The Effect of Vitamin D Supplementation to Parameter of Sarcopenia in Elderly People: a Systematic Review and Meta-Analysis.

Background: Vitamin D plays an essential role in promoting skeletal muscle metabolism. Several studies show that vitamin D may help the elderly prevent sarcopenia. Nevertheless, the outcome remains debatable. Our meta-analysis aimed to summarize the effect of vitamin D supplementation on sarcopenia-related parameters. Methods: We searched PubMed, Cochrane, Springer, SAGE Journals, and Scopus abstracts on 10th December 2021 for relevant studies. We included articles that studied the effect of vitamin D on muscle mass, muscle strength, and physical performance. The aim was to measure the muscle mass, muscle strength, and physical performance both at baseline and at the end of the intervention. Results: A total of 6,628 participants from 35 studies were included. Most of the studies used oral vitamin D, whereas only one study used intramuscular injection. The effect of vitamin D supplementation showed no effect on appendicular skeletal muscle mass (SMD = .05 [95% CI, .33 - .44], p = .79). Regarding muscle strength, vitamin D supplementation did not have a significant effect on muscle strength which is handgrip strength (p = .26). Respecting physical performance, vitamin D supplementation did not affect TUG (Timed Up and Go) (p = .45). Conclusions: Vitamin D supplementation had minimal effect on sarcopenia-related parameters. Further research into understanding the role of Vitamin D in preventing the progressivity of sarcopenia still needs to be explored.

Diagnostic and Therapeutic Approaches for a Diabetic Patient Presenting with Secondary Syphilis and Severe Odynophagia.

Syphilis, an infectious disease caused by the spirochete Treponema pallidum, represents a pervasive global epidemic. Secondary syphilis is typically marked by the emergence of highly contagious mucocutaneous manifestations, including non-pruritic rashes on the palms and soles of the feet, alopecia, mucous patches, and condyloma lata. Here, we report a rare case of a 30-year-old male with newly discovered type 2 diabetes mellitus who presented with severe odynophagia due to secondary syphilis, confirmed by both nontreponemal VDRL/RPR and treponemal TPHA tests. Following the administration of a single-dose intramuscular injection of benzathine penicillin G 2.4 million units, the symptoms gradually decreased, allowing the patient to regain his health.

Puzzling Clinical Appearance of a Pancreatic Tuberculosis Case.

Tuberculosis (TB) is generally known as an infectious disease caused by Mycobacterium tuberculosis. Not only the lungs, TB can also infect various other organs. Pancreatic TB is a rare manifestation of extrapulmonary TB infection accounting for only 0-4.7% of the total TB cases worldwide. It's still intricating for clinicians to diagnose pancreatic TB due to the extremely rare prevalence and non-specific clinical signs and symptoms. Herein we report a 71-year-old male patient complaining of jaundice and weight loss. Clinical condition, laboratory and tumor markers, also MRI imaging showed no abnormality. We made the diagnosis through histopathological examination of tissues extracted from bypass biliodigestive procedure, showing granulomas, along with confirmed bacteriological analysis with Ziehl Nelsen staining. This patient received Fixed Drug Combination (FDC) of anti-tuberculosis therapy for 6 months. The patient gained weight, had an improvement of serum bilirubin level and had no remaining lesion in abdominal CT scan.

EBV-IgA antibody responses in endemic and nonendemic populations with nasopharyngeal carcinoma: tumour marker prognostication study and a cross-sectional study.

