Intro: In mid-May 2022,a monkeypox virus(MPXV) outbreak was identified in the UK,reporting new cases later in Portugal and Spain,and recently being declared a public health emergency by the WHO. The aim of this study was to describe the microbiological characteristics of MPXV infection in Barcelona. Methods: Clinical samples from patients with MPXV infection suspicion attended at Hospital Universitari Vall d'Hebron (HUVH) and Barcelona's primary healthcare centres were collected from May to July 2022. Laboratory-confirmation was initially performed by an in-house Orthopoxvirus RT-PCR assay until June,when commercial LightMix Modular Orthopoxvirus or MPXV-specific RT-PCR assays(RocheApplied Science,Germany)were available. Findings: A total of 802 samples from 511 patients were included. MPXV was laboratory-confirmed in 77.3%(395/511)of cases, 20.4%(104/511) were negative, while the remaining 2.3%(12/511) were unconclusive probably due to inhibitions or low-quality samples. Most confirmed cases were male patients(97.7%;n=386/395) and the median age was 37 years(IQR:31-44). Weekly MPXV incidence constantly increased. Discussion: The MPXV incidence trends reveal a high burden. Secondary related cases are expected when wide circulation occurs into the community. Samples from skin lesions had the best diagnostic performance;genital-chancre,throat and rectal samples also revealed higher viral loads, suggesting active viral replication and source of infection.Urine samples were positive but showing lower viral loads. Conclusion: The 2022 MPXV outbreak has had a high burden in Barcelona.Skin specimens seem to be the sample of choice for diagnosis.Even though MPX pathogenesis in humans is not still well-defined,viral replication seems to occur in oral,genital and rectal mucosa,suggesting a source of infection and playing a role in transmission,in contrast with other fluids like urine.These results are key information for prevention measures.

Gonorrhoea infections are frequently diagnosed at extragenital locations in asymptomatic individuals and are historically related to poor recovery in culture, which hinders antimicrobial susceptibility testing. The aim of this study was to evaluate recovery rates of Neisseria gonorrhoeae by culture among asymptomatic individuals who tested positive by nucleic acid amplification tests between 2018 and 2019 in Barcelona (Spain). In total, 10 396 individuals were tested for N. gonorrhoeae on first‐void urine, rectal, pharyngeal and/or vaginal swabs depending on sexual behaviour. Overall infection prevalence was 5·5% (95% confidence interval [CI] 5·0–5·9). Seven hundred and ten samples were positive corresponding to 567 individuals. The most common site of infection was the pharynx (71·3%), followed by rectum (23·1%) and genitals (4·7%) (P < 0·0001). The N. gonorrhoeae recovery rate in culture, time from positive screening to culture specimen and inoculation delay were calculated. Recovery rate was 21·7% in pharynx, 66·9% in rectum and 37·0% in genitals (25·0% vagina, 71·4% urethra) (P < 0·0001). Median culture collection time was 1 [0; 3] days, and median inoculation delay was 5·01 [4·99–7·99] h, with no impact on N. gonorrhoeae recovery, P = 0·8367 and P = 0·7670, respectively. Despite efforts towards optimizing pre‐analytical conditions, the N. gonorrhoeae recovery rate in asymptomatic individuals is unacceptably low (especially for pharynx), representing a problem for monitoring antimicrobial‐resistant infections.

Introduction and Objectives: The outbreak of COVID-19 has overwhelmed healthcare systems all over the world. The aim of this article is to describe the process of transforming the Vall d’Hebron University Hospital, the second largest hospital in Spain, into a COVID-19 centre coordinating response to the pandemic in its reference area. Materials and methods: The study draws on the experience of the authors in transforming the hospital into a comprehensive resource in response to the COVID-19 pandemic. The strategy is based on four central strategies: early planning, coordination of all healthcare agents in its reference area, definition of clear leadership roles, and the organisation of care based on multidisciplinary teams with minimal recruitment of new staff. Results: The transformation strategy enabled the hospital to cope with the surge in patients without exceeding its capacity. During the response phases, which amounted to a period of 57 days, 3,106 patients consulted the ER and 2,054 were admitted, 346 of whom were treated at the ICU. To accommodate the number of adult COVID-19 patients, adult ICU availability was progressive increased by 371%, and ordinary beds increased by 240. A total of 671 staff members went on sick leave after testing positive for COVID-19. Conclusion: The transformation experience of the hospital provides insight into how effectively adapt the structures and functioning of large hospitals. The relevance of territorial coordination during the pandemic is stressed as an effective strategy that contributed coping the pandemic.

