continental Croatia: A Human Case Series and Update on Prevalence in Foxes

Human alveolar echinococcosis (HAE), caused by the metacestode stage of Echinococcus multilocularis, has emerged in many European countries over the last two decades. Here, we report the first data on the new HAE focus with increasing incidence in central Croatia, describe its clinical presentation and outcomes in diagnosed patients, and provide an update on the prevalence and geographic distribution of Echinococcus multilocuaris in red foxes. After the initial case in 2017 from the eastern state border, from 2019 to 2022, five new autochthonous HAE cases were diagnosed, all concentrated in the Bjelovar-Bilogora County (the county incidence in 2019 and 2021: 0.98/10⁵, in 2022: 2.94/10⁵/year; prevalence for 2019-2022: 4.91/10⁵). The age range among four female and two male patients was 37-67 years. The patients' liver lesions varied in size from 3.1 to 15.5 cm (classification range: P2N0M0-P4N1M0), and one patient had dissemination to the lungs. While there were no fatalities, postoperative complications in one patient resulted in liver transplantation. In 2018, the overall prevalence of red foxes was 11.24% (28/249). A new focus on HAE has emerged in central continental Croatia, with the highest regional incidence in Europe. Screening projects among residents and the implementation of veterinary preventive measures following the One Health approach are warranted.

Corynebacterium glucuronolyticum in men with and without urethritis syndrome: An underrecognized pathogen or a bona fide commensal?

BACKGROUND

By analysing the largest collection of Corynebacterium glucuronolyticum (C. glucuronolyticum) isolates from a single centre thus far, we aimed to appraise a potential causal link between an infrequently isolated species and the urethritis syndrome in men.

METHODS

A total of 1055 Caucasian male individuals with or without urethritis syndrome were included in this single-centre case-control study. Group-wise comparisons were pursued by analysing sociodemographic, behavioural and microbiological specificities between the two groups. C. glucuronolyticum isolates from urethral specimens were identified using the analytical profile index biotyping system (API Coryne) and additionally confirmed by MALDI-TOF mass-spectrometry, with subsequent determination of their antimicrobial sensitivity profiles. Statistical significance was set at p < 0.05 (two-tailed).

RESULTS

C. glucuronolyticum was isolated in 5.08% of study participants with urethritis syndrome and 3.60% of those without it (p = 0.303). In the urethritis group, the species was more frequently found as a sole isolate (p = 0.041) and after prior infection with Chlamydia trachomatis (p = 0.025). The most frequent presentation of urethritis included a clear discharge in small or moderate amounts, without any pathognomonic findings. The resistance rates were 62.22% for clindamycin, 42.22% for tetracycline and 26.67% for ciprofloxacin.

CONCLUSIONS

Our study provides major insights on the relevance of urethral C. glucuronolyticum in non-gonococcal urethritis, with significant implications for further aetiological research and management approaches.

Is strongyloidiasis currently autochthonous in Croatia? A retrospective study

BACKGROUND

Autochthonous human infections with Strongyloides stercoralis have been well documented in many European regions. By exploring patients' data, we aimed to find elements for its current endemicity in Croatia.

METHODS

This retrospective descriptive study analysed epidemiological and clinical data of patients treated for strongyloidiasis from January 2010 to May 2019 at a teaching hospital in Zagreb, Croatia. The diagnosis was made by direct methods using light microscopy and/or serology.

RESULTS

Among 65 patients with strongyloidiasis, 60% were men, and 78.5% were 50-79 y of age. The sensitivity of the examination of three stool samples after concentration, saline provocation and serology was 26.2, 80.7 and 86.2%, respectively. Clinical presentation included asymptomatic patients with eosinophilia (41.5%), chronic symptomatic infection (33.8%), acute infection (18.5%) and hyperinfection (6.2%). Twenty patients (30.8%) were immunosuppressed; among four of whom developed hyperinfection, two died. Initially 71.7% of patients were treated with albendazole and 13.3% with ivermectin, with an equal parasitological cure rate (72.2% and 75%; p=0.09). In 11 patients, acute infection was autochthonous in its origin.

CONCLUSIONS

Strongyloidiasis is currently endemic in Croatia and immunosuppressed travellers to this region should be advised to take precautions. Patients undergoing immunosuppression and organ donors from Croatia should be screened.