Nasopharyngeal carcinoma (NPC) is the most prevalent head and neck cancer in Indonesia, with 100% Epstein-Barr virus (EBV) infection in tumor cells. NPC is rare in the Netherlands. The involvement of EBV in NPC pathogenesis is reflected by early onset aberrant IgA antibody responses to various EBV proteins. Screening for elevated EBV-IgA levels is proposed for NPC risk assessment in endemic countries but is poorly studied in nonendemic regions. This study analyzed the overall diversity (immunoblot) as well as the prevalence and normalized levels of IgA responses to immunodominant peptide epitopes of EBV proteins VCA P18, EBNA 1, and Zebra (Zta) (N-terminus, P 125, P 130, full-length recombinant Zebra) in Indonesian (n=50) and Dutch (n=50) patients with NPC. The results confirmed that elevated levels of IgA-VCA P18 and IgA-EBNA 1 were found in both NPC populations, but that IgA-Zta was more variable. IgA-Zta responses were more pronounced in Indonesian NPC cases, reflecting more frequent EBV reactivation overall. IgA-VCA P18 and IgA-EBNA are independent tumor markers and are both necessary for NPC risk assessment. Overall, these results confirmed the diagnostic benefit of combined IgA-VCA P18/-EBNA 1 testing for NPC risk assessment in endemic and nonendemic populations.

Purple Urine Bag Syndrome in Urinary Tract Infection.

Purple urine bag syndrome (PUBS) is an unusual manifestation of urinary tract infection, characterized by purple discoloration of urine. Due to its rarity, it can be challenging for some physicians to manage it properly. In addition, its striking appearance can cause concern to some patients. This condition usually occurs in the debilitated geriatric population with prolonged use of an indwelling urinary catheter. However, our case highlights the development of PUBS in a young adult with a relatively short period of urinary catheterization.

Duration of SARS-CoV-2 RNA Shedding Is Significantly Influenced by Disease Severity, Bilateral Pulmonary Infiltrates, Antibiotic Treatment, and Diabetic Status: Consideration for Isolation Period.

Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) ribonucleic acid (RNA) shedding is an important parameter for determining the optimal length of isolation period required for coronavirus disease 2019 (COVID-19) patients. However, the clinical (i.e., patient and disease) characteristics that could influence this parameter have yet to be determined. In this study, we aim to explore the potential associations between several clinical features and the duration of SARS-CoV-2 RNA shedding in patients hospitalized with COVID-19. A retrospective cohort study involving 162 patients hospitalized for COVID-19 in a tertiary referral teaching hospital in Indonesia was performed from June to December 2021. Patients were grouped based on the mean duration of viral shedding and were compared based on several clinical characteristics (e.g., age, sex, comorbidities, COVID-19 symptoms, severity, and therapies). Subsequently, clinical factors potentially associated with the duration of SARS-CoV-2 RNA shedding were further assessed using multivariate logistic regression analysis. As a result, the mean duration of SARS-CoV-2 RNA shedding was found to be 13 ± 8.44 days. In patients with diabetes mellitus (without chronic complications) or hypertension, the duration of viral shedding was significantly prolonged (≥13 days; p = 0.001 and p = 0.029, respectively). Furthermore, patients with dyspnea displayed viral shedding for longer durations (p = 0.011). The multivariate logistic regression analysis reveals that independent risk factors associated with the duration of SARS-CoV-2 RNA shedding include disease severity (adjusted odds ratio [aOR] = 2.94; 95% CI = 1.36-6.44), bilateral lung infiltrates (aOR = 2.79; 95% CI = 1.14-6.84), diabetes mellitus (aOR = 2.17; 95% CI = 1.02-4.63), and antibiotic treatment (aOR = 3.66; 95% CI = 1.74-7.71). In summary, several clinical factors are linked with the duration of SARS-CoV-2 RNA shedding. Disease severity is positively associated with the duration of viral shedding, while bilateral lung infiltrates, diabetes mellitus, and antibiotic treatment are negatively linked with the duration of viral shedding. Overall, our findings suggest the need to consider different isolation period estimations for specific clinical characteristics of patients with COVID-19 that affect the duration of SARS-CoV-2 RNA shedding.

A rare case of Weil's disease with acute pancreatitis and acute kidney injury: focus on management - a case report.

