[Should Tetanus Vaccine Booster be Given Earlier in Individuals Living with HIV?] / HIV ile Yasayan Bireylerde Tetanos Asisinin Rapeli Daha Erken Yapilmali Mi?

The incidence rate of tetanus has dramatically decreased following the discovery of the tetanus vaccine. A decennial booster dose is necessary to maintain the protective antibody levels after the primary vaccination schedule. The recommendations for the tetanus booster doses in adult "people living with acquired immune deficiency virus (HIV)" (PLWH) is similar to those for the general population. However, the duration of protective antibodies in PLWH is unknown. The aim of this study was to determine the factors affecting the response of HIV-infected individuals to tetanus vaccine and to evaluate the role of tetanus antitoxin level in determining the timing of the booster dose. PLWH attending the Adult Vaccination Unit of Ege University Faculty of Medicine Infectious Diseases and Clinical Microbiology Department were tested for tetanus antibodies from 30 October to 30 November 2020. Demographic information and the history of primary vaccination and booster doses were derived from medical files. Tetanus antibodies were detected with "enzyme immunoassay (EIA)" method with Clostridium tetani toxin 5S IgG-"enzyme linked immunosorbent assay (ELISA)" kit (Nova Lisa, Novatec Immundiagnostica, Germany). Antibody levels <0.01 IU/ml were considered negative, 0.01-0.5 IU/ml weak positive, 0.51-1.0 IU/ml positive and > 1.1 IU/ml strong positive. A level ≥ 0.50 IU/ml was considered as protective. The study included 146 PLWH [men (n= 126) and women (n= 40)]. The mean age was 39.5 ± 11.20 years (range: 18-65). Protective antibody level was detected in 114 (78.1%) participants. Receiver operating characteristics (ROC) analysis revealed that the ideal lower limit of CD4+ T cell count during booster vaccination for a person to develop protective antibody level was calculated as ≥ 218 cell/mm3. In the multivariate analysis, it was found that age <50 years (OR= 16.4, 95% CI= 4.9-55.2), the absence of AIDS at the time of diagnosis (OR= 6.7, 95% Cl= 1.05-17.4) and CD4+ T cell count ≥ 218 cells/mm3 at the time of vaccination (OR= 4.2, 95% CI= 1.05-17.4) were associated with protective levels of antibody. Protective levels of tetanus antibodies in PLWH are lower than the general population. It should be considered that the booster dose may be required earlier, especially in PLWH who are > 50 years old, with CD4+ T lymphocyte count <200 cells/mm3 during previous booster vaccination and who had AIDS at the time of the diagnosis.

Outbreak caused by NDM-1- and RmtB-producing Escherichia coli in Bulgaria.

Twelve consecutive carbapenem-resistant Escherichia coli isolates were recovered from patients (infection or colonization) hospitalized between March and September 2012 in different units at a hospital in Bulgaria. They all produced the carbapenemase NDM-1 and the extended-spectrum-ß-lactamase CTX-M-15, together with the 16S rRNA methylase RmtB, conferring high-level resistance to all aminoglycosides. All those isolates were clonally related and belonged to the same sequence type, ST101. In addition to being the first to identify NDM-producing isolates in Bulgaria, this is the very first study reporting an outbreak of NDM-1-producing E. coli in the world.

Missed Opportunities in HIV Testing in Turkiye: Implications for Late Diagnoses.

BACKGROUND: Late diagnosis of HIV infection is a major global problem. In Turkiye, only 41%-50% of people living with HIV are diagnosed, suggesting that many opportunities for HIV testing might be missed. SETTING: The aim of this study was to determine the missed testing opportunities for HIV in healthcare settings in Turkiye and the predictors for missed opportunities (MOs). METHODS: The study included patients with a new HIV diagnosis, presenting to care between January 2018 and December 2020. They were given a verbal questionnaire face to face, by a telephone call or an online meeting for visits to a health care setting within the year before their diagnosis. Electronic medical records were also examined. RESULTS: The sample included 198 patients with at least 1 visit to any health care setting, with a total of 1677 visits. Patients had an indication for HIV testing in 51.3% (861/1677) of the visits; an HIV test was not offered in 77.9% (671/861) and was considered a MO. The highest number of MOs was in emergency departments (59.8%) (180/301). The most common reason for visiting was constitutional symptoms and indicator conditions (55.4%) (929/1677). University graduates and those with a CD4+ T-cell count <200/mm 3 were more likely to have a MO. CONCLUSIONS: Many opportunities to diagnose HIV at an early stage are missed in health care settings in Turkiye. Considering the rapidly increasing number of new diagnoses in the last decade, urgent action needs to be taken.

