DOI: 10.3897/folmed.68.e182189

Authors: Georgi Lukanov, Atanas Panev, Lubomir Tzvetanov, Kevork Kaykchian, Alexander Gerchev, Plamen Kinov, Slaveyko Djambazov

Abstract: Abstract Introduction: Total hip arthroplasty is one of the most successful modern surgical procedures, yet periprosthetic joint infection (PJI) remains a serious complication associated with disability and increased postoperative mortality. Aim: This study highlights the importance of identifying the causative microorganism and its antibiotic susceptibility profile for the successful application of a one-stage revision protocol in treating PJI. Materials and methods: Between October 2017 and July 2023, 33 patients underwent one-stage revision total hip arthroplasty. Preoperative joint aspiration and intraoperative periprosthetic tissue sampling were performed in all cases, with microbiological analysis conducted. The study group consisted of 15 men and 18 women, with a mean postoperative follow-up of 33 months (range 2–66 months). Results: A pathogen was identified in 31 patients. Staphylococcus epidermidis was the most common microorganism, responsible for 44.1% of infections. Staphylococcus aureus was found in 14.7% of cases. Enterococcus faecalis was isolated in three patients, and Serratia marcescens in two. No infection recurrence was recorded during follow-up. Complications included two postoperative dislocations, both managed with closed reduction, and one death due to pulmonary embolism. Functional outcomes improved, with the mean Harris Hip Score increasing from 54.3 preoperatively to 72.3 postoperatively. Conclusion: In this selected cohort, one-stage revision was associated with favorable short- to mid-term outcomes. These findings suggest that, when guided by precise microbiological diagnosis and multidisciplinary management, one-stage revision may be a viable option for carefully selected patients with periprosthetic hip infection.

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DOI: 10.3897/folmed.68.e172980

Authors: Blagovest Petrov, Kostadin Kostadinov, Ivan Dechev, Krasimira Eneva

Abstract: Background: Sexually transmitted infections (STIs) have been linked to male infertility; however, the available evidence from Eastern Europe is inconclusive. Aim: The present study therefore set out to assess the prevalence and etiology of STIs, focusing on Trichomonas vaginalis, among infertile Bulgarian men. Materials and methods: A retrospective monocentric study was conducted at Thorax Hospital, Plovdiv, between May 2018 and May 2024, on 359 infertile and subfertile men. The study adhered to the World Health Organization (WHO) guidelines for the evaluation of semen parameters. Ejaculate, prostatic secretions and urethral swabs were subjected to a culture and microscopy procedure for 16 pathogens. The associations between semen quality and these parameters were examined using t-tests, chi-squared tests and logistic regression. Results: Sexually transmitted infections were detected in 48.5% (174/359). Frequent pathogens were Ureaplasma urealyticum (29.5%), group B streptococcus (25.1%), Enterococcus spp. (13.9%), and coagulase-negative staphylococci (CoNS) (13.9%). The prevalence of T. vaginalis was 6.7% (24/359) and associated with lower progressive motility (β=−7.66 percentage points; p=0.028, uncorrected). Coinfections occurred in 42.1%, monoinfections in 39%. Prostatic secretions were more often positive than ejaculate (54.7% vs. 46.9%; p=0.06). No significant between-group differences were seen for sperm concentration (43.9 vs. 46.7 million/mL, p=0.307) or symptoms (21.3% vs. 27.6%, p=0.206). Multivariable models found no independent clinical predictors (all p>0.05), while pathogen burden correlated with motility (r =−0.152, p=0.004). Conclusion: Sexually transmitted infections (STIs), particularly U. urealyticum and T. vaginalis, are common in infertile Bulgarian men and often remain asymptomatic. Routine broad-spectrum screening, including prostatic sampling, is warranted to detect treatable causes and potentially optimize fertility outcomes. Prospective studies should determine whether the eradication of these infections improves semen quality. These findings emphasize the necessity for standardized, comprehensive diagnostics and meticulous interpretation of colonizers versus pathogens in infertility evaluations to inform management decisions.