Topical medication as an initial therapeutic option for protruding and non-protruding condylomata acuminata of the distal urethra

Genital warts (also known as condylomata acuminata) caused by the human papillomavirus (HPV) represent one of the most common sexually transmitted infections. Although they are usually found in the outer genital region, a small proportion of men can present with (often unrecognised) intraurethral warts, generally limited to the distal urethra and urethral meatus. This poses a treatment challenge not adequately addressed by the current guidelines. Here, we present two cases of low-risk HPV-positive patients with protruding and non-protruding condylomata acuminata of the distal urethra, which were treated successfully by using two different topical regimens (ie, a combination of policresulen and imiquimod for one patient and 5-fluorouracil monotherapy for the other). Although this type of management results in lower rates of tissue destruction and complications and may be given preference as an initial therapeutic option, additional prospective comparative clinical studies are needed to elucidate its potential in similar cases.

SARS-CoV-2 Seroprevalence and Neutralizing Antibody Response after the First and Second COVID-19 Pandemic Wave in Croatia

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus with a pandemic spread. So far, a total of 349,910 SARS-CoV-2 cases and 7687 deaths were reported in Croatia. We analyzed the seroprevalence and neutralizing (NT) antibody response in the Croatian general population after the first (May–July 2020) and second (December 2020–February 2021) pandemic wave. Initial serological testing was performed using a commercial ELISA, with confirmation of reactive samples by a virus neutralization test (VNT). A significant difference in the overall seroprevalence rate was found after the first (ELISA 2.2%, VNT 0.2%) and second waves (ELISA 25.1%, VNT 18.7%). Seropositive individuals were detected in all age groups, with significant differences according to age. The lowest prevalence of NT antibodies was documented in the youngest (<10 years; 16.1%) and the oldest (60–69/70+ years; 16.0% and 12.8%, respectively) age groups. However, these age groups showed the highest median NT titers (32–64). In other groups, seropositivity varied from 19.3% to 21.5%. A significant weak positive correlation between binding antibody level as detected by ELISA and VNT titer (rho = 0.439, p < 0.001) was observed. SARS-CoV-2 NT antibody titers seem to be age-related, with the highest NT activity in children under 10 years and individuals above 50 years.

A 'pathogenic needle' in a 'commensal haystack': Genetic virulence signatures of Corynebacterium glucuronolyticum that may drive its infectious propensity for the male urogenital system

The predominance of the genus Corynebacterium in the healthy male urogenital system contributes to the resident microbiome of not only the distal urethra, but potentially the proximal urethra and urinary bladder as well. However, for certain species in this genus, pathogenic potential was described, and the salient representative is Corynebacterium glucuronolyticum (C. glucuronolyticum) implicated in cases of urethritis and prostatitis in men. Nonetheless, some still question whether C. glucuronolyticum can actually be considered pathogenic or rather just a commensal species fortuitously isolated in patients with urogenital symptoms and/or syndromes. Although pathogen/commensal dichotomy is not always clear-cut, we hypothesize that specific genetic markers may expose C. glucuronolyticum as a convincingly pathogenic Corynebacterium. More specifically, characteristic pathogenic gene constellation inherent to this species (most notably the presence of specific sortase/SpaA-type pili gene clusters, but also the augmentative role of type VII secretion system) may significantly facilitate host tissue adhesion, with subsequent suppression/evasion of the immune response and acquisition of vitally important nutrients. Consequently, these genetic markers differentiate C. glucuronolyticum from its commensal counterparts, and give this species a pathogenic facet, which can be even further influenced by the Allee effect. In this paper we also propose a specific methodological approach on how to analyze C. glucuronolyticum epithelial colonization capacity and explore inceptive host cell-pathogen interactions that manipulate host environment and immune responses. This entails moving from approaches based primarily on overall homology of primary sequences towards specific structure-function studies to precisely evaluate all stakeholders involved in pili assemblage, cell adhesion and the expression of other virulence traits. In the era of high precision medicine, the hypothesized roles of C. glucuronolyticum adhesion systems in both virulence and nutrient acquisition may also reveal promising targets for future drug developments.