Nasal high-flow oxygen therapy (NHF) may spread the severe acute respiratory syndrome coronavirus (SARS-CoV-2) through respiratory droplets and contact with fomites. This concern leads to significant controversies regarding recommendations for its use in different evidence-based guidelines of therapy in coronavirus infectious disease 2019 (COVID-19) patients [[1]Raoof S. Nava S. Carpati C. Hill N.S. High-flow, noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure.Chest. 2020; 158: 1992-2002Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar]. We, therefore, aimed to determine whether NHF use for COVID-19 patients was associated with higher environmental surface SARS-CoV-2 contamination compared with those who were intubated and mechanically ventilated (MV). We performed an observational, single-centre study initially including 10 consecutive critically ill COVID-19 patients who required intensive care unit (ICU) admission (five NHF and five MV). All patients were admitted to ICU negative-pressure single rooms with 12 air changes per hour. Closed-aspiration systems were used in mechanically ventilated patients. Patients with NHF only wore surgical masks above the NHF cannula when healthcare personnel were inside the room. The Ethics Committee of Vall d’Hebron University Hospital approved this study (PR(AG)225/2020), and the need for informed consent was waived due to the observational nature of the study. Confirmation of SARS-CoV-2 persistence on environmental surfaces was based on the detection of viral genome by reverse-transcription quantitative polymerase chain reaction (RT-qPCR). Sample collection was performed within the first 24 h of admission and after three days, before the daily room cleaning, from the following sites: bedside monitor, mechanical ventilator screen, computer keyboard, nurse medication trolley, infusion pumps, patient sheet, bed handle, personnel protective equipment (gloves, coat, protection glasses, hat), stethoscope, room floor at 1.5 m distance from the patient, and a filter paper placed immediately before the room high-efficiency particulate air (HEPA) filter. Environmental and equipment surfaces (approximately 5 × 5 cm) were sampled using moistened sterile swabs. If all samples were negative, inclusion of two additional patients (one of each group (NHF and MV)) was planned. Two more samples were collected for these two additional patients. First, air sampling of room air was performed using a Sartorius MD8 microbiological sampler, containing a gelatine membrane filter for a fixed given sample volume of 1000 L by placing the sampler near the patient (50 cm). After sampling, the filter was immediately sent to the lab where 3 mL of Dulbecco's modified Eagle medium (DMEM; Lonza, Allendale, NJ, USA) was added and frozen at -80°C until the analysis was performed. A second additional sample from the NHF cannula of the non-intubated patient was also obtained. The swabs were transferred immediately into 3 mL of DMEM, sent out to the microbiology laboratory and frozen at -80°C until RT-qPCR analyses were perfiormed. Total nucleic acids were extracted using NucliSENS EasyMAG (BioMérieux, Marcy l’Etoile, France) according to the manufacturer's instructions. Detection of SARS-CoV-2 genome was carried out by a commercial multiplex RT-qPCR assay (TaqMan™ 2019-nCoV Assay Kit v2, Thermofisher, USA). SARS-CoV-2 samples containing viral RNA, as determined by RT-qPCR, were assessed for the presence of infectious virus by titration in Vero E6 cells (ATCC® CRL384 1586™), as previously reported [[2]Rodon J. Muñoz-Basagoiti J. Perez-Zsolt D. Noguera-Julian M. Paredes R. Mateu L. et al.Identification of Plitidepsin as potent inhibitor of SARS-CoV-2-induced cytopathic effect after a drug repurposing screen.bioRxiv. 2020; (04.23.055756)https://doi.org/10.1101/2020.04.23.055756Crossref Scopus (0) Google Scholar,[3]Brustolin M. Rodon J. Rodríguez de la Concepción M. Ávila-Nieto C. Cantero G. Pérez M. et al.Protection against reinfection with D614- or G614-SARS-CoV-2 isolates in hamsters.bioRxiv. 