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DOI: 10.3897/folmed.68.e161534

Authors: Iurii Mochalov, Marina Kryvtsova, Serhii Tsuperiak, Bogdan Mykhailychenko, Nutsu Guzo, Alla Kizim

Abstract: Introduction: Lateral sinus lift is a common procedure in the field of dentistry, employed for the purpose of preparing the maxilla for subsequent dental implantation. This procedure is associated with a significant risk of intra- and postoperative complications, largely attributable to the presence of pathogenic microorganisms within the oral cavity and maxillary sinus. Aim: The aim of the present study was to determine the species composition of the microorganisms (pathogenic and opportunistic) in four biotopes in the maxillofacial region (Schneiderian membrane, pharynx, nasal passage, and oral mucosa) during a planned sinus lift and detect their sensitivity to antibiotics. Materials and methods: Biological material (swabs) was examined bacteriologically by cultivating it on standard and differential diagnostic nutritional media; antibiotic sensitivity of the isolated strains was assessed using the disk diffusion method. Results: The ambiguous picture of microorganism persistence in the various biotopes of the maxillofacial region was identified. , Pseudomonas aeruginosa, and Candida were detected in clinically significant amounts in the maxillary sinuses of healthy patients. Ceftriaxone and cefoperazone/sulbactam were the most effective antibiotics against microorganisms isolated in clinically significant concentrations across all biotopes. Cefuroxime was effective against 75% of all bacteria tested. Gatifloxacin was effective, with no cases of resistance reported. The fungi in the maxillary sinus mucoperiosteum were sensitive to fluconazole, ketoconazole, and clotrimazole, but only moderately sensitive to itraconazole and nystatin. Conclusion: The findings suggest that patients undergoing sinus lift surgery may have fewer options for prophylactic antibacterial therapy. Bacteriological studies on oral and nasal mucosa do not predict the presence of pathogenic microorganisms in the maxillary sinus.

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DOI: 10.3897/folmed.67.e144634

Authors: Marina Raquel Gomes Coelho, Luzia Bismarck, Manuel Ribeiro, Rita de Mora Féria, Teresa Vilaça

Abstract: Q fever is a systemic zoonotic infection with a wide range of clinical presentations leading to a laborious diagnosis. We present a case of a 28-year-old man who was diagnosed with acute Q fever with typical hepatic and bone marrow involvement, characterized by acute hemolytic anemia, which is not commonly associated with this disease. This underscores the importance of including Q fever in the differential diagnosis when facing unexplained systemic or hematologic abnormalities.

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DOI: 10.3897/folmed.67.e152245

Authors: Savaş Gegin, Ahmet Cemal Pazarlı, Burcu Özdemir, Levent Özdemir, Esra Arslan Aksu

Abstract: Aim: This study aimed to identify bacterial pathogens causing chronic obstructive pulmonary disease (COPD) exacerbations and asthma attacks by evaluating nasopharyngeal swabs tested by polymerase chain reaction (PCR) and simultaneous sputum cultures from hospitalized patients, and to assess the contribution of PCR to causative agent identification. Materials and methods: Patients hospitalized with COPD exacerbations or asthma attacks from September 2022 to May 2023 were included. Bacterial pathogens were evaluated using PCR on nasopharyngeal swab samples, with simultaneous sputum culture results recorded. Analyzed pathogens included Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, Bordetella pertussis, Legionella pneumophila, and Chlamydia pneumoniae. Frequencies of pathogens detected by PCR and culture were compared. Results: The study included 911 patients. Nasopharyngeal swabs and simultaneous sputum cultures were obtained from 448 patients with COPD exacerbations and 127 patients with asthma attacks. In COPD exacerbations, H. influenzae was detected in 52 (8.7%) patients and S. pneumoniae in 32 (5.3%) by PCR, compared to 2 (0.4%) and 3 (0.7%) patients by sputum culture, respectively. In asthma attacks, H. influenzae was detected in 20 (6.5%) patients and S. pneumoniae in 11 (3.5%) patients by PCR, with S. pneumoniae detected by sputum culture only in 1 (0.8%) patient. H. influenzae and S. pneumoniae were significantly higher in COPD exacerbations and asthma attacks using PCR (p<0.05). Conclusion: PCR may detect bacterial pathogens in COPD exacerbations and asthma attacks more effectively than sputum culture within the context of this study.