The value of systematic screening for Trichinella antibodies among individuals with eosinophilia in recognizing outbreak events: a seroprevalence study from Croatia

Although trichinellosis represents one of the most significant global foodborne zoonotic diseases, human seroprevalence studies are scarce. Due to its endemicity in Croatia, the aims of this study were to establish the general prevalence of Trichinella infection in Croatian individuals presenting with eosinophilia during a 5-year period, and to assess the value of such screening endeavours for early detection/differentiation of outbreaks. A total of 1342 serum samples were collected from male and female subjects presenting with peripheral blood eosinophilia between 2013 and 2017, and tested for Trichinella IgG antibodies by employing commercial qualitative ELISA and Trichinella Excreted/Secreted (E/S) Western blot methods. The overall positivity was 3.65%, ranging from 0.49% to 1.50% between 2013 and 2016, but rising to 10.98% in 2017; such ten-fold increase in seroprevalence forecasted the epidemic situation in Croatia. Overall the prevalence of the infection rose with the increasing age and the rate was highest among those older than 40 years of age (p=0.003), without any significant sex-based differences (p=0.438). Considering the early appearance of eosinophilia in the infected individuals, this type of systematic screening can be seen as an additional epidemiological tool to unveil the trichinellosis outbreak in a timely manner.

Latent Toxoplasma gondii infection is associated with decreased serum triglyceride to high-density lipoprotein cholesterol ratio in male patients with schizophrenia

BACKGROUND

Previous studies suggested a complex association between Toxoplasma gondii (TG) infection and host lipid metabolism. Both TG infection and metabolic disturbances are very common in patients with schizophrenia, but this relationship is not clear.

METHODS

In this cross-sectional study, we evaluated the association between TG seropositivity, serum lipid levels, body mass index (BMI) and metabolic syndrome (MetS) in 210 male inpatients with schizophrenia.

RESULTS

In our sample of schizophrenia patients, with the mean age of 43.90 ± 12.70 years, the rate of TG seropositivity was 52.38% and the prevalence of MetS was 17%. Patients with the TG antibodies had lower serum triglyceride levels and body weight compared to TG seronegative patients, despite having more frequently received antipsychotics (clozapine, olanzapine risperidone and quetiapine), which are well known to induce weight gain and metabolic abnormalities. However, the only significant change in metabolic parameters, observed in TG seropositive patients with schizophrenia, was decreased serum triglyceride to high-density lipoprotein cholesterol (HDL-C) ratio. No associations were observed between TG seropositivity and serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and glucose levels, waist circumference, BMI and the rate of MetS.

CONCLUSION

This is the first report of the association between TG infection and decreased serum triglyceride to HDL-C ratio in a sample of carefully selected men with chronic schizophrenia.

The impact of Corynebacterium glucuronolyticum on semen parameters: a prospective pre-post-treatment study

Corynebacterium glucuronolyticum (C. glucuronolyticum) is a rare isolate that is only recently being acknowledged as a potential urogenital pathogen. The bibliographical references on this bacterial species are scarce, and its influence on all semen parameters was hitherto unknown - therefore, the aim of this study was to evaluate its effects on a range of sperm quality parameters. A prospective approach to compare semen parameters before and after treatment was used in this study. C. glucuronolyticum in semen specimens was identified using analytical profile index biotyping system (API Coryne) and additionally confirmed by matrix-assisted laser desorption/ionization time-of-flight mass-spectrometry (MALDI-TOF MS), with the determination of antimicrobial susceptibility by Kirby-Bauer method. Semen analysis was performed according to the criteria from the World Health Organization (with the use of Tygerberg method of sperm morphology categorization). Very strict inclusion criteria for participants also included detailed medical history and urological evaluation. From a total of 2169 screened semen specimens, the inclusion rate for participants with C. glucuronolyticum that satisfied all the criteria was 1.01%. Antibiogram-guided treatment of the infection with ensuing microbiological clearance has shown that the resolution of the infection correlates with statistically significant improvement in the vitality of spermatozoa, but also with a lower number of neck and mid-piece defects. Parameters such as sperm count, motility and normal morphology were not affected. In addition, susceptibility testing revealed a trend towards ciprofloxacin resistance, which is something that should be considered when selecting an optimal treatment approach. Albeit it is rarely encountered as a monoisolate in significant quantities, C. glucuronolyticum may negatively influence certain sperm parameters; therefore, it has to be taken into account in the microbiological analysis of urogenital samples.