Endogenous Endophthalmitis Caused by Aspergillus lentulus in an Immunocompromised Patient with Lung Cancer

A 78-year-old man with a history of lung cancer, chemotherapy, radiotherapy, and coronavirus disease 2019 infection experienced visual deterioration of two-weeks' duration in his right eye. There was multifocal, yellowish-white retinitis foci, vascular engorgement, and scattered intraretinal hemorrhages extending from posterior pole to retinal periphery in the right eye, whereas the left eye was normal. Intravitreal vancomycin, ceftazidime, clindamycin, and dexamethasone were given for endogenous endophthalmitis initially. Vitreous culture confirmed the presence of Aspergillus lentulus, and he was treated with intravitreal amphotericin-B and voriconazole injections together with systemic amphotericin-B, voriconazole, posaconazole, and micafungin therapy. During follow-up, vitreoretinal surgery was performed because of rhegmatogenous retinal detachment, and he received one additional cycle of chemotherapy due to recurrence of the cancer. Although the retina was attached, enucleation was eventually required due to painful red eye. Atypical squamous cells beneath the neurosensory retina suggesting metastasis were noted on histopathological examination. Timely ocular examination is crucial for any immunocompromised patient having ocular symptoms. High level of suspicion for a fungal etiology is a must in these patients.

Prevalence of Cardiovascular Disease and Comparison of Risk Category Predictions of Systemic Coronary Risk Evaluation Score-2 and 4 Other Cardiovascular Disease Risk Assessment Tools Among People Living with Human Immunodefficiency Virus in Türkiye.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of mortality among people living with HIV (PLWH). We aimed to assess the prevalence of diagnosed CVD and the risk of CVD among PLWH using 5 different tools. METHODS: This retrospective, cross-sectional study was conducted in 20 tertiary centers in Türkiye between October 2021 and March 2022, among 1425 PLWH aged 40-75 years. About 82.7% were male, with a median age of 51. Web-based tools for each score were used for CVD risk calculations. RESULTS: Of 1425 PLWH enrolled, 10.8% had confirmed CVD, and 1132 had their risk scores evaluated. Of those participants, 42.8% had a higher risk of CVD (10-year risk of atherosclerotic CVD risk score (ASCVD) above 7.5%), and according to the European Society of Cardiology systemic coronary risk evaluation 2 (SCORE2), 71.7% had a high- to very high-risk rate. The agreement between various CVD risk tools varied, with Framingham heart study risk score (FRS), modified FRS, data collection on adverse effects of anti-HIV drugs (DAD), and SCORE2 for high-risk countries showing overall agreement rates of 82%, 94%, 91%, and 36%, respectively, compared to ASCVD. According to the 2021 European and 2019 American Cardiology guidelines, 75.3% and 47.1% of PLWH would be eligible for lipid-lowering agents, respectively. CONCLUSION: The diagnosed CVD prevalence highlighted the importance of monitoring cardiovascular health and comorbidities in this population. SCORE2 identified a greater number of individuals at high/very high risk compared to other prediction tools. The implementation of CVD prevention through lipid-lowering therapy was far from desired levels in our cohort.

Never forget ocular syphilis: A case series from a single tertiary centre.

A retrospective analysis of 10 consecutive patients who had serologically confirmed ocular syphilis between June 2020 and February 2023 was performed. All cases presented with ocular manifestations. Eight patients were diagnosed with syphilis and two patients with syphilis/human immunodeficiency virus co-infection. Type and duration of antibiotic treatments were diverse among the patients. Four patients had intramuscular benzyl-penicillin G 2.4 million units (MU) weekly for three weeks; four, intravenous ceftriaxone for 14 days; one, intravenous penicillin G 24 MU/day for 14 days; and the remaining patient, intravenous penicillin G 24 MU/day for a week and then oral doxycycline for two weeks. As adjunctive therapy to systemic antibiotics, oral corticosteroids in three patients and intravitreal ceftazidime (2.25 mg/0.1 mL) injections in one patient were administered. In conclusion, ocular syphilis is a re-emerging phenomenon; prompt diagnosis and proper antibiotic treatment can prevent serious ocular complications.

Awareness of HIV pre-exposure prophylaxis among men who have sex with men using apps for sexual encounters in Turkiye.