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DOI: 10.3897/folmed.67.e143604

Authors: Yathin Reddy Putta, Anitha Pandi, Jayaseelan Vijayashree Priyadharsini

Abstract: Introduction: Hepatocellular carcinoma (HCC) is a leading global cancer, often linked to various factors, including viral infections and metabolic disorders. Recent studies suggest that microbial infections, particularly from oral pathogens like Prevotella intermedia (Pi), may elevate the progression of HCC through dysbiosis and chronic inflammation. Aim: In view of this, the study aimed to identify candidate genes in high-fat diet-fed mice infected with Pi and to assess the relevance of these orthologous genes in the development of human HCC. Materials and methods: The GEO dataset, GSE136937, was employed to identify the differentially expressed genes across two datasets viz., regular chow-fed and high-fat diet-fed mice infected with Pi. A comparison was made between normal vs. high-fat diet-fed mice infected with Pi to demonstrate the influence of the microbial factor on the development of metabolic disorders and cancer. The identified DEGs were subjected to protein-protein interaction (PPI) analysis and gene ontology (GO) assessments. Human orthologs were evaluated for gene expression status and survival using the TCGA dataset. Results: The analysis revealed numerous DEGs between infected and uninfected groups. The top 20 DEGs (16 upregulated, 4 downregulated) were further investigated in liver hepatocellular carcinoma patients (TCGA). Notably, genes RMND1 and CYP3A43 displayed similar expression patterns in both mouse and human datasets. High RMND1 expression was associated with poor prognosis, while low CYP3A43 expression indicated a poor survival outcome in HCC patients. Conclusion: Metabolic disorders in conjunction with microbial dysbiosis together could support the malignant phenotype by modifying the expression profiles of key genes involved in carcinogenesis. More intense experimental and in vivo studies are needed to further confirm the association of these candidate genes with HCC.

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DOI: 10.3897/folmed.66.e129478

Authors: Atanaska Petrova, Ivan N. Ivanov, Liubomir Paunov, Angel Uchikov, Ivan Stoikov, Todor Kantardjiev, Marianna Murdjeva

Abstract: Here we describe the first detected VIM-2-producing representative of Pseudomonas putida group – Pseudomonas kurunegalensis from the largest Bulgarian hospital – St George University Hospital in Plovdiv. A 59-year-old female patient with right-sided lung abscess was hospitalized in the Second Clinic of Thoracoabdominal Surgery. She was repeatedly treated for pulmonary infections. Punctate from the abscess cavity was taken for microbiological investigation. Identification process and antimicrobial susceptibility were performed by Vitek 2. The species group P. putida was confirmed with MALDI-TOF system and whole genome sequencing defined it as P. kurunegalensis. Antibiotic susceptibility testing revealed susceptibility only to tobramycin and colistin. All phenotypic tests for carbapenemase and metallo-beta-lactamase (MBL) production were positive. Multiplex PCR was performed to search for nine common carbapenemase encoding genes whereas the variable region of the integron was determined by DNA sequencing. Molecular assays confirmed the presence of blaVIM-2 located within a typical Class I integron including also an aacA29b aminoglycoside N(6’)-acetyltransferase casette. Despite P. putida not being a common pathogen, it still could survive in hospital conditions causing difficult-to-treat infections and becoming a source of resistant genes, including MBL-encoding genes.