Sociodemographic, Sexual Behavior, and Microbiological Profiles of Men Attending Public Health Laboratories for Testing for Sexually Transmitted Diseases

In order to identify the groups at risk of sexually transmitted diseases (STDs), we assessed the sociodemographic profiles of men testing for STD, their sexual habits, and the results of microbiological analysis. During a three-year period, a total of 700 men older than 18 years of age completed the questionnaire regarding sociodemographic and sexual behavior. Urethral swabs were taken for microbiological analysis. Thirty-three percent of respondents reported not using condoms. Those that do not use condoms were predominantly less educated, unmarried but in steady relationships, employed, with children, and smokers. Alcohol or drug usage before sexual intercourse was disclosed by 21.4% of respondents, and 10.3% respondents reported sexual intercourses with commercial sex workers. Finally, 24.0% respondents reported sexual relations abroad. In 28.1% of subjects, one or more pathogens were observed in urethral swabs. The most commonly diagnosed microorganism was Ureaplasma urealyticum, followed by Chlamydia trachomatis, Mycoplasma hominis, Trichomonas vaginalis, and Neisseria gonorrhoeae. This study identified several factors that may contribute to the general risk of STD transmission, which will serve to better understand the transmission dynamics and implementation of adequate prevention programs.

Increased prevalence of toxoplasma gondii seropositivity in patients with treatment-resistant schizophrenia

Introduction

Previous studies suggested that patients with schizophrenia had an increased prevalence of antibodies against toxoplasma gondii (TG) and that those seropositive patients had higher symptom severity. However, there is no data on the relationship between treatment-resistant schizophrenia (TRS) and TG seroprevalence.

Objectives

To determine the association between TRS and TG seropositivity, and to further investigate the relationship between TG seropositivity and different clinical features of schizophrenia.

Methods

In this cross-sectional study, we included 210 male inpatients with schizophrenia. TG seropositivity was determined by ELFA assay. Treatment-resistance was defined as a failure of at least 2 adequate anti-psychotic trials. Data were analyzed using χ2 test or Mann–Whitney test.

Results

The rate of TG seropositivity in the entire sample was 52.3%, whereas 47.6% of patients met the definition for treatment-resistance. Seropositive patients had twice the rate of treatment–resistance compared to seronegative patients (63.6% vs. 30.0%, P < 0.0001). Moreover, in the seropositive group, the patients were older (47.6 ± 12.2 vs. 39.81 ± 12.01 years, P < 0.0001), had higher number of previous hospitalizations (13.9 ± 11.7 vs. 9.6 ± 8.5, P = 0.0073), and increased Calgary depression scale for schizophrenia (CDSS) total score (7.8 ± 4.5 vs. 6.3 ± 3.8, P = 0.012). There were no differences between the groups in the age of disease onset, smoking, positive and negative syndrome scale (PANSS) total, positive and negative scores, and the life-time history of suicide attempts.

Conclusions

Our results support the hypothesis that TG seropositivity might contribute to treatment-resistance in schizophrenia, at least in male patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Seroepidemiology of Hepatitis E in Selected Population Groups in Croatia: A Prospective Pilot Study

Hepatitis E has become an emerging infection in many European countries. We analysed the prevalence of hepatitis E virus (HEV) infection in selected population groups in Croatia. Overall HEV IgG seropositivity was 5.6%, while 1.9% participants showed IgM antibodies suggestive of recent infection. No IgM-positive sample was positive for HEV RNA. HEV IgG antibodies were most prevalent in alcohol abusers (8.9%) and war veterans (8.6%), compared with 6.1% among injecting drug users and 2.7% in healthcare professionals. No individual with high-risk sexual behaviour tested HEV seropositive. HEV IgG positivity increased significantly with age from 1.8% to 2.3% in individuals younger than 40 years to 11.3% in individuals older than 50 years (P = 0.023). The mean age of HEV-positive participants was significantly higher than that of HEV-negative participants (50.9 ± 11.8 years versus 41.2 ± 11.8 years, P = 0.008). Seroprevalence rates were significantly higher in residents of suburban and rural areas compared with residents of urban areas (14.5% versus 2.5%, P = 0.003). Additionally, an increasing prevalence of HEV IgG antibodies was observed from 1.8% in participants living in families with two household members to 12.1% in those living with more than four members (P = 0.046). Gender, marital status, educational level, sexual orientation, source of drinking water, history of blood transfusions, surgical procedures, tattooing and travelling were not associated with HEV seroprevalence. Logistic regression showed that living in suburban/rural areas was the main risk factor for HEV seropositivity (OR = 6.67; 95%CI = 1.89-25.0; AOR = 7.14, 95%CI = 1.89-25.0).

Antibiotic susceptibility of isolates from paediatric intensive care units in Zagreb

AIM

Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program is a longitudinal global surveillance study to monitor in vitro data on microbial susceptibility in centers that prescribe meropenem. Results of the six years period (2002-2007) for the antimicrobial efficacy of meropenem compared to other broad-spectrum agents against Gram-negative and Gram-positive isolates collected at pediatric intensive care units of the University Hospital Center Zagreb in Croatia were reported.