The clinical spectrum of leptospirosis ranges from subclinical infection and anicteric fever to Weil's disease, a severely fatal infection. Acute inflammation of the pancreas is a rare manifestation of Weil's disease, and renal involvement is a hallmark in severe forms, leading to acute kidney injury (AKI) and representing a major risk factor for death. The aim of the case report was to present the clinical manifestations of Weil's disease with acute pancreatitis and AKI and to highlight the management of its complications. Case presentation: A 22-year-old male patient presented to the hospital with a chief complaint of a persisting fever, abdominal pain, nausea and vomiting, decreased appetite, malaise, and urine and feces discoloration. The patient's residence had flooded 2 weeks ago. Laboratory tests were performed and the patient was diagnosed with Weil's disease with the complication of acute pancreatitis, AKI, hyperkalemia, hyponatremia, hypotonic hypovolemic, metabolic acidosis, and hypoalbuminemia. Clinical discussion: The patient was treated with intravenous (i.v.) ceftriaxone at a dose of 2×1 g, i.v. metoclopramide at a dose of 3×10 mg, i.v. calcium gluconate at a dose of 1 g followed by dextrose (D) 40% with insulin 2 IU for six times, avoided nephrotoxic drugs, and fluid balance was maintained at I=O+500 ml. The patient received hemodialysis due to refractory hyperkalemia. Posttreatment follow-up presented improvements in complaints and laboratory parameters. Conclusion: Management of severe leptospirosis or Weil's disease with the complication of acute pancreatitis and AKI requires antibiotics and supportive therapy including adequate fluid resuscitation, proper and adequate nutrition, as well as the initiation of hemodialysis.

Factors associated with disease severity of COVID­19 in patients with type 2 diabetes mellitus.

Diabetes mellitus causes a decline in immunological function, an increase in proinflammatory cytokines, and a prothrombotic state, thus providing risk factors for the severity of coronavirus disease 2019 (COVID-19) in patients with type 2 diabetes mellitus (T2DM). The aim of the present study was to analyze the risk factors associated with the severity of COVID-19 in patients with T2DM. A cross-sectional observational study was performed on 201 patients with T2DM from May 1 to August 31, 2020 and admitted to the isolation ward of Dr Soetomo General Hospital (Surabaya, Indonesia). The patients were divided into severe (108 cases; 53.7%) and non-severe (93 cases; 46.3%) groups, which were considered the dependent variables. Univariate and multivariate analysis was performed. The independent variables were age, sex, diabetes onset, chronic complications, presence of hypertension, randomized blood glucose, HbA1c, albumin, and neutrophil-lymphocyte ratio (NLR). A P-value <0.05 was considered to be statistically significant. The median age of the 201 subjects was 56 years, with 70.1% <60 years old, 52.7% male, 76.1% with diabetes onset <10 years, and 108 patients (53.7%) in severe condition. The results of the bivariate analysis revealed that diabetes onset >10 years (OR 2.5; P=0.011) was associated with severity of COVID-19 in patients with T2DM, however hypoalbumin (OR 1.93; P=0.054) was not associated with disease severity. Furthermore, multivariate analysis revealed that male sex (OR 2.07; P=0.042), age (≥60 years) (OR 2.92; P=0.008), HbA1c (≥8%) (OR 3.55; P=0.001), hypertension (OR 4.07; P=0.001), and an NLR ≥7.36 (OR 6.39; P=0.001) were associated with severe COVID-19. Collectively, it was revealed that increased NLR, hypertension, poor glycemic control, older age, and male sex were risk factors associated with the severity of COVID-19 among diabetic patients.

Challenges and adversities among doctors in the era of healthcare disruption: Reflection from COVID-19 pandemic.

The doctor's profession is noble and tied up with quite strict rules, both in terms of ethics as well as discipline. Naturally, there is a problem of asymmetrical information between doctors and patients, often leading to misunderstandings. The purpose of this review is to map the available evidence related to the challenges and difficulties faced by doctors in the era of disruption. The evidence indicate that disruption of health services has both positive and negative effects. Many aspects related to the use of technology in the medical practices including innovation, cost-effectiveness, and quality improvement. However, psychologically, the doctors often get frustrated by internal or external triggers. The external factors, ranges from the equipment and work procedures, for instance, using high technology, communication with management, inter-professional relationships, patients, and their families. Volatility, uncertainty, complexity, and ambiguity (VUCA) could cause stress and burnout. In this case, doctors are highly vulnerable, and consequently, have the potential to make mistakes. Therefore, the adversity faced by doctors ought to be mapped. Resilience is a barrier against stress and burnout and the ability to adapt in resilience among doctors is important factor in dealing with the disruption era.