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DOI: 10.3897/folmed.66.e136356

Authors: Ehab Qasim Talib, Ghada Ibrahim Taha, Dhuha Mahmood Ali, Sahar Hashim Al-Hindawi, Fadia Abd Almuhsin Al-Khayat, Israa Amer Hasan

Abstract: In the field of implantology, peri-implantitis is still a common complication of implant failure. Similar to periodontal disease, this kind of pathological condition is characterized by inflammation of the tissues surrounding dental implants or fillings. The sources of infection have been shown to be chronic periodontitis and poor maintenance of the communion. A thorough examination of the intricate components of peri-implantitis was sought in this review in order to identify common characteristics of the disease with regard to bacteria, biofilm formation, host immunological responses, diagnostic tools, and therapeutic treatments. The aim of this study was to provide a detailed overview of the different bacterial species associated with peri-implantitis, a clinical condition similar to periodontitis, characterized by a higher prevalence of staphylococci and enteric bacteria. The study underscores the importance of employing sophisticated diagnostic methods like cone beam computed tomography. It covers a range of therapeutic approaches including surgical and non-surgical techniques as well as strategies stressing host-modification and photodynamic treatment. The study was conducted using pertinent publications from scientific databases, including Scopus, Google Scholar, PubMed, and Web of Science. We searched these databases using the following terms: periodontitis, microbial, dental implants, peri-implantitis, and biofilm formation.

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DOI: 10.3897/folmed.66.e124015

Authors: Petya Argirova, Angel Todev, Yordan Kalchev, Simona Zlatanova, Mariyana Stoycheva-Vartigova

Abstract: COVID-19 presents with respiratory symptoms and signs in the majority of cases. The central nervous system can be affected directly or indirectly, which is demonstrated by a number of neurological abnormalities and complications. The aim of this study is to present a clinical case of SARS-CoV-2-associated encephalitis and highlight the severity of this neurological illness over the course of COVID-19. Etiological diagnosis methods include examination of the nasopharyngeal swab and cerebrospinal fluid by PCR. A 45-year-old man with fever, altered consciousness, and tonic-clonic seizures was admitted to the Clinic of Infectious Diseases, St George University Hospital, Plovdiv. The diagnosis of COVID-19 encephalitis is based on typical clinical and laboratory data, positive SARS-CoV-2 PCR, and exclusion of other likely causative agents into the cerebrospinal fluid. The patient was discharged two weeks after admission without neurological sequelae. The case confirms the clinical variety of COVID-19 and the possibility of severe neurological manifestations. Encephalitis is a rare but potentially life-threatening condition. Physicians should be aware of encephalitis in SARS-CoV-2 patients with neurological symptoms.

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DOI: 10.3897/folmed.66.e123181

Authors: Ausama Fathallh, Fouad Al-Sudani, Sabreen Almuhssen, Shaymaa Hassoon

Abstract: Introduction: Malnutrition in children is epidemic in developing countries. Several health issues and consequences are believed to develop due to this phenomenon. Children’s oral health is also affected by malnutrition. The main aspects of oral health status are caries experience, the existence of cariogenic bacteria, and salivary immunoglobulin A. Materials and methods: This comparative study included 87 school children aged 12 years. Participants with systemic disease were excluded. An oral examination was conducted to record the DMFT score, then saliva samples were collected in the morning using an unstimulated method. Salivary IgA were analyzed using Sandwich ELISA technology. Malnutrition was based on body mass index (BMI) which was computed as weight/height2 (kg/m2). Ethical approval was granted by the ethical committee at the Faculty of Dentistry. Informed consents from children’s parents were gained prior to the start of the study. Results: Compared to the normal weight group, the results of this study showed that overweight and obesity are inversely correlated with the mean DMFT and the number of S. mutans and S. sobrinus. Salivary IgA was negatively correlated with overweight and obesity, compared to normal weight group. Conclusions: Children suffering from malnutrition are at risk of developing oral health diseases. Treating malnutrition will therefore improve children’s overall oral health.

