Archives of Clinical Infectious Diseases
Volume:13 Issue: 4, Aug 2018

Methicillin-resistant Staphylococcus epidermidis (MRSE) remains one of the most prevalent drug-resistant bacteria causing health care infections. Limited data are available about how the frequency of MRSE changed in Iran over the past years. The current study aimed at determining the frequency of MRSE in different cities of Iran.
Databases including Web of Sciences, Scopus, Embase, Medline, and Iranian databases were searched to find studies addressing the frequency of MRSE in Iran published from Mar 2006 to Jan 2016. The data were analyzed using comprehensive meta-analysis version 2.2 (Biostat). Of the 139 records identified in the databases, 15 studies met the inclusion criteria.
The analyses showed that the frequency of MRSE infections was 73.9% [95% confidence interval (95% CI) 61.4 - 83.4] among culture-positive cases of S. epidermidis in different parts of Iran. The frequency of MRSE was higher in the studies conducted from 2011 to 2015, based on further stratified analyses.
The regular surveillance on antimicrobial susceptibility pattern and formulation of definite antibiotic policy may control high rate of MRSE associated infections in Iran. Moreover, rapid and reliable diagnosis of MRSE isolates and regular screening of the personnel and surfaces of hospitals in terms of MRSE are indispensable.

The treatment of bacterial infections is increasingly complicated due to the ability of bacteria to develop resistance to antimicrobial agents. The aim of this study was to survey the antimicrobial susceptibility patterns of several pathogens isolated from in- and out-patients at Mofid children’s hospital.
From October 2015 to April 2016, Escherichia coli, Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus, and Enterococcus spp. detected from clinical (urine and non-urine) specimens of inpatient and outpatient were survived. Sensitivity was measured by disc diffusion method based on the CLSI recommendation.
Totally, E. coli (62.7%) and P. aeruginosa (42.3%) were the predominantly isolated pathogens in this study from urine culture and non-urine culture, respectively. All cultured staphylococcal isolates were susceptible to vancomycin. The most effective antibiotics for Gram-negative bacteria were meropenem, amikacin, and imipenem, in sequence. None of the Gram-negative bacteria was sensitive to tetracycline.
Our findings showed that there was a considerable geographic variation in bacterial patterns and antibiotic susceptibility properties. Therefore, monitoring of antibiotic sensitivity pattern is helpful for selecting antibiotics for empiric therapy.

Quorum-sensing systems are considered as important mechanisms for pathogenesis and bacterial communication. The accessory gene regulator (agr) is one of the quorum-sensing systems in staphylococci, which is generally conserved. It is believed that there is a correlation between agr groups and infection. Multiple-locus VNTR analysis is a method for bacterial typing, previously applied for several different species of bacteria. This study aimed at determining the diversity of Staphylococcus epidermidis accessory gene regulator and clonality in clinical isolates from intensive care unit patients, Tehran, Iran.
A total of 59 Staphylococcus epidermidis isolates were obtained from intensive care unit patients. The MLVA was performed for S. epidermidis isolates, using seven VNTR loci, including SE2395, SE0331, SE 828, SE1632, SE0175, Se2, and Se4. Specific primers were used for agr diversity determination.
The agr type I was observed in 29 (49%), while each of the agr type II and agr type III were observed in 10 (17%). Furthermore, 10 (17%) isolates were untypeable with using primers. In total, 49 MLVA genotypes were discriminated. Isolates were classified to six clonal complexes. Of the 59 isolate, 33 were included in clonal complex 1 (CC1), the largest of which harbored 15 (45.4%) agr type I.
Agr type I was observed in the majority of the isolates. The MLVA results of this study suggest that there was a clone with 33 samples, comprised of 56% of isolates; smaller clones each comprised of two to seven isolates, and four isolates in the form of singleton. It seems that big clone isolates were settled in the intensive care unit (ICU), and singleton isolates entered the ward by visitors or medical personnel and caused infection.