METHODS

A total of 110 Gram-negative and 43 Gram-positive pathogens from pediatric specimens were tested. The minimum-inhibitory concentrations (MICs) were determined by broth microdilution method according to CLSI.

RESULTS

There was no resistance to either imipenem or meropenem observed for Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis. High resistance rates of K. pneumoniae to ceftazidime and gentamicin (50%) are a raising concern. Pseudomonas aeruginosa was the most resistant Gram-negative species with two (12%) of the strains resistant to meropenem, three (18%) to imipenem, 10 (47%) to gentamicin and six (35%) to piperacillin/tazobactam and ciprofloxacin. According to our results meropenem remains an appropriate antibiotic for the treatment of severe infections caused by Gram-negative bacteria in pediatric population.

CONCLUSIONS

The results indicate that meropenem has excellent potency and spectrum of activity despite being prescribed for a long time for the treatment of seriously ill patients, and still appears to be a reliable option for the initial empirical therapy of serious nosocomial infections in children. However, later studies have shown the emergence of carbapenem-resistant Gram-negative bacteria after 2008.

Dirofilaria repens as a cause of subconjunctival infection in a 77-years old female patient from Croatia--a case report

The zoonotic parasites of the genus Dirofilaria are on the increase as an accidental finding or as a cause of disease in humans worldwide. Human dirofilariasis usually manifests as either subcutaneous infiltrates or lung parenchymal disease, in many cases asymptomatically. We report the case of a 77-year old female patient presenting with irritation and pain in her left eye. Ophthalmologic examination of the temporal part of her left eye revealed motile and threadlike organism, which was surgically extracted and morphologically identified as Dirofilaria. Further molecular diagnostics with polymerase chain reaction (PCR) confirmed that the isolated organism is Dirofilaria repens. Due to already recognized autochthonous occurrence of human dirofilariasis in Croatia, human dirofilariasis must be included in the differential diagnosis of patients presenting with subcutaneous nodules, eye affection and other potential manifestations of this disease.

[Virology diagnosis of re-emergent infections: dengue virus]

Dengue is acute viral disease transmitted to humans by Aedes mosquitoes (Ae. aegypti, Ae. albopictus). Dengue virus belongs to the family Flaviviridae, genus Flavivirus. There are four dengue virus serotypes (1-4) which are maintained endemically. The disease is endemic in tropical and subtropical areas between latitudes 35 degrees N and 35 degrees S. Infections may be asymptomatic or may produce a wide spectrum of diseases: non-specific febrile illness, dengue fever, dengue haemorrhagic fever or dengue shock syndrome. For the first time in Croatia, Ae. albopictus was registered in Zagreb in October 2004. In autumn 2005, additional records of Ae. albopictus presence were made in many places along the Adriatic coast. During 2007, two cases of imported dengue fever were reported in Croatia, after which similar imported cases appeared continually. In August 2010, the first autochthonous case of dengue fever was recorded on the peninsula Peljesac. Though Croatia is not endemic for dengue, the existence of a corresponding vector and a latent threat by imported dengue cases demand state-of-the-art and timely diagnostics. The most commonly used methods in laboratory diagnosis of dengue infections involve detection of viral RNA, antigen detection and serologic methods (detection of antibodies).

The role of IgG avidity in diagnosis of cytomegalovirus infection in newborns and infants

To evaluate the value of IgG avidity in diagnosis of congenital cytomegalovirus (CMV) infection in newborns and infants we collected serum samples from 40 infants under 12 months of age with suspected congenital CMV infection. Sera were tested for IgM, IgG and IgG avidity. For 25 of them, virus isolation and/or polymerase chain reaction (PCR) on urine specimens were performed. Thirteen (32.5%) patients showed the presence of CMV IgM antibodies, 3 (7.5%) had equivocal IgM result, and 24 (60.0%) patients had IgG antibodies only. Using IgG avidity, CMV infection (low avidity index-AI) was documented in 61.5% IgM positive and 54.2% IgM negative patients. Eight of nine (88.8%) IgM positive patients were positive either on virus isolation or PCR. In IgM negative patients, 46.6% urine cultures were positive for CMV and 66.6% were PCR positive. According to age, IgG avidity demonstrated acute/recent primary CMV infection in 58.8% patients younger than three months compared with 91.7% and 81.8% in 3-6 and 6-12 months old babies, respectively. In conclusion, IgG avidity is useful in diagnosis of CMV infection either in IgM positive or IgM negative children older than 3 months of age. In infants less than 3 months, transplacentally derived maternal IgG antibodies of high avidity influence on the IgG avidity result. In these children, CMV infection should be confirmed by direct virologic methods such as virus isolation or PCR.