2021; (2021.01.07.425729)https://doi.org/10.1101/2021.01.07.425729Crossref Scopus (0) Google Scholar]. Vero E6 cells were cultured in DMEM (Lonza) supplemented with 2% foetal calf serum (FCS; EuroClone), 100 U/mL penicillin (ThermoFisher Scientific, Life Technologies), 100 μg/mL streptomycin (ThermoFisher Scientific, Life Technologies), and 2 mM glutamine (ThermoFisher Scientific, Life Technologies). Direct samples and serial 10-fold dilutions in supplemented DMEM were transferred to Vero E6 monolayers. Plates were monitored daily under a light microscope and wells were evaluated for the presence of cytopathic effect (CPE) at 6 days after infection. Results are expressed as median (25th–75th percentile). The main characteristics of the patients included in this study are summarized in Table I. Two of the patients were initially included as MV patients (only had samples at day 1 of MV) and subsequent samples were collected when they were supported with NHF after extubation (Cases 1 and 2 among MV patients that correspond to Cases 6 and 8 among NHF patients, respectively). A total of 252 environmental samples were collected from the first 10 patients. No differences between the time of positive nasopharyngeal swab collection and time of environmental sample collection were observed (median of three days (one to five) in NHF and four (three to nine) in MV patients; P=0.222). At the time of first collection, patients with NHF were supported with a median flow of 55 Lpm (50–60) and had a median respiratory rate of 23 (22–24) bpm and a SpO2/FIO2 ratio of 154 (145–192). The RT-qPCR reactions were negative for all the tested surfaces.Table IGeneral characteristics of the population includedCaseAgeSAPS IIIAPACHE IINo. of quadrants in chest X-rayD-dimer (ng/mL)IL-6 (mg/dL)Type of roomType of respiratory supportDays from positive RT-qPCR to first sample collection13723194171100ICU single-room with negative pressureMV32564918263292359ICU single-room with negative pressureMV334913224221195ICU single-room with negative pressureMV945530224317753ICU single-room with negative pressureMV357167314953103ICU single-room with negative pressureMV1063723204171100ICU single-room with negative pressureNHF174432212225108ICU single-room with negative pressureNHF68564918263292359ICU single-room with negative pressureNHF59542522413214541ICU single-room with negative pressureNHF4106930314456365ICU single-room with negative pressureNHF111722326217022Intermediate care, double-roomNHF112393819433192656ICU single-room with negative pressureMV5APACHE II, Acute Physiology and Chronic Health disease Classification System; IL, interleukin; MV, mechanical ventilation; NHF, nasal high flow; RT-qPCR, real-time reverse-transcription polymerase chain reaction; SAPS III, Simplified Acute Physiology Score. Open table in a new tab APACHE II, Acute Physiology and Chronic Health disease Classification System; IL, interleukin; MV, mechanical ventilation; NHF, nasal high flow; RT-qPCR, real-time reverse-transcription polymerase chain reaction; SAPS III, Simplified Acute Physiology Score. An additional 29 samples were obtained from two more patients. Only the sample collected from the NHF cannula was positive for SARS-CoV-2 RNA. This NHF cannula positive sample was inoculated to susceptible Vero E6 cells, but no CPE was observed after a six-day observation period. Therefore, no infectious SARS-CoV-2 was found in any of the environmental samples collected in this study. However, the degree of surface and air contamination from SARS-CoV-2 in a previous study was highly heterogeneous [[4]Birgand G. Peiffer-Smadja N. Fournier S. Kerneis S. Lescure F.X. Lucet J.C. Assessment of air contamination by SARS-CoV-2 in hospital settings.JAMA Open Netw. 2020; 3e2033232Crossref PubMed Scopus (65) Google Scholar]. The singularity of the present study is that it includes the largest data on the environmental persistence of SARS-CoV-2 in the rooms of COVID-19 patients being treated with NHF. Moreover, we compared the environmental contamination associated with NHF use to MV. Lack of environmental contamination in an ICU environment with negative-pressure rooms was observed in both groups. Indeed, it has recently been shown that NHF by itself may not increase aerosol generation in healthy volunteers in a negative-pressure room [[5]Gaeckle N.T. Lee J. Park Y. Kreykes G. Evans M.D. Hogan