Acinetobacter baumannii (A. baumannii) is an important opportunistic pathogen responsible for nosocomial infections worldwide at recent decades. Biofilm formation by A. baumannii leads to antibiotic resistance and survives on abiotic and biotic surfaces. In the present study we aimed to assess the ability of biofilm formation in clinical and environmental isolates of A. baumannii by phenotypic methods and to detect the presence of genes involving in the biofilm development; bap, ompA, csuE, abaI, and blaPER-1by PCR method. Totally 120 A. baumanniin isolates, 98 clinical, and 22 environmental were evaluated for biofilm formation using the modified Microtiter plate method, Congo red agar methods, and the existence of genes related to biofilm by standard PCR. The phenotypic results showed that the biofilm formation rate was 10.8% isolates that in environmental A. baumannii isolates were higher than clinical isolates. The abaI, csuE, and ompA genes were detected in all isolates with biofilm formation and the bap and blaPER-1genes were positive in 14.2% and 13.3% of A. baumannii isolates, respectively. The sequence of genes were submitted in NCBI. Based on our results, the Congo red agar method was significantly better than the Microtiter plate technique for phenotypic evaluation of biofilm formation in the A. baumannii. Our study indicates that abaI, csuE, and ompA genes were detected in all isolates unlike the bap and blaPER-1genes.

Nocardia species are nocardiosis agents particularly in immune disorder patients with the clinical manifestations including fatigue, malaise, weight loss, cough, and dyspnoea. Due to time - consuming bacterial culture and insufficient phenotypic tests alone, rapid molecular assays for the diagnosis of Nocardia are essential. The primary objective of this study was the analysis of the polymerase chain reaction - restriction fragment length polymorphism (PCR - RFLP) and PCR sequencing of 16S rRNA gene for the identification and differentiation of Nocardia species.
32 Nocardia isolates were identified by single digestion of 441 - nt fragments of the 65 - heat - shock protein gene with endonucleases BstEII, MspI, and HinfI and sequencing of 16S rRNA gene. These isolates were collected from the soil of various geographical regions of Iran by paraffin baiting technique in our previous study.
Some of the isolates had new patterns that were not identified by PCR - RFLP of hsp65 gene in literature; therefore, they were identified by sequence analysis of 16S rRNA gene. Six strains of Nocardia with new DNA banding patterns in PCR - RFLP of hsp65 (A and B) could not be identified by their hsp65 restriction - endonucleases fragment patterns. Strain En49 after analysis of sequencing data was recognized as Nocardia coubleae , which its PCR - RFLP profile of hsp65 has not been reported in the literature so far.
The PCR - RFLP - hsp65 is faster than other sequencing-based techniques, but species accurate identification in strains with new PCR - RFLP profiles is not possible. The 16S rRNA gene sequencing is a suitable method to determine the percent similarity and phylogenetic relationships of Nocardia species.

Ventilator-associated infections caused by extended-spectrum beta-lactamases (ESBL)-producing Pseudomonas aeruginosa leads to severe complications.
This research evaluated ESBL-producing P. aeruginosa carrying integron class 1 and class 2 isolated from patients with ventilator-associated nosocomial infections, admitted in to the intensive care unit (ICU) of eighteen hospitals in the north of Iran.
The antibiotic susceptibility test was performed using minimum inhibitory concentration (MIC). The ESBL isolates were tested by the polymerase chain reaction (PCR) for the presence or absence of CTX, VEB, SHV, GES, and integron class 1 and 2 genes.
Out of the total of 205 patients at the ICUs with nosocomial infections (NIs), ESBL-producing P. aeruginosa was responsible for 14.63% of NIs. The prevalence of ventilator-associated infection for ventilator-associated pneumonia (VAP) was (25 patients) 83.33%, also 16.6% (five patients) had sepsis due to VAP. Distribution of CTX, VEB, SHV, and GES genes was 13 (43.33%), four (13.33%), ý26 (86.66%), and zero (0%), respectivelyý. The strains carrying integron class 1 and class ýý2ý were 26 (86.66%) and two (6.66%), respectively. Regarding ESBL genes, six types of strains were observed to carry these genes.
The presence of P. aeruginosa isolates containing different ESBL genes isolated from patients admitted to ICUs of eighteen hospitals, signifies the importance of employing antimicrobial stewardship in hospitals for avoiding unnecessary antibiotics prescription for empiric therapy, especially for critically ill patients at the ICUs.