The role of mediator suppressor of cytokine signaling (SOCS), toll-like receptor 3 (TLR-3) and nuclear factor kappa B (NFκB) on cytokine production during dengue virus infection.

Inability to understand the pathogenesis of severe dengue, in particular the control mechanism of immune responses, has led to high mortality rate for patients with dengue shock syndrome (DSS). The aim of this study was to determine the control mechanism of cytokine production by mediator suppressor of cytokine signaling (SOCS), toll-like receptor 3 (TLR-3) and nuclear factor kappa B (NFκB) during DENV infection. Peripheral blood mononuclear blood cells (PBMC), isolated from healthy individuals, were infected with dengue virus (DENV)-2 strain SJN-006 Cosmopolitan genotype (isolated from Bali, Indonesia). The relative gene expression of SOCS-3, TLR-3, NFκB, and the cytokine genes (interleukin (IL)-6, IL-8, interferon inducible protein 10 (IP-10), and macrophage inflammatory protein-1 beta (MIP-1ß)) were measured using qRT-PCR at 6, 12 and 24 hours post infection (hpi). Student t-test and Mann-Whitney test were used to compare the gene expressions while causal correlations were analyzed using regression test and path analyses. DENV-2 infection increased the gene expression of SOCS-3, TLR-3, and NFκB after 12 and 24 hpi. The expression of IL-6, IL-8, IP-10, and MIP-1ß genes was increased and peaked at different times post-infection. NFκB and SOCS-3 genes likely have role in the upregulation of IL-8 and IL-6 gene expression, respectively. MIP-1ß gene expression was significantly induced by both NFκB and SOCS-3. In conclusion, our study suggested that SOCS-3, TLR-3, and NFκB are important in regulating the production of IL-6, IL-8, IP-10, MIP-1ß during early phase of DENV-2 infection. This enriches our understanding on pathogenesis pathway of DENV-associated cytokine storm.

The characteristics of bacteremia among patients with acute febrile illness requiring hospitalization in Indonesia.

Blood culturing remains the "gold standard" for bloodstream infection (BSI) diagnosis, but the method is inaccessible to many developing countries due to high costs and insufficient resources. To better understand the utility of blood cultures among patients in Indonesia, a country where blood cultures are not routinely performed, we evaluated data from a previous cohort study that included blood cultures for all participants. An acute febrile illness study was conducted from July 2013 to June 2016 at eight major hospitals in seven provincial capitals in Indonesia. All participants presented with a fever, and two-sided aerobic blood cultures were performed within 48 hours of hospital admission. Positive cultures were further assessed for antimicrobial resistance (AMR) patterns. Specimens from participants with negative culture results were screened by advanced molecular and serological methods for evidence of causal pathogens. Blood cultures were performed for 1,459 of 1,464 participants, and the 70.6% (1,030) participants that were negative by dengue NS1 antigen test were included in further analysis. Bacteremia was observed in 8.9% (92) participants, with the most frequent pathogens being Salmonella enterica serovar Typhi (41) and Paratyphi A (10), Escherichia coli (14), and Staphylococcus aureus (10). Two S. Paratyphi A cases had evidence of AMR, and several E. coli cases were multidrug resistant (42.9%, 6/14) or monoresistant (14.3%, 2/14). Culture contamination was observed in 3.6% (37) cases. Molecular and serological assays identified etiological agents in participants having negative cultures, with 23.1% to 90% of cases being missed by blood cultures. Blood cultures are a valuable diagnostic tool for hospitalized patients presenting with fever. In Indonesia, pre-screening patients for the most common viral infections, such as dengue, influenza, and chikungunya viruses, would maximize the benefit to the patient while also conserving resources. Blood cultures should also be supplemented with advanced laboratory tests when available.

