Germs

11 pages, 6714 KB

Open AccessCase Report

Enterococcal Infective Endocarditis with Meningocerebral and Articular Involvement: An