[Virologic and epidemiological characteristics of non-polio infection in Croatia over a ten-year period (2000-2009)]

AIM

The aim of the present study was to show the virologic and epidemiological characteristics of non-polio enterovirus (NPEV) infection over a ten-year period in Croatia.

METHODS

During the 2000-2009 period, the Laboratory for Enteroviruses, Croatian Public Health Institute analyzed 2754 clinical samples collected from 1880 patients with a clinical picture of enteroviral infection. The diagnosis of enteroviral infection was confirmed by virus isolation in cell culture. Viruses were typed using indirect immunofluorescence and/or neutralization assay.

RESULTS

NPEV was proven in 394 (21%) of 1880 patients. Males were more commonly infected than females, at a ratio of 1.8:1, while the number of infected cases was highest among preschoolers and schoolchildren. Patients with isolated NPEV were most frequently diagnosed with aseptic meningitis (234/394; 59.4%). Infections were most commonly caused by echoviruses (218/394; 55.3%), followed by Coxsackie B (126/394; 32.0%) and Coxsackie A (31/394; 7.9%) viruses, rarely by echovirus 22 - parechovirus 1 (16/394; 4.1%) and enterovirus 71 (3/394; 0.8%). In most cases, echoviruses of the following serotypes were proven: 6, 9, 11, 13, 14, 18 and 30 (45/218, 21%; 14/218, 6.4%; 18/218, 8.3%; 15/218, 6.9%; 11/218, 5.0%; 55/218, 25.2% and 42/218, 19.3%), while serotypes 2, 3, 4, 5, 7, 12, 20, 21,25 and 26 were evidenced in a minority of patients or individual cases. Coxsackie B5 was the predominant serotype among Coxsackie B viruses (50/126, 40%), while Coxsackie A9 was most common Coxsackie A virus (26/31, 84%). Coxsackie B5 and B4 viruses were continually detected during the study period and appeared more frequently every four to five years. The most common echovirus isolate was echovirus 18, detected continually between 2000 and the outbreak year of 2006. Echovirus 6 and echovirus 30 were also isolated continually with peaks in 2002 and 2008, or 2002, 2006 and 2008.

CONCLUSION

The results of this study pointed to a specific pattern of the occurrence of certain NPEV serotypes in Croatia. The epidemic pattern (echovirus 18 and Coxsackie 81) was characterized by peaks with an elevated number of isolations in given years. Contrary to this, endemic viruses were isolated in similar counts every year (Coxsackie B3), or manifested milder epidemic peaks every few years (echoviruses 30 and 6, Coxsackie B4 and B5). Data on NPEV infections, given their serotype and specific pattern of occurrence, contribute significantly to prompt diagnostic, clinical and epidemiological response to NPEV infections.

Antimicrobial susceptibility and beta-lactamase production of selected gram-negative bacilli from two Croatian hospitals: MYSTIC study results

The meropenem yearly Susceptibility Test Information Collection (MYSTIC) programme is a global, longitudinal resistance surveillance network that monitors the activity of meropenem and compares its activity with other broadspectrum antimicrobial agents. We now report the antimicrobial efficacy of meropenem compared to other broad-spectrum agents within the selective Gram-negative pathogen groups from two Croatian Hospitals investigated between 2002-2007. A total of 1510 Gram-negative pathogens were tested and the minimum-inhibitory concentrations (MICs) were determined by broth microdilution method according to CLSI.There was no resistance to either imipenem or meropenem observed for Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis in both medical centers. High resistance rates of K. pneumoniae to ceftazidime (18%), cefepime (17%) and gentamicin (39%) are raising concern. Acinetobacter baumannii turned out to be the most resistant Gram-negative bacteria with 81% resistant to ceftazidime, 73% to cefepime, 69% to gentamicin and 71% to ciprofloxacin. Almost 20% of Pseudomonas aeruginosa strains were resistant to imipenem, 13% to meropenem, 69% to gentamicin and 38% to ciprofloxacin.The prevalence of extended-spectrum beta-lactamases (ESBLs) in E. coli was 10% and in K. pneumoniae 49%. PCR and sequencing of the amplicons revealed the presence of SHV-5 in nine E. coli strains and additional tem-1 beta-lactamase five strains. Five K. pneumoniae strains were positive for bla(SHV-5 )gene. Eight ESBL positive Enterobacter spp. strains were found to produce tem and CtX-m beta-lactamases. Plasmid-mediated AmpC beta-lactamases were not found among K. pneumoniae, E. coli and Enterobacter spp. Three A. baumannii strains from Zagreb University Center were identified by multiplex PCR as OXA-58 like producers. Six A. baumannii strains from Split University Center were found to possess an ISAba1 insertion sequence upstream of bla(OXA-51 )gene. According to our results meropenem remains an appropriate antibiotic for the treatment of severe infections caused by Gram-negative bacteria. These data indicate that despite continued use of meropenem, carbapenem resistance is not increasing among species tested, except for A. Baumannii, in the two study hospitals and suggest that clinicians can still administer carbapenems as a reliable and effective choice in managing serious nosocomial infections.