Multicenter Study of the Risk Factors and Outcomes of Bloodstream Infections Caused by Carbapenem-Non-Susceptible Acinetobacter baumannii in Indonesia.

The prevalence of bacteremia caused by carbapenem-non-susceptible Acinetobacter baumannii (CNSAB) continues to increase, and it is associated with a high mortality rate. Early recognition of infection and mortality determinants risk factors is necessary for adequate antibiotic administration. We aimed to determine the risk factors and outcomes of CNSAB bacteremia in Indonesia. A multicenter case-control study was conducted in three referral hospitals in Indonesia. Data were collected retrospectively from January 2019 to December 2021. Cases were defined as patients with bacteremia where CNSAB was isolated from the blood, while the controls were patients with bacteremia caused by carbapenem-susceptible A. baumannii (CSAB). Risk factors for bacteremia and mortality associated with CNSAB bacteremia were determined using univariates analysis (chi-squared and Student's t-test or Mann-Whitney test) and multivariate logistic regression analysis. A total of 144 bacteremia patients were included, of whom 72 patients were for each case and control group. The final model of multivariate regression analysis revealed that bacteremia source from the lower respiratory tract (adjusted odds ratio (aOR): 3.24; 95% CI: 1.58-6.63, p = 0.001) and the use of central venous catheter (aOR: 2.56; 95% CI: 1.27-5.18; p = 0.009) were independent risk factors for CNSAB bacteremia. Charlson Comorbidity Index ≥ 4 (aOR: 28.56; 95% CI: 3.06-265.90, p = 0.003) and Pitt Bacteremia Score ≥ 4 (aOR: 6.44; 95% CI: 1.17-35.38; p = 0.032) were independent risk factors for mortality due to CNSAB bacteremia. Only high Pitt Bacteremia Score was an independent risk factor for mortality of CSAB bacteremia. In conclusion, we identified the risk factors for CNSAB-associated bacteremia and the risk factors for death, which are relevant for empiric therapy and infection control prevention, as well as prognosis evaluation of patients with bloodstream infections.

The susceptibility pattern and distribution of blaOXA-23 genes of clinical isolate Acinetobacter baumannii in a tertiary hospital, Indonesia.

INTRODUCTION: Acinetobacter baumannii, a pathogen of concern in hospitals worldwide, has diverse antimicrobial resistance mechanisms leading to limiting the antibiotic options and carbapenemase enzyme production is one of the common mechanisms in carbapenem resistance. The epidemiology and resistance pattern of clinical isolates are critical in developing a prevention and treatment strategy. The aim of this was to determine the prevalence and resistance pattern of carbapenem non-susceptible strains (CNS) A. baumannii at Arifin Achmad General Hospital, Pekanbaru, Indonesia. METHODOLOGY: Data were retrieved from the culture and susceptibility test results from various clinical specimens from January 2015 to December 2019. A susceptibility test was conducted using Vitek 2 Compact following the manufacturer's protocol. To explore the genetic profile of CNS A. baumannii, we amplified the blaOXA-23 and blaOXA-51 genes, carbapenemase producing genes, using a duplex polymerase chain reaction (PCR) among 24 isolates Chi-squared was used to assess the factors associated with the presence of CNS A. baumannii. RESULTS: Between 2015-2019, 1.263 A. baumannii isolates were tested and the prevalence of CNS A. baumannii was 50%. The trend decreased from 53% in 2016 to 45% in 2019. The proportion of CNS A. baumannii was higher among samples from patients treated in the Intensive Care Unit (ICU) compared to non-ICU (p < 0.001). The CNS A. baumannii was also more frequently detected from sputum than from non-sputum samples (p = 0.009). CNS A. baumannii were highly resistant to almost all antibiotics and the highest susceptibility was to amikacin, tigecycline, and trimethoprim/sulfamethoxazole with 64%, 53%, and 43%, respectively. The blaOXA-23 gene was detected in 92% of tested CNS A. baumannii isolates. CONCLUSIONS: The prevalence of CNS A. baumannii is high at Arifin Achmad Hospital Riau, Indonesia. This is also supported by the high prevalence of the blaOXA-23 gene among tested isolates. Based on the antibiotic susceptibility pattern there are limited antibiotic choices for CNS A. baummannii urging the strengthening of antimicrobial stewardship programs in the country.