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DOI: 10.3897/folmed.66.e124561

Authors: Sahar Mohammadi Baladezaee, Mehrdad Gholami, Elham Amiri, Hamid Reza Goli

Abstract: Aims: Pseudomonas aeruginosa plays an important role in hospital infections caused by several virulence factors, such as elastase and proteases. This study aimed to evaluate the prevalence of LasA, LasB, and PIV genes, encoding these enzymes, in clinical isolates of P. aeruginosa. Materials and methods: One hundred clinical isolates were collected from patients admitted to educational and therapeutic hospitals of Mazandaran Province, North Iran. The isolates were identified by the standard microbiological and biochemical tests. The bacterial DNA was extracted by the alkaline lysis method, and the presence of relevant genes was detected using the PCR method. The data were analyzed using SPSS v. 23 and the chi-square test. A p-value <0.05 was considered statistically significant. Results: In 100 clinical isolates of P. aeruginosa, the LasA, LasB, and PIV genes were presented with a frequency of 97%, 96%, and 97%, respectively. Of the total number of samples, 39 patients were female and 61 were male. Also, the majority of the patients were between 61 and 70 years old. Conclusion: LasA, LasB, and PIV are highly prevalent in clinical isolates of P. aeruginosa, indicating the importance of these genes as key virulence factors in P. aeruginosa pathogenicity in this region.

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DOI: 10.3897/folmed.66.e111038

Authors: Zahra Panahi, Mina Owrang, Hamid Reza Goli

Abstract: Aim: Due to the importance of exotoxin A and pyocyanin in the pathogenicity of this bacterium, we decided to evaluate the prevalence of genes encoding these virulence factors in clinical isolates of P. aeruginosa. Materials and methods: In this study, 100 clinical isolates were collected and identified by conventional biochemical tests. The ability to produce pyocyanin was determined by culture in a specific liquid medium (GSNB) at 37°C. The DNAs of the bacteria were extracted by the SDS method and a PCR test was performed to identify the exoA, phzA1B1C1D1E1F1G1, phzM, and phzS genes. Results: In this study, 90 isolates were pyocyanin-producing in phenotypic test. Also, 96%, 98%, 92%, and 96% of the isolates carried exoA, phzM, phzS, and phzA1B1C1D1E1F1G1 genes, respectively. Interestingly, 2 isolates lacking the exoA gene did not have the phzM and phzS genes at the same time, but the other 2 isolates carrying all three gene loci required for pyocyanin synthesis. Also, among the strains that lacked the ability to produce pyocyanin, 2 isolates concurrently lacked the phzS and phzA1B1C1D1E1F1G1 genes and 2 isolates simultaneously lacked the phzM and phzS genes, while the 2 isolates did not carry only the phzS gene. The other 2 isolates did not contain only phzA1B1C1D1E1F1G1 operon. Conclusion: The presence of the phzA1B1C1D1E1F1G1 operon, along with the phzM and phzS genes, plays a significant role in the production of pyocyanin pigment. However, the high prevalence of exoA gene in this study indicates the importance of this factor for vaccine designing.

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DOI: 10.3897/folmed.65.e79966

Authors: Andreana Angelova, Mariya Atanasova, Kostadin Ketev, Zeyra Halil, Ivanka Paskaleva, Gergana Lengerova, Teodora Dimcheva, Neli Korsun, Mariana Murdjeva

Abstract: The Coronavirus Disease 2019 (COVID-19) caused by a novel coronavirus (SARS-CoV-2) affects mainly older adults. Those with comorbidities are at a higher risk of severe disease and even death. The symptomatic infection rate of children is lower, manifestations are milder, and severe forms are scarce. We present here two children with severe COVID-19 and a respiratory syncytial virus, with the goal of emphasizing the possibility of coinfection with a severe course and a different result. The microbiological diagnosis was made using multiplex PCR. This assay not only provided an early and accurate diagnosis but also aided in the implementation of contact precautions. Further research should be done to determine the influence of coinfection on the clinical course and outcome of pediatric patients.