BACKGROUND: New HIV diagnoses are rising in Turkiye. Men who have sex with men (MSM) are estimated to be the main driver of the epidemic. Pre-exposure prophylaxis (PrEP) was proven to be effective in reducing new HIV diagnoses and PrEP recently became available in Turkiye. OBJECTIVE: To assess awareness of and willingness to use PrEP and the level of off-licence use among MSM. METHODS: An anonymous self-completed questionnaire was sent out over the Hornet Gay Social Network from December 2019 to February 2020, available in Turkish and Arabic. It included 20 questions on HIV and STI testing, PrEP awareness, PrEP use, willingness to use, chemsex and sexual happiness level. RESULTS: Overall 4761 respondents who responded to more than 1/3 of the questions were eligible for analyses; 5.5% was Arabic speaking. The mean age was 30.5 years, 31.4% had never tested for HIV, 40.5% knew what PrEP was, the most common source of knowledge was the internet (44.5%), 2.5% (120) had used PrEP in the last 12 months and 1.7% (83) was current users. PrEP users had accessed drugs over the internet (47.6%), pharmacy (23%), and friends (13.8%). Almost 40% were willing to use PrEP in the following 6 months. Younger and Arabic speaking respondents had lower rates of HIV testing (p = .001) and lower awareness for PrEP than comparators (p = .004). CONCLUSION: Awareness and willingness to use PrEP is high among MSM in Turkiye. The recent availability of PrEP in the country is a big step forward in terms of prevention.

The Effect of the Pandemic on Antifungal Use: What Has Changed?

Objective: During the COVID-19 pandemic, antimicrobial and antifungal stewardship programs have lost their priority. Although all parenteral antifungals were used with the recommendations of infectious diseases specialists in the pre-pandemic period, most consultations were delayed during the pandemic because of the workload of infectious diseases specialists. In this period, antifungal treatments in hospitalized patients were managed by mostly primary physicians. Therefore, we aimed to detect the change in the consumption of antifungals during the pandemic. Materials and Methods: The data on the antifungal drug use by month and clinics, the number of beds, and the occupancy rate of the clinics were obtained from the hospital information registration system. We defined each drug according to the World Health Organization Anatomical Therapeutic Chemical (WHO ATC) coding system and determined the defined daily dose (DDD). The antifungal consumption (DDD/ 100 bed-days) in pre-pandemic and pandemic periods was compared. Results: During the pandemic, the antifungal consumption increased two-fold (2019:7.43; 2020:18.03 DDD/100 bed-days). The highest antifungal consumption rate was in the hematology- oncology-hematopoietic stem cell transplantation (HSCT) clinics with 2.5-fold (2019:39.86; 2020:98.48 DDD/ 100 bed-days) increase. Liposomal amphotericin B consumption made up the majority of this with a four-fold increase in the hematology-oncology-HSCT clinics. Conclusion: We detected a dramatic increase in antifungal consumption in both ICUs and inpatient clinics during pandemic. A novel antifungal stewardship approach is urgently needed.

Fungal colonization and infections in patients with COVID-19 in intensive care units: A real-life experience at a tertiary-care hospital.

PURPOSE: To evaluate the management of patients with COVID-19 in the intensive care units (ICUs) with fungal infection/colonization and to highlight diagnostic problems in these patients. METHODS: We included all patients with a COVID-19 diagnosis who were aged ≥18 years and followed in the ICU for the first 8 months. Patient data were obtained from medical records. We compared the risk factors, laboratory data, and outcomes of patients with fungal infection/colonization. RESULTS: A total of 118 patients (81 men and 37 women) were included. The mean age was 70.3 ± 14.8 (35-94) years. Of the patients, 79 (66.9%) patients were ≥65 years old. Fungal infection/colonization was detected in 39 (33.1%) patients. Fungi were isolated from 34 (28.8%) patients. Ten fungal species were isolated from 51 samples (the most common being Candida albicans). Three patients (2.5%) had proven candidemia. We observed two (1.7%) possible cases of COVID-19-associated pulmonary aspergillosis (CAPA). Eighteen patients (15.3%) underwent antifungal therapy. The risk of fungal infection/colonization increased as the duration of invasive mechanical ventilation increased. The fatality rate was 61.9% and increased with age and the use of mechanical ventilation. The fatality rate was 4.2-times-higher and the use of mechanical ventilation was 35.9-times-higher in the patients aged ≥65 years than in the patients aged <65 years. No relationship was found between fungal colonization/infection, antifungal treatment, and the fatality rate. CONCLUSION: During the pandemic, approximately one-third of the patients in ICUs exhibited fungal infection/colonization. Candida albicans was the most common species of fungal infection as in the pre-pandemic area. Because of the cross-contamination risk, we did not performed diagnostic bronchoscopy and control thorax computed tomography during the ICU stay, and our patients mainly received empirical antifungal therapy.