Antibiotic Resistance in Non-Typhoidal Salmonella enterica Strains Isolated from Chicken Meat in Indonesia.

The increase in antibiotic resistance in non-typhoidal Salmonella enterica (NTS) has been confirmed in Indonesia by this study. We confirmed the virulence genes and antimicrobial susceptibilities of clinical NTS (n = 50) isolated from chicken meat in Indonesia and also detected antimicrobial resistance genes. Of 50 strains, 30 (60%) were non-susceptible to nalidixic acid (NA) and all of them had amino acid mutations in gyrA. Among 27 tetracycline (TC) non-susceptible strains, 22 (81.5%) had tetA and/or tetB. The non-susceptibility rates to ampicillin, gentamicin or kanamycin were lower than that of NA or TC, but the prevalence of blaTEM or aadA was high. Non-susceptible strains showed a high prevalence of virulence genes compared with the susceptible strains (tcfA, p = 0.014; cdtB, p < 0.001; sfbA, p < 0.001; fimA, p = 0.002). S. Schwarzengrund was the most prevalent serotype (23 strains, 46%) and the most frequently detected as multi-antimicrobial resistant. The prevalence of virulence genes in S. Schwarzengrund was significantly higher than other serotypes in hlyE (p = 0.011) and phoP/Q (p = 0.011) in addition to the genes above. In conclusion, NTS strains isolated from Indonesian chicken had a high resistance to antibiotics and many virulence factors. In particular, S. Schwarzengrund strains were most frequently detected as multi-antimicrobial resistant and had a high prevalence of virulence genes.

Association between Sarcopenia and Insulin-Like Growth Factor-1, Myostatin, and Insulin Resistance in Elderly Patients Undergoing Hemodialysis.

Sarcopenia is common in hemodialysis patients, especially in the elderly patients undergoing hemodialysis. Various factors may contribute to the occurrence of sarcopenia, such as anabolic and catabolic imbalance. This study aims to investigate the correlation of insulin-like growth factor-1 (IGF-1) levels as an anabolic factor, myostatin levels, and insulin resistance as catabolic factors with sarcopenia in the pathogenesis of sarcopenia in elderly patients undergoing hemodialysis. A total of 40 subjects aged 60 years or more who undergoing hemodialysis in Dr. Soetomo Hospital Surabaya were included in this cross-sectional study. Sarcopenia was diagnosed according to Asian Working Group Sarcopenia 2019 criteria. IGF-1, myostatin, and insulin resistance levels were measured once before hemodialysis. Subjects with sarcopenia diagnosis were 33 (82.5%), that is, 19 (47.5%) men and 14 (35%) women. There were 28 (70%) of the subjects diagnosed with severe sarcopenia. Furthermore, there were significant differences in the characteristics and geriatric parameters between the sarcopenia and nonsarcopenia groups. There were differences between the two groups in hemoglobin levels, IGF-1 levels, myostatin levels, homeostasis model assessment-insulin resistance (HOMA-IR) levels, muscle mass, handgrip strength, body mass index status, mini nutritional assessment status, and physical activity scale for elderly status (all p < 0.05). Correlation analyses showed that IGF-1 levels negatively correlated with sarcopenia status in elderly patients undergoing hemodialysis (p < 0.05). On the contrary, myostatin and HOMA-IR levels were positively correlated with sarcopenia status in elderly patients undergoing hemodialysis (all p < 0.05). Based on this recent study, IGF-1, myostatin, and insulin resistance were significantly correlated with sarcopenia in elderly patients undergoing hemodialysis.

National early warning score (NEWS) 2 predicts hospital mortality from COVID-19 patients.