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DOI: 10.3897/folmed.65.e76154

Authors: Paulina Teper, Anna Sotirova, Agnieszka Kowalczuk, Barbara Mendrek, Tsvetelina Paunova-Krasteva

Abstract: Introduction: The number of published biofilm studies and novel ways for studying them has risen dramatically in recent years, owing to the broad application of biofilms in medicine. Some bacteria develop biofilms that are highly resistant to antimicrobial agents, resulting in persistent infections. This necessitates the development of alternative methods for combating biofilms. In this regard, the application of cationic polymers is a good candidate for realization of this strategy. Aim: The aim of our study was to investigate the potential of a newly synthesized covalently attached star copolymer of N,N’-dimethylaminoethyl methacrylate and hydroxyl-bearing oligo(ethylene glycol) methacrylate [P(DMAEMA-co-HOEGMA)] to silica surfaces and its quaternized version [P(QDMAEMA-co-HOEGMA)] for destruction of biofilms formed by Bacillus subtilis or Pseudomonas aeruginosa. Materials and methods: Model strains representing different genera and taxonomic groups were selected for the study. The anti-biofilm activities of two different newly synthesized cationic polymers were investigated by observation (live/dead staining) of the viability of bacterial cells within the biofilm. Results: The results obtained by the live/dead labeling of bacterial biofilms show a substantial decrease in the viability of population in the presence of cationic polymers, better expressed at B. subtilis. Conclusions: The studied two immobilized on silica wafers newly synthesized star copolymers exhibited potential for anti-biofilm effects. The results demonstrated combined potential for reducing the viability of bacterial cells within the biofilms and probably for loosening the biofilm matrix. The effect was better expressed in B. subtilis.

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DOI: 10.3897/folmed.64.e72257

Authors: Yordan Kalchev, Marianna Murdjeva

Abstract: The incidence of infections affecting the central nervous system has increased in recent years, making neuroinfections a current global health problem. The central nervous system is quite well protected from the external and internal environments, although it is susceptible to infection by a wide variety of pathogens. The etiological diversity further complicates the management of such infections because it is important to identify correctly the specific cause in order to choose the most appropriate antimicrobial therapy. Diagnosis is made not only based on clinical and epidemiological data but also on the results of clinical laboratory and microbiological examination of cerebrospinal fluid. This article aims to review current microbiological methods in the diagnosis of acute central nervous system infections and help healthcare providers to recognize their advantages and limitations in order to manage their patients appropriately.

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DOI: 10.3897/folmed.64.e68987

Authors: Neli Vilhelmova, Ivanka Nikolova, Kaloyan D. Georgiev, Iliya J. Slavov

Abstract: Introduction: Based on traditional medicine, many countries use various plant products (fruits, leaves and other plant parts) as food supplements or in the form of tea. The use of these plant sources has been established through the years of use and the proven benefits of their ingredients to improve human health. Aim: In the present study, we have focused on the effect of Lycium barbarum fruit extract and methylxanthines isolated from Pu-erh (MXP) and Bancha (MXB) tea leaves on Herpes simplex virus type 1 (HSV-1), poliovirus 1 (PV1) and coxsackievirus B1 (CVB1) virus in vitro. Materials and methods: We used in vitro antiviral and virus attachment assays to determine the effects of the three extracts we studied. Results: None of the extracts showed significant inhibition of replication of the three treated viruses but a remarkable inhibitory effect on extracellular virions of HSV-1 was exhibited 30 minutes after exposure, especially by the Lycium barbarum extract. The inhibitory effect of the three extracts on the level of adsorption of the HSV-1 to sensitive cells (MDBK) was also significant, with the most pronounced effect of the MXP. The protective effect of the extracts against herpes infection on healthy cells was also determined, the MXP showing the most notable effect. Conclusions: The three studied extracts can be used effectively in the treatment of herpes infections, as well as in infections with other enveloped viruses.

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DOI: 10.3897/folmed.64.e76901

Authors: Elizabeta V. Bachiyska, Yuliana A. Atanasova, Ana I. Baykova, Stanislava P. Yordanova