Seroprevalence of TORCH infections in women of childbearing age in Croatia

During 2005-2009, a seroepidemiological study was carried out in Croatia to define the population susceptible to common TORCH agents among pregnant and non-pregnant women of childbearing age. The IgG seroprevalence was 29.1% forT. gondii, 94.6% for rubella, 75.3% for cytomegalovirus (CMV), 78.7% for herpes simplex virus type 1 (HSV-1), and 6.8% for HSV-2. Acute toxoplasmosis and CMV infection (positive IgM antibodies with low IgG avidity) were documented in 0.25% and 0.09% women, respectively. IgM prevalence was 1.2% for both HSV-1 and HSV-2. None of the participants showed acute rubella infection. Seropositivity to T. gondii and HSV-2 varied significantly between age groups (p = 0.001 and p = 0.036, respectively). Women residing in rural regions showed a significantly higher seroprevalence rate for T. gondii, CMV, and HSV-1 than urban women (T. gondii: 44.0% vs. 25.4%, p < 0.001; CMV: 85.0% vs. 73.1%, p = 0.018; HSV-1: 86.0% vs. 76.4%, p = 0.041).

Trichophyton Spp. fungal keratitis in 22 years old female contact lenses wearer

Fungal keratitis represents one of the most difficult forms of microbial keratitis to diagnose and treat successfully. It is difficult to obtain correct diagnosis and topical antifungal preparations. Fungi can cause severe stromal necrosis and enter the anterior chamber by penetrating an intact Descemet membrane. The most common pathogens are filamentous fungi (Aspergillus and Fusarium spp.) and Candida albicans. The incidence of Trichophyton spp. keratitis is 5%. A 22 years old female contact lenses wearer after keratitis developed corneal melting syndrome, spontaneous perforation of the cornea and complicated cataract of the left eye. Conjunctival swab was sterile as well as first sample of corneal tissue and sample from the anterior chamber. Urgent therapeutic perforating keratoplasty (PK), was performed together with extracapsular cataract extraction and the implantation of the intraocular lens in the posterior chamber. The patient was treated with ciprofloxacin and diflucan (systemic therapy); with dexamethason and atropin (subconjunctivaly) and chlorhexidine, brolene, levofloxacin, polimyxin B, and dexamethason/neomycin (topically). Microbiology evaluation was performed once again following excisional biopsy of the intracameral portion of the lesion. The presence of Trichophyton spp. was finally confirmed. Itraconazole and garamycin were included in the systemic therapy. Corneal graft was clear for 17 days but decompensated 28 days after the PK. After two weeks microorganisms invaded the vitreous and caused endophthalmitis. Despite urgent pars plana vitrectomy patient developed endophthalmitis, lost light sensation and developed phthysis. Evisceration and the implantation of silicon prosthesis was done. Perforating keratoplasty is a method of choice in treating severe infectious keratitis unresponsive to conservative treatment but without the eradication of microorganisms it cannot restore the vision or save the eye. Trichophyton spp. may cause a severe disease of the anterior and posterior part of the eye which may finish with the lost of vision/eye. Prompt diagnosis and treatment of Trichophyton spp. keratitis are essential for a good visual outcome.

[Microbiological diagnosis of trichinellosis]

Trichinellosis is a parasitic mammalian disease caused by roundworms from the Trichinella genus. It is an important zoonosis with humans becoming infected by eating raw or inadequately cooked infested meat. The disease is widespread and represents a public health problem. According to the World Health Organisation estimations, some 11 million people are infected by Trichinella annually. Trichinellosis has a broad clinical presentation, ranging from asymptomatic to fatal. Since there are no pathognomonic signs or symptoms, clinical diagnosis is difficult and the only reliable diagnostic methods are those parasitological.