Background: COVID-19 has a high risk of mortality, especially in patients with comorbid diseases such as cardiac disease, type 2 diabetes mellitus, chronic kidney disease, and hypertension. The National Early Warning Score (NEWS) is a tool that helps in identifying changes in patient conditions that require intensive treatment. Objective: Analyzing NEWS-2 to identify the risk of death in COVID-19 patients. Methods: This research was conducted from June to July 2020 by using quota sampling. The number of participants in this study was 112 participants (case group = 56 participants and control group = 56 participants). Participants were assessed for NEWS-2 and evaluated for their treatment outcomes. The analysis used in this study was the Chi-squared test and logistic regression with p < 0.05. Results: 45 participants died of having NEWS-2 score >5, and as many as 50 participants showed an improvement in their condition by having NEWS-2 score 5 (OR = 34.091; p < 0.001). The accuracy of NEWS-2's assessment of mortality of COVID-19 patients had a sensitivity of 80.4% and a specificity of 89.3%. There were several comorbid diseases that had a significant relationship on mortality of COVID-19 patients such as cardiac disease (ß = 5.907; 1.107-31.527 95% CI; p = 0.038), T2DM (ß = 3.143; 1.269-7.783 95% CI; p = 0.013), CKD (ß = 3.851; 1.195-12.416 95% CI; p = 0.024), and hypertension (ß = 2.820; 1.075-7.399 95% CI; p = 0.035). Conclusion: The NEWS-2 can be used to identify the risk of death of COVID-19 patients.

Distribution of Carbapenemase Genes among Carbapenem-Non-Susceptible Acinetobacter baumanii Blood Isolates in Indonesia: A Multicenter Study.

Carbapenem non-susceptible Acinetobacter baumannii (CNSAB) is an important pathogen that causes nosocomial bacteremia among critically ill patients worldwide. The magnitude of antibiotic resistance of A. baumanii in Indonesia is expected to be significant; however, the data available are limited. The aim of this study was to analyze the genetic profiles of CNSAB isolates from patients with bacteremia in Indonesia. CNSAB isolates from blood cultures of bacteremia patients in 12 hospitals in Indonesia were included. The blood cultures were conducted using the BacT/Alert or BACTEC automated system. The CNSAB were identified with either Vitek 2 system or Phoenix platform followed by a confirmation test using a multiplex polymerase chain reaction (PCR) assay, targeting the specific gyrB gene. The carbapenemase genes were detected by multiplex PCR. In total, 110 CNSAB isolates were collected and were mostly resistant to nearly all antibiotic classes. The majority of CNSAB isolates were susceptible to tigecycline and trimethoprim-sulfamethoxazole (TMP-SMX), 45.5% and 38.2%, respectively. The blaOXA-51-like gene was identified in all CNSAB isolates. Out of the total, 83.6% of CNSAB isolates had blaOXA-23-like gene, 37.3% blaOXA-24-like gene, 4.5% blaNDM-1 gene, 0.9% blaIMP-1 gene, and 0.9% blaVIM gene. No blaOXA-48-like gene was identified. The blaOXA-23-like gene was the predominant gene in all except two hospitals. The presence of the blaOXA-24-like gene was associated with resistance to tigecycline, amikacin, TMP-SMX and cefoperazone-sulbactam, while blaOXA-23-like gene was associated with resistance to TMP-SMX and cefoperazone-sulbactam. In conclusion, the blaOXA-23-like gene was the predominant gene among CNSAB isolates throughout Indonesia. A continuous national surveillance system needs to be established to further monitor the genetic profiles of CNSAB in Indonesia.

Hematologic and coagulopathy parameter as a survival predictor among moderate to severe COVID-19 patients in non- ICU ward: a single-center study at the main referral hospital in Surabaya, East Java, Indonesia.