Jr., C.J. Aerosol generation from the respiratory tract with various modes of oxygen delivery.Am J Respir Crit Care Med. 2020; 202: 1115-1124Crossref PubMed Scopus (93) Google Scholar]. Interestingly, despite it being impossible to place living SARS-CoV-2 on a surface to obtain a positive control for obvious safety reasons, we could obtain one positive RT-qPCR from the nasal cannula of one of the non-intubated patients suggesting that the sample collection and PCR technique was correctly performed. These results were similar to the previous results reported by Colaneri et al. [[6]Colaneri M. Seminari E. Novati S. Asperges E. Biscarini S. Piralla A. et al.Severe acute respiratory syndrome coronavirus 2 RNA contamination of inanimate surfaces and virus viability in a health care emergency unit.Clin Microbiol Infect. 2020; 26: 1094.e1-1094.e5Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar], who obtained a unique positive PCR sample from inside the helmet of one non-intubated patient. The limitations of this study are that, firstly, air sampling was performed in only two patients and we cannot exclude that with increasing the litres of air sampling, we could probably obtain a positive sample. Secondly, the study was performed in ICU rooms with negative pressure and use of closed-aspiration systems in intubated patients and therefore its results may not be generalizable to other hospital environments. Despite these limitations, our results suggest that, with adequate infrastructure, NHF does not increase environmental surface contamination in critically ill patients with COVID-19. O.R., V.R.G. and J.V.A. contributed to the conception and design of the study, the acquisition, analysis and interpretation of the data and drafting the manuscript. A.P. and J.R. contributed to the acquisition, analysis and interpretation of the data and drafting the manuscript. A.A., L.A., M.C., J.S., T.P. and R.F. contributed to the conception and design of the study and interpretation of the data. All authors critically revised and approved the final version of the manuscript. O.R. reports speaker fees from Hamilton Medical, Ambu and Aerogen Ltd and a research grant from Hamilton Medical. He also received non-financial research support from Timpel and Masimo Corporation in the last five years all outside the submitted work. This study was funded by a grant from Instituto de Salud Carlos III of the Spanish Health Ministry (COV20-01054).

BACKGROUND:Neisseria gonorrhoeae (NG) isolates with high-level azithromycin resistance (HL-AziR) have emerged worldwide in recent decades, threatening the sustainability of current dual-antimicrobial therapy.OBJECTIVES:This study aimed to characterize the first 16 NG isolates with HL-AziR in Barcelona between 2016 and 2018.METHODS:WGS was used to identify the mechanisms of antimicrobial resistance, to establish the MLST ST, NG multiantigen sequence typing (NG-MAST) ST and NG sequence typing for antimicrobial resistance (NG-STAR) ST and to identify the clonal relatedness of the isolates with other closely related NG previously described in other countries based on a whole-genome SNP analysis approach. The sociodemographic characteristics of the patients included in the study were collected by comprehensive review of their medical records.RESULTS:Twelve out of 16 HL-AziR isolates belonged to the MLST ST7823/NG-MAST ST5309 genotype and 4 to MLST ST9363/NG-MAST ST3935. All presented the A2059G mutation in all four alleles of the 23S rRNA gene. MLST ST7823/NG-MAST ST5309 isolates were only identified in men who have sex with women and MLST ST9363/NG-MAST ST3935 were found in MSM. Phylogenomic analysis revealed the presence of three transmission clusters of three different NG strains independently associated with sexual behaviour.CONCLUSIONS:Our findings support the first appearance of three mild outbreaks of NG with HL-AziR in Spain. These results highlight the continuous capacity of NG to develop antimicrobial resistance and spread among sexual networks. The enhanced resolution of WGS provides valuable information for outbreak investigation, complementing the implementation of public health measures focused on the prevention and dissemination of MDR NG.