Painless Acanthamoeba keratitis in a soft contact lens wearer--case report

Aim of our paper is to present a case of painless Acanthamoeba keratitis in a soft contact lens wearer. A 17-year-old male, highly myopic, prolonged soft contact lens wearer, presented to us with painless red watery right eye having remarkably diminished vision. Last six weeks he was treated elsewhere for the microbial keratitis with no improvement. No pain was reported and on the direct questionnaire about it he denied it. There was marked mixed conjunctival and ciliary injection. A central stromal opacity with a pronounced surrounding corneal ring of inflammatory infiltration and epithelial defect was seen on biomicroscopy of the right eye. Circular pannus was already formed reaching epithelial defect overlying corneal ring infiltrate. Acanthamoeba spp in the corneal sample was confirmed. Prolonged therapy with 0.02% chlorhexidine digluconate solution combined with 0.1% hexamidine solution resulted in corneal healing left with a large central dense stromal opacity with circular pannus reaching peripheral third of the cornea but with very thin blood vessels and the best corrected visual acuity of 0.1 tested on Snellen chart. In conclusion, even in a lack of typical symptom for Acanthamoeba keratitis such as pain, this amoeba should be ruled out especially in a soft contact lens wearer.

Sensitivity and specificity of various beta-lactam antibiotics and phenotypical methods for detection of TEM, SHV and CTX-M extended-spectrum beta-lactamases

The aim of this study was to compare the sensitivity and specificity of six different beta-lactam antibiotics using five phenotypical tests for detection of extended spectrum beta-lactamases (ESBLs) based on synergism of beta-lactam antibiotics and clavulanate. Experiments were performed on a set of 80 Klebsiella pneumoniae strains and 105 Escherichia coli strains with previously characterized ESBLs (SHV, TEM and CTX-M). ESBLs were detected by five different phenotypical methods: MIC (minimum inhibitory concentration) determination of beta-lactam antibiotics with and without clavulanate, double-disk synergy test (DDST), inhibitor-potentiated disk-diffusion test (IPDDT), CLSI-Clinical and Laboratory Standard Institution (former NCCLS) combined-disk-test, and modified MAST-disk-diffusion test (MAST-DD-test). Seven antibiotics were tested as indicators of ESBL production: ceftazidime, cefotaxime, ceftriaxone, aztreonam, ceftibuten, cefpodoxime and cefepime. Ceftazidime and aztreonam were the best indicators for SHV-5, SHV-12 and TEM beta-lactamases whereas cefotaxime and ceftriaxone were the most sensitive in detection of SHV-2 and CTX-M beta-lactamases in DDST, IPDDT and CLSI test. MIC determination of beta-lactam antibiotics with and without clavulanate was the most sensitive method. DDST was the least sensitive test. Double-disk synergy test, which is the most frequently used test for detection of ESBLs in routine laboratories, was the least sensitive independently of the indicator antibiotic. Since MIC determination is a very laborious and time consuming method, we would recommend the NCCLS combined disk test or IPDD test for detection of ESBLs in routine laboratories with 5 mm zone augmentation breakpoint.

Milker's nodule--case report

Milker's nodule (noduli mulgentium) is a benign viral skin disease caused by parapoxvirus, a poxvirus that is endemic in cattle. The virus is usually transmitted to cattle handlers from infected cows. We present a case of a 25-year-old housewife who milked cows on her family farm and developed itchy, purplish red nodules on her fingers and hands, and lymphangiitis of the right arm. Two weeks before, several cows on her family farm were treated by a veterinarian under the diagnosis of pseudocowpox. She was treated with orally administered amoxicillin with clavulanic acid 2 g for 10 days, with complete resolution of lymphangiitis. The nodules resolved in several weeks.

[Rare cause of keratitis--Acanthamoeba spp]

Free-living amoebas, members of the genus Acanthamoeba are ubiquitous microorganisms that can be found in the soil, waters and dust. In immunosuppressed patients they are described as etiological agents of granulomatous amoebal encephalitis, pulmonary and skin infections. Acanthamoebal keratitis is described in previously healthy people which wear contact lenses. It is a serious disease which unrecognized at the right moment could cause losing of sight and eye. In this article we describe a female patient in whom acanthamoebal keratitis was diagnosed.