Background : This research aimed to examine and analyze risk factors for death, hematologic parameters and coagulation in COVID-19 patients at RSUD Dr. Soetomo Surabaya, one of the referral centers for probable COVID-19 patient cases in East Java. Method : This was a retrospective analytical study by taking secondary data on patients with probable COVID-19 cases who were treated in hospital isolation rooms from May to September, 2020. Result : Of 538 probable COVID-19 patients, 217  tested positive, with an average age of 52.11±13.12 years, and there were 38 death cases. Hematologic parameters, such as white blood cell, neutrophil and lymphocyte counts, were significantly different in the deceased group. On the other hand, coagulation parameters, consisting of D-dimer, CRP, PT, and aPTT showed significantly similar value in the deceased group. Univatiate analysis concluded that chronic kidney disease, diabetes mellitus, coronary heart disease, WBC, NLR, and PPT counts could predict the mortality, while multivariate analysis revealed that coronary heart disease was the only significant independent predictor of mortality. Conclusion : This research shows that hematologic and coagulation parameters were increased in the majority of COVID-19 patients and the deceased group. While the number of neutrophils and WBC increases, the number of lymphocytes decreases significantly with increasing disease severity. Coronary heart disease is an independent predictor of mortality.

Quantitative cytokine level of TNF-α, IFN-γ, IL-10, TGF-ß and circulating Epstein-Barr virus DNA load in individuals with acute Malaria due to P. falciparum or P. vivax or double infection in a Malaria endemic region in Indonesia.

Plasmodium falciparum Malaria and Epstein-Barr Virus (EBV) infection are risk factors in the development of Burkitt's lymphoma. In Indonesia, 100% of the population is persistently infected with EBV early in life and at risk of developing EBV-linked cancers. Currently, 10.7 million people in Indonesia are living in Malaria-endemic areas. This cross-sectional study was initiated to investigate how acute Malaria dysregulates immune control over latent EBV infection. Using blood and plasma samples of 68 patients with acute Malaria and 27 healthy controls, we measured the level of parasitemia for each plasmodium type (P. falciparum, P. vivax, and mixed) by microscopy and rapid test. The level of 4 regulatory cytokines was determined by quantitative ELISA and the level of circulating EBV genome by real-time PCR targeting the single copy EBNA-1 sequence. All Plasmodium-infected cases had high-level parasitemia (>1000 parasites/ul blood) except for one case. EBV-DNA levels were significantly more elevated in P. falciparum and P. vivax infections (P<0.05) compared to controls. EBV-DNA levels were not related to age, gender, Malaria symptoms, or plasmodium type. TNF-α and IL-10 levels were increased in Malaria cases versus controls, but IFN-γ and TGF- ß levels were comparable between the groups. Only TNF-α levels in P. falciparum cases showed a clear correlation with elevated EBV DNA levels (R2 = 0.8915). This is the first study addressing the relation between EBV (re)activation and cytokine responses during acute Malaria, revealing a clear correlation between pro-inflammatory cytokine TNF-α and EBV-DNA levels, specifically in P. falciparum cases, suggesting this cytokine to be key in dysregulating EBV homeostasis during acute P. falciparum Malaria.

Prevalence of HIV Infection and Resistance Mutations in Patients Hospitalized for Febrile Illness in Indonesia.

HIV prevalence in Indonesia is increasing, and only 64% of infected individuals know their status. In a prospective cohort of 1,453 hospitalized patients with unexplained fever, 46 (3.2%) had HIV, including 15 (1.1%) patients without a prior HIV diagnosis. Among 31 subjects previously known to have HIV, 21 (68%) had been receiving combination antiretroviral therapy (cART) at the time of enrollment. Of 39 HIV cases with HIV RNA levels ≥ 100 copies/mL, sequencing for genotype analysis and resistance testing was successful in 30 (77%) subjects. The most common HIV subtypes were AE (90%) and B (10%). Five (16.7%) subjects had resistance mutations to nucleoside and non-nucleoside reverse transcriptase inhibitors, and all of them were on cART. No evidence of transmitted drug resistance was found in newly diagnosed individuals. Hospital-based screening may be an efficient method to expand HIV testing and identify a significant number of new cases. Access to care, close monitoring, expansion of anti-retroviral options, and ensuring availability of CD4 determinations, viral load testing, and genotyping are crucial to control of the epidemic in Indonesia.