Abstract: Introduction: Nontuberculous mycobacteria (NTM) are representatives of the genus Mycobacterium with a worldwide distribution, associated mainly with water, soil, and biofilms. Some of NTMs, such as Mycobacterium avium complex (MAC), are etiological agents of human diseases – disseminated or with different localization, most often pulmonary. Aim: In the present study, we analyzed Mycobacterium intracellulare isolates recovered from clinical specimens of tuberculosis (TB) suspected patients in Bulgaria, 2018-2020. Materials and methods: The cultures were grown on solid and liquid media. For species identification, we used immune chromatographic (TB Ag MPT64) test and Line Probe Assay (LPA) from the positive cultures. Results: M. intracellulare was identified in 32 patients from 82,780 specimens. It was predominantly isolated in females – 62.5% vs. 37.5% in males. The most affected age group was 65 years and over (38%). The distribution of the isolates in Bulgaria was uneven. Most of them (65.6%) were concentrated in two districts of the country: Plovdiv and Sofia-city. All strains were sensitive to macrolides and aminoglycosides except one with macrolide resistance. NTM pulmonary disease was confirmed in 16 patients with M. intracellulare isolate. Conclusions: Analysing the 32 M. intracellulare isolates identified among TB suspected patients in Bulgaria between 2018 and 2020, we found that only half of them met the American Thoracic Society (ATS) diagnostic criteria for NTM pulmonary disease. For the remaining patients with M. intracellulare isolates we did not have sufficient data to support this diagnosis. Efforts by Bulgarian respiratory and microbiological societies are needed for adherence to the international guidelines.

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DOI: 10.3897/folmed.64.e70554

Authors: Stanislava Yordanova, Elizabeta Bachiyska, Elisa Tagliani, Ana Baykova, Yuliana Atanasova, Andrea Spitaleri, Daniela Maria Cirillo

Abstract: Introduction: The transmission of drug-resistant tuberculosis is one of the greatest challenges facing the global tuberculosis control. Aim: The aim of the study was to investigate the resent transmission of rifampicin resistant tuberculosis in Bulgaria and to describe the mutations related to the antimicrobials’ resistance using whole genome sequencing. Materials and methods: As part of an ECDC funded pilot study for evaluation of the systematic use of whole genome sequencing (WGS) of Mycobacterium tuberculosis (MTB) surveillance (EUSeqMyTB), Bulgaria provided 65 rifampicin resistant isolates over a three years’ timeframe (2017-2019) representing 87.5% of the notified rifampicin resistant cases. Drug resistance prediction and relatedness analysis of the resistant isolates was performed in collaboration with San Raffaele Scientific Institute, Milan, Italy. Results: Almost all of the isolates were identified as Euro-American lineage (96.9%); 18.5% of the isolates were found to be resistant to fluoroquinolones, but no mutations conferring resistance to bedaquiline or linezolid could be identified. Less than half (43.3%) of the isolates were clustered (<5 SNPs distance) into a total of seven national SNP-based clusters, while a total of six isolates were found to be part of different cross-border clusters. All clustered cases originated from Bulgaria. Conclusions: WGS has proven to be a reliable tool for surveillance and tracing of recent transmission of tuberculosis and has the potential for resistance prediction for most of the antituberculosis drugs.

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DOI: 10.3897/folmed.64.e64795

Authors: Yoana P. Georgieva, Petya A. Gardjeva, Mariana N. Katsarova, Petko I. Bozov, Kalina P. Gercheva, Marianna A. Murdjeva, Stela Z. Dimitrova

Abstract: Introduction: Scutellaria extracts and its constituents, especially the characteristic flavonoids such as baicalein and its glycoside baicalin, exhibit significant antimicrobial activity. Aim: To perform a comparative analysis of flavonoid composition and antimicrobial activity of extracts obtained from aerial parts and roots of Scutellaria altissima from the regions of Mezek and Bachkovo, Bulgaria. Materials and methods: 70% ethanol and aqueous extracts of aerial parts and roots of S. altissima were used. HPLC analysis of S. altissima extracts was performed. Microbiological tests were done on clinical isolates of Streptococcus mitis, Staphylococcus aureus, Escherichia coli, and Candida albicans. Minimal bactericidal and minimal bacteriostatic concentrations of S. altissima extracts were determined by the agar method. Results: The ethanol extracts contain flavonoids approximately twice as much in comparison with the aqueous extracts. The baicalin content in the aerial parts of S. altissima from the region of Mezek is 5 times higher than that in the roots. S. altissima extracts have effective antimicrobial activity against S. mitis only. The minimal bactericidal concentration of ethanol extracts of S. altissima aerial parts and S. altissima roots is 2000 µg/ml and 8000 µg/ml at 24 hours, respectively. The bactericidal effect of aqueous extracts occurs at 48 hours at minimal bactericidal concentration of S. altissima aerial parts – 2000 µg/ml and of S. altissima roots – 6000 µg/ml. Conclusions: The finding that extracts of Bulgarian S. altissima possess effective antimicrobial properties against S. mitis suggests that it can be used as a potential source for the development of natural antimicrobial agents to suppress oral pathogens and prevent some oral infections.