Introduction: There are few data on the frequency of virological remission in African individuals after treatment with antiretroviral therapy (ART) in primary HIV infection (PHI). Methods: We studied participants (n = 82) from South Africa and Uganda in Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion, the first trial of treatment interruption in African individuals with PHI randomized to deferred ART or 48 weeks of immediate ART. All were female and infected with non-B HIV subtypes, mainly C. We measured HIV DNA in CD4+ T cells, CD4+ cell count, plasma viral load (pVL), cell-associated HIV RNA and T-cell activation and exhaustion. We explored associations with clinical progression and time to pVL rebound after treatment interruption (n = 22). Data were compared with non-African Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion participants. Results: Pretherapy pVL and integrated HIV DNA were lower in Africans compared with non-Africans (median 4.16 vs. 4.72 log10 copies/ml and 3.07 vs. 3.61 log10 copies/million CD4+ T cells, respectively; P < 0.001). Pre-ART HIV DNA in Africans was associated with clinical progression (P = 0.001, HR per log10 copies/million CD4+ T cells increase (95% CI) 5.38 (1.95–14.79)) and time to pVL rebound (P = 0.034, HR per log10 copies/ml increase 4.33 (1.12–16.84)). After treatment interruption, Africans experienced longer duration of viral remission than non-Africans (P < 0.001; HR 3.90 (1.75–8.71). Five of 22 African participants (22.7%) maintained VL less than 400 copies/ml over a median of 188 weeks following treatment interruption. Conclusion: We find evidence of greater probability of virological remission following treatment interruption among African participants, although we are unable to differentiate between sex, ethnicity and viral subtype. The finding warrants further investigation.

Objectives: The aim was to describe pregnancy outcomes after Zika virus (ZIKV) infection in a nonendemic region. Methods: According to the Spanish protocol issued after the ZIKV outbreak in Brazil in 2015, all pregnant women who had travelled to high-burden countries were screened for ZIKV. Serological and molecular tests were used to identify ZIKV-infected pregnant women. They were classified as confirmed ZIKV infection when reverse transcription (RT) PCR tested positive, or probable ZIKV infection when ZIKV immunoglobulin M and/or immunoglobulin G and ZIKV plaque reduction neutralization tests were positive. Women found positive using molecular or serological tests were prospectively followed-up with ultrasound scans and neurosonograms on a monthly basis until delivery; magnetic resonance imaging and amniotic fluid testing were performed after signed informed consent. Samples of placenta, and fetal and neonatal tissues were obtained. Results: Seventy-two pregnant women tested positive for ZIKV infection: ten were confirmed by RT-PCR, and 62 were probable cases based on serological tests. The prevalence of adverse perinatal outcomes was 33.3% (three out of nine, 95% CI 12.1-64.6%): two cases of congenital ZIKV syndrome (CZS) and one miscarriage, all born to women infected in the first trimester of gestation. All ZIKV-confirmed women had persistent viraemias beyond 2 weeks (median 61.50 days; IQR 35.50-80.75). Amniotic fluid testing was only positive in the two fetuses with anomalies. Conclusion: The prevalence of perinatal adverse outcomes for women with ZIKV-confirmed infection was 33.3%. Amniocentesis for ZIKV RT-PCR is recommended when fetal abnormalities are found. Intensive prenatal and postnatal follow-up of ZIKV-infected pregnancies is advised in confirmed cases. (C) 2019 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Seasonal influenza is a cause of hospitalization, especially in people with underlying disease or extreme age, and its severity may differ depending on the types and subtypes of circulating viruses. We investigated the factors associated with ICU admission or death in hospitalized patients with severe laboratory-confirmed influenza according to the viral type and subtype. An observational epidemiological study was carried out in patients aged ≥18 years from 12 Catalan hospitals between 2010 and 2016. For each reported case we collected demographic, virological and clinical characteristics. A mixed-effects logistic regression model was used to estimate crude and adjusted ORs. 1726 hospitalized patients were included: 595 (34.5%) were admitted to the ICU and 224 (13.0%) died. Lower ICU admission was associated with age ≥75 years in all influenza types and subtypes and with age 65-74 years for type A. In contrast, the 65-74 and ≥75 years age groups were associated with an increased risk of death in all types and subtypes, especially for type B (aOR 27.42, 95% CI: 4.95-151.93 and 15.96; 95% CI: 3.01-84.68). The comorbidity most closely associated with severe outcomes was immune deficiency, which was associated with death for type B (aOR 9.02, 95% CI: 3.05-26.69) and subtype A(H1N1)pdm09 (aOR 3.16, 95% CI: 1.77-5.66). Older age was a differential factor for ICU admission and death: it was associated with lower ICU admission but a risk factor for death. The comorbidity with the closest association with death was immune deficiency, mainly in influenza type B patients.