Hospital-acquired pneumonia (HAP) prevalence is related to patients’ population and diagnostic methods. HAP incidence is reported in different studies from 9% to 46%. The current study aimed at evaluating the etiology of HAP in patients admitted to intensive care units (ICUs).
The patients admitted to ICU of Imam Reza hospital (a tertiary care and teaching hospital in Mashhad, Northeast of Iran) were evaluated for HAP based on the following criteria: fever, leukocytosis, purulent discharge, new radiologic findings, changes in O2 saturation, and ventilator setting. Blood and endotracheal aspirates cultures were performed for all patients. Demographic characteristics were recorded in a checklist.
Among the 88 adult patients enrolled in the current study, the most frequent radiologic finding was patchy infiltration in chest X-ray (71.6%). Mean age of the patients was 58 ± 20.1 years; mean hospital stay was 63 ± 40.8 days; mean interval between hospitalization and pneumonia development was 20.9 ± 16.8 days; and 41 patients (46.6%) died. Acinetobacter spp. were the most frequent microorganisms in purulent discharge and methicillin-resistant Staphylococcus aureus (MRSA) were the main bacteria isolated from blood culture.
Early diagnosis and appropriate antibiotic therapy can decrease HAP mortality and morbidity. The current study findings revealed that Acinetobacter app. were the most frequent cause of HAP in ICU patients in the studied center, which should be considered at the time of diagnosis and empirical antibiotics administration. Appropriate infection control and preventive measures should also be taken in ICUs to prevent HAP, especially against those caused by Acinetobacter spp.

Human T-lymphotropic virus type 1 (HTLV-1) virus belongs to retroviruses and is involved in the etiology of adult T-lymphocytic leukemia (ATL) and tropical spastic paraparesis (TSP). This virus could be transmitted through transfusion of contaminated blood or blood products, from the mother to the child or fetus, sexual intercourse, and sharing contaminated syringe needles among addicted individuals. There is no report regarding the prevalance of HTLV-1 among hemodialysis patietns in Tehran.
In this descriptive study, 150 patients, who were under hemodialysis from four military hospitals of Tehran were included. Serum samples were screened to measure the titer of HTLV-1 antibodies by Dia-Pro ELISA kits. Enzyme linked immunosorbent assay (ELISA) positive samples were checked by the western blot method.
The results indicated that age of the patients was in the range of 24 to 88 years old and the mean age of patients was 63.58 ± 13.41 years. Among all patients, only one patient (0.66%) had positive anti HTLV-1 ELISA test in the serum while other patients (99.4%) had negative results. The positive sample was confirmed by Western blot analysis.
The prevalence rate of HTLV-1 among hemodialysis patients was not high in Tehran. However, it is necessary to take preventive measures to reduce its spread, especially through infectious hemodialysis machines.

Tuberculosis (TB) is a major global health problem. The goal is to end the global TB epidemic. TB treatment averted 49 million deaths globally from 2000 to 2015. If everyone with TB had a timely diagnosis and high-quality treatment, the TB case fatality rate would be lower in all countries. The main source of infection is untreated smear positive pulmonary TB; the next step should be the examination of the sputum for Mycobacterium sp. Bacteriologic evaluation through culture and /smear microscopy is essential to monitor the response to treatment. Monitoring acid-fast bacilli (AFB) smear should be undertaken at 2, 5, and 6 months. The currently recommended treatment for the new cases of drug-susceptible TB is a 6-month regimen of 4 first-line drugs: isoniazid (INH), rifampin (RIF), ethambutol (ETM), and pyrazinamide (PZA). Treatment success rates of at least 85% for new cases of drug-susceptible TB are regularly reported to the world health organization (WHO) by its 194 member states. The global TB drug facility supplies a complete 6-month course for about US$ 40 per person.
The current study aimed at evaluating the effectiveness of directly observed treatment short course (DOTS), AFB-negative/AFB-positive sputum after a 2- month treatment with the 4 first-line drugs.
A total of 700 patients with tuberculosis referred to Sanabad Health Center of Mashhad, Iran from March 2005 to March 2008 were retrospectively studied. Then, 360 new smear-positive pulmonary TB were chosen. After 2 months of treatment with 4 anti-tubercular agents, age, gender, nationality, and AFB -negative, AFB-positive of sputum smear were recorded in 2 groups.
Females were infected more than males. There were treatment success rates of at least %86.4 for new cases of drug-susceptible TB. Age, gender, and nationality were not related to the changes in sputum (negative-positive).
DOTS were effective in the current study. In low- and middle-income countries, in patients with TB cavity, diabetes, malnutrition, immune disorder, and cigarettes smoking, the sputum smear and culture testing on the days 15 and 30 of treatment until the completion of the treatment should be done.