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DOI: 10.3897/folmed.64.e63624

Authors: Ivva Philipova, Viktoryia Levterova, Ivan Simeonovski, Todor Kantardjiev

Abstract: Introduction: Mycoplasma genitalium is an established cause of sexually transmitted infections in men and women. Current guidelines recommend azithromycin and moxifloxacin as first- and second-line treatment, respectively. However, azithromycin treatment failure has been increasingly reported. The aim of this study was to determine the efficacy of azithromycin and alternative antibiotic regimens in a prospective cohort of M. genitalium-positive patients, and macrolide resistance mutations associated with azithromycin failure. Materials and methods: Consecutive eligible M. genitalium-positive patients attending the National Center of Infectious and Parasitic Diseases in Sofia, Bulgaria between 1 January 2018 and 31 December 2020 were treated with azithromycin and retested by polymerase chain reaction 21-28 days after completion of the treatment. Cure was defined as M. genitalium-negative result on the test of cure. Cases failing azithromycin were treated with moxifloxacin and retested another 21-28 days after treatment. Pre- and post-treatment samples were assessed for macrolide resistance mutations by conventional DNA sequencing. Results: Of 21 patients treated with azithromycin, 11 (52.4%) were cured. Pre- and post-treatment macrolide resistance mutations were detected in 10 (47.6%) patients, and all of them failed azithromycin. Moxifloxacin was effective in all cases failing azithromycin; and all were M. genitalium-negative at the test of cure after moxifloxacin treatment. Conclusions: In this study a high azithromycin failure rate (47.6%) in an M. genitalium-positive cohort in association with high levels of pretreatment macrolide resistance was reported. Moxifloxacin was highly effective in treating macrolide-resistant infections. These findings necessitate implementation of new diagnostic and therapeutic strategies such as sequential antimicrobial therapy for M. genitalium guided by a macrolide-resistance assay.

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DOI: 10.3897/folmed.63.e65248

Authors: Denis Niyazi, Temenuga Stoeva, Svilena Atanasova, Rumyana Markovska, Ilina Micheva

Abstract: Aim: The aim of this study was to evaluate the clinical significance of Aspergillus Galactomannan antigen (GM) test for the diagnosis of invasive pulmonary aspergillosis (IPA) in patient with hematological malignancies, including patients undergoing hematopoietic stem cell transplantation (HSCT).Materials and methods: Between January 2016 and June 2019, ninety patients were tested for GM. A total of 134 blood and 19 bronchoalveolar lavage (BAL) samples were analyzed using Platelia Aspergillus Ag Enzyme-Immuno Assay (Bio-Rad Laboratories). The median age of patients was 63 years (range 25–81). Fifty-six patients (62.2%) were male. All patients were allocated into five groups on the basis of their GM results.Results: A positive GM antigen test was detected in 16 patients (17.7%). Of these, ten had positive serum samples (group I). After re-testing, 1 patient from group I gave a negative result. Five patients with negative serum samples gave positive BAL results (group II). One patient had positive both serum and BAL samples (group III). Fifteen GM positive patients (9 from group I, group II, and III) were categorized as probable IPA. Thirty-six patients (40%) negative for GM (group IV) were considered with a possible IPA. IPA was excluded in 38 patients (42.2%) (group V). Anti-mould therapy was initiated in all 15 patients who were considered to be cases with probable IPA. IPA was the immediate cause of death in 3 cases (25%).Conclusions: Our results demonstrated the clinical applicability of the GM test for screening of IPA in high-risk patients with hematological malignancies and HSCT.

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