We describe a case of a pregnant woman with Zika virus (ZIKV) infection and a foetus with severe brain malformations. ZIKV tested positive in amniotic fluid at 19 weeks but was negative at delivery. The newborn did not meet the case definition of congenital ZIKV syndrome because neither ZIKV RNA nor IgM antibodies were detected; however, prenatal brain lesions were confirmed after birth (Graphical Abstract).

Objectives: This study aimed to characterize the chronically infected general hepatitis C virus (HCV) population in Barcelona using a highly sensitive subtyping method that can identify the 67 recognized HCV subtypes and diagnose mixed infection by various genotypes/subtypes in a single individual. The resulting information has implications for selecting optimal direct-acting antiviral (DAA) treatment for each patient and establishing public healthcare policies in our setting. Methods: Consecutive HCV patients (treatment-naive or interferon-based failures) attending Vall d'Hebron Hospital outpatient clinics from February 2015 to May 2016 (N=1473) were included in the study. Patient samples were characterized using HCV subtyping by next-generation ultra-deep pyrosequencing. Results: The following genotypes (G) were found: G1 (1126/1473 (76.4%)), G4 (145/1473 (9.8%)), G3 (135/1473 (9.2%)), G2 (51/1473 (3.5%)), and G5 (1/1473 (0.1%)). Twenty-two subtypes were seen: 1b (790/1473 (53.6%)), 1a (332/1473 (22.5%)), 3a (133/1473 (9.0%)), 4d (105/1473 (7.1%)), 4a (29/1473 (2.0%)), and 2c (25/1473 (1.7%)), with 16 low-prevalence subtypes accounting for the remaining 3.0% (44/1473). There was a worrisome 1.0% (15/1473) of mixed infections. G2 (51/1473 (3.5%)) showed a high level of heterogeneity. Analyses by age groups showed a predominance of G1b over G1a (428/506 (84.6%) vs. 24/506 (4.7%)) in patients born before 1950 (N=506/1473), and similar percentages of these subtypes in those born between 1951 and 1975 (N=834/1473) (315/834, 37.8% vs. 266/834, 31.9%) and after 1976 (N=133/1473) (47/133, 35.3% vs. 42/133, 31.6%). Conclusions: Subtype distribution showed a higher level of heterogeneity than was expected, particularly for G2. Prevalence of mixed infections was around 1%. HCV subtype distribution related to patient age group suggested that patients born from 1936 to 1975 in our setting should undergo screening for the infection. Next-generation sequencing enabled better classification of candidates for DAA-based treatment. (C) 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Most attention is given to seasonal influenza and respiratory syncytial virus outbreaks, but the cumulative burden caused by other respiratory viruses (RV) is not widely considered. The aim of the present study is to describe the circulation of RV in the general population during six consecutive seasons from 2006 to 2012 in Catalonia, Spain. Cell culture, immunofluorescence and PCR-based assays were used for the RV laboratory-confirmation and influenza subtyping. Phylogenetic and molecular characterizations of viral haemagglutinin, partial neuraminidase and matrix 2 proteins were performed from a representative sampling of influenza viruses. A total of 6315 nasopharyngeal samples were collected, of which 64% were laboratory-confirmed, mainly as influenza A viruses and rhinoviruses. Results show the significant burden of viral aetiological agents in acute respiratory infection, particularly in the youngest cases. The study of influenza strains reveals their continuous evolution through either progressive mutations or by segment reassortments. Moreover, the predominant influenza B lineage was different from that included in the recommended vaccine in half of the studied seasons, supporting the formulation and use of a quadrivalent influenza vaccine. Regarding neuraminidase inhibitors resistance, with the exception of the 2007/08 H275Y seasonal A(H1N1) strains, no other circulating influenza strains carrying known resistance genetic markers were found. Moreover, all circulating A(H1N1)pdm09 and A(H3N2) strains finally became genetically resistant to adamantanes. A wide knowledge of the seasonality patterns of the RV in the general population is well-appreciated, but it is a challenge due to the unpredictable circulation of RV, highlighting the value of local and global RV surveillance.