Although Malassezia genusare part of the skin normal flora, under certain conditions, they become pathogenic. Catheter-related fungemia, caused by Malassezia, which is associated with biofilm formation, is considered a nosocomial infection.
The aim of this study was to evaluate the ability of Malassezia globosa and Malassezia restricta in biofilm formation.
Biofilm formation was carried out using catheter segments in 12-well plates. Results were measured using 3-(4, 5- dimethylthiazol-2-yl)-2, 5-diphenyl-tetrazolium bromide (MTT) colorimetric assay in 96-well plates. The data was analyzed using univariate Analysis of Variance (ANOVA) or Repeated Measures ANOVA. P values of ≤ 0.05 were considered statistically significant. Statistical analyses were performed using IBM SPSS Statistics version 22.0 software.
Both M. globosa and M. restricta species were able to form biofilms in vitro. Malassezia restricta was more capable than M. globosa to form biofilms, yet, significant differences were not observed (P = 0.192).
Over time, Malassezia biofilms matured. Due to the above species ability in forming biofilm, they could play an important role in fungemia that should be considered in therapeutic procedures.

Carbapenems are a broad-spectrum class of beta-lactam antibiotics, which are used in treatment of multi-drug resistant infections. Unfortunately, global emerging and spreading of carbapenemase, especially New Delhi metallo β lactamase 1 (blaNDM-1), is a concern in the treatment of multi drug-resistant agents. Here, we report the appearance of blaNDM-1producing Escherichia coli (E. coli) in Iran for the first time.
In this study, 2 blaNDM-1producing E. coli strains were isolated from 2 burn wounds of patients in the Motahari hospital, Tehran. The isolates were resistant to carbapenems (imipenem, meropenem and ertapenem) and other common antibiotics except nitrofurantoin. Combined Disk Test showed that the isolates could not produce blaAmpC and blaKPC carbapenemase, whereas they can produce metallo-β-lactamases (MBL). However, genetic detection using Polymerase Chain Reaction amplification with specific primers for blaKPC, blaIMP, blaVIM-1, blaVIM-1 – blaVIM-37, and blaNDM-1genes showed that only the blaNDM-1gene is amplified from the resistant isolates. Further sequencing of PCR products confirmed the presence of the blaNDM-1gene in these isolates.
The emerging of blaNDM-1producing E. coli is a new threat for to the health system in Iran, due to the spreading of the blaNDM-1gene among pathogenic bacteria, which resulted in the emergence of multi drug resistant photogenes. Therefore, early identification of these isolates is mandatory.

Echinococcosis is still an important public health challenge in endemic areas that is associated with considerable morbidity. A complicated pulmonary hydatid cyst can be a daunting situation if not diagnosed and managed properly.
Our case was a young female with a huge pulmonary hydatid cyst who developed a sudden rupture of cyst. She was operated by an erroneous diagnosis of a complicated diaphragmatic hernia which resulted in a life-threatening event.
Based on a broad range of clinical presentations and diverse radiographic appearances, the diagnosis of a complicated pulmonary hydatid cyst is not always straightforward. A pulmonary hydatid cyst, which obscures the diaphragmatic shadow, might be misdiagnosed as a diaphragmatic hernia on plain radiography. Accurate diagnosis depends on a precise clinical judgment particularly in endemic regions, otherwise serious morbidity is anticipated.

Cerebellar mucormycosis is a rapidly progressing fungal infection that often involves immunocompromised patients. Herein, we present the case of a 20-year-old man with history of type-I diabetes mellitus and thalassemia major, who presented with headache, fever, and cough and gradually developed vertigo and ataxia during the course of admission. His imaging studies showed a space-occupying lesion in the posterior fossa and therefore he underwent craniotomy and the mass was removed. The pathological study revealed the mucormycosis infection of the cerebellum with small necrotic foci. The patient had no neurological signs or symptoms after the operation and he was discharged in good conditions after three weeks. He had no sign of recurrence and the MRI showed complete resolution of the lesion after follow-up.