According to the WHO, chronic Chagas disease (CD) diagnosis is based on two serological techniques. To establish a definitive diagnosis, the results must be concordant. In cases of discordances, the WHO proposes repeating serology in a new sample, and if results remain inconclusive, a confirmatory test should be performed. This study, conducted at two Tropical Medicine Units in Europe over 4 years, aims to assess the diagnostic yield of TESA-(trypomastigote excretedesecreted antigens) blot as a confirmatory technique in patients with inconclusive and discordant results. Of 4939 individuals screened, 1124 (22.7%) obtained positive results and 165 (3.3%) discordant results. Serology was repeated in 88/165 sera and discrepancies were solved in 25/88 (28.4%) cases. Patients without a definitive diagnosis were classified in two different groups: Group 1, including patients with inconclusive results despite retesting (n = 63), and Group 2, including patients with discordant results not retested (n = 77). TESA-blot was performed for all of Group 1 and 39/77 of Group 2 and was positive for 33/63 (52.4%) and 21/39 (53.8%), respectively. Analysis of Group 1 results showed a moderate agreement between results of the ELISA based on native antigen and TESA-blot (kappa 0.53). In contrast, a clear disagreement was observed between the ELISA based on recombinant antigens and TESA-blot (kappa < 0). A sizeable proportion of patients are suspected to have CD with inconclusive results or in whom re-testing is not feasible. TESA-blot was positive in half of these patients, highlighting the need for a confirmatory assay in European centres caring for exposed individuals. Z. Moure, CMI 2016; 22: 788 (C) 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

We describe here the first pregnant women described with Zika virus (ZIKV) infection in Europe. One of the cases was a probable coinfection with dengue virus (DENV) and the most prolonged viraemia ever reported. We communicate the protocol established in our setting as a response for the international emergency. The first patient was a Colombian woman in her 40s living in Spain who had travelled to Colombia in the months of December 2015 and January 2016. Three days after her return, at approximately 10 weeks’ gestation, she observed a maculopapular, nonconfluent rash affecting her trunk and limbs, with no fever or other concurrent symptoms. Fifteen days later, she contacted the outpatient service of the International Health Unit at Vall d’Hebron Hospital, Barcelona, where an arboviral infection was suspected and a serum sample was taken. To confirm ZIKV diagnosis, anti-ZIKV immunoglobulin (Ig) M and IgG antibodies (Arboviral Fever Mosaic, Euroimmun, Germany) and specific retrotranscriptase (RT) PCR, RealStar ZIKV RT-PCR Kit and a modification from Balm et al. [[1]Balm M.N. Lee C.K. Lee H.K. Chiu L. Koay E.S. Tang J.W. A diagnostic polymerase chain reaction assay for Zika virus.J Med Virol. 2012 Sep; 84: 1501-1505Crossref PubMed Scopus (146) Google Scholar]) were performed at the Spanish National Microbiology Center at Instituto Carlos III, Madrid. RT-PCR and ZIKV IgG were positive and ZIKV IgM was negative. Anti–chikungunya virus (CHKV) antibodies were negative. Anti-DENV IgM and IgG (Dengue VirClia Monotest, Vircell, Granada, Spain) showed positive results. It was considered a confirmed case of ZIKV infection according to approved diagnostic criteria. The second patient was a Spanish woman in her 30s who had traveled to Colombia during similar dates. Ten days after her arrival to Colombia, at 22 weeks’ gestation, she experienced a rash on the face and trunk that was self-limited in 12 hours, with no other concurrent symptoms. She contacted the Unit of International Health upon her return, 20 days later, and a serum sample was obtained for DENV, CHKV and ZIKV serology. Anti-CHKV IgG/IgM and anti-DENV IgM were negative, but anti-DENV IgG was positive. For ZIKV, both IgM and IgG were positive, and serum neutralization confirmed the positive results, discarding cross-reaction with other viruses. It was considered a case of ZIKV infection according to the approved diagnostic criteria. The same day the results were known, obstetricians assessed both patients. Prenatal ultrasounds, including neurosonography, were performed. The gestational age of the women’s fetuses were 14 and 27 weeks, respectively; no apparent foetal malformations were detected. Both pregnant women are currently under strict supervision. The working group designed and launched a protocol to diagnose and follow up all pregnant women coming from endemic ZIKV areas in order to be able to promptly detect foetal microcephaly and ZIKV infection among women at risk. The protocol is described in Fig. 1. In the first case, specific RT-PCR detected viraemia 15 days after the onset of symptoms; this was confirmed by a second RT-PCR. Viraemia for ZIKV is usually shorter [[2]Hayes E.B. Zika virus outside Africa.Emerg Infect Dis. 2009; 15: 1347-1350Crossref PubMed Scopus (611) Google Scholar]; further studies are needed to assess the likely time ranges. DENV IgM was also positive; coinfection cannot be excluded. Further studies are needed to determine if these circumstances may be risk factors for foetal involvement. In the second case, in which RT-PCR was not performed and DENV IgG was also positive, seroneutralization was performed in order to confirm the case, as serologic cross-reactivity between ZIKV and DENV has been reported [[3]Lanciotti R.S. Kosoy O.L. Laven J.J. Velez J.O. Lambert A.J. Johnson A.J. et al.Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007.Emerg Infect Dis. 2008; 14: 1232-1239Crossref PubMed Scopus (1599) Google Scholar]. A complete follow-up has been set until delivery because the impact on the foetus is not yet well established [[4]Adibi J.J. Marques Jr., E.T. Cartus A. Beigi R.H. Teratogenic effects of the Zika virus and the role of the placenta.Lancet. 2016; 387: 1587-1590Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar]. Moreover, these women live in Europe, far from the endemic areas for arbovirosis. These cases provide information about the evolution of the infection without reexposure to the virus. Key points to complete the appropriate diagnosis are a good clinical history adapted to every moment to the changing situation, laboratory capacity to quickly implement new techniques and a timely and appropriate follow-up of the affected women. The authors particularly acknowledge the Spanish Network on Tropical Diseases Research, especially groups RD12/0018/0021 and RD12/0018/0006. All authors report no conflicts of interest relevant to this article.

Human respiratory syncytial virus (HRSV) is one of the most common viral aetiological agents in the youngest population. In the present study a novel HRSV-B BA genotype is first described based on the phylogenetic analysis of the coding hypervariable region 2 sequences of G protein from strains detected during the 2014-2015 season. Among all strains detected in the last season, 44% belonged to this new genotype. Therefore, it highlights the importance of a continuous HRSV surveillance to monitor the emergence and spread of new genotypes or variants with genetic changes that may affect antigenic and tropism features.

Therapy for recurrent Clostridium difficile-associated diarrhea (CDAD) is challenging. We evaluated the frequency, associated risk factors, and prognosis of first CDAD recurrences. Prospective cohort study of all consecutive cases of primary CDAD diagnosed in a university hospital from January 2006 to June 2013. Recurrent infection was defined as reappearance of symptoms within 8 weeks of the primary diagnosis, provided that CDAD symptoms had previously resolved and a new toxin test was positive. Predictors of a first episode of recurrent CDAD were determined by logistic regression analysis. In total, 502 patients (51.6 % men) with a mean age of 62.3 years (SD 18.5) had CDAD; 379 (76 %) were cured, 61 (12 %) had a first recurrence, 52 (10 %) died within 30 days of the CDAD diagnosis, nine (2 %) required colectomy, and one was lost to follow-up. Among the 61 patients with a first recurrence, 36 (59.3 %) were cured, 15 (23.7 %) had a second recurrence, nine (15.3 %) died, and one (1.7 %) required colectomy. On multivariate analysis, age older than 65 years (OR 2.04; 95 % CI, 1.14-3.68; P < 0.02) and enteral nutrition (OR, 3.62; 95%CI, 1.66-7.87; P < 0.01) were predictors of a first recurrence. A risk score was developed for first CDAD recurrence using the predictive factors and selected biological variables. In our CDAD cohort, 12 % of patients had a first recurrence of this disease, in which the prognosis was less favorable than that of the primary episode, as it heralded a higher risk of additional recurrences. Patient age and enteral nutrition were predictors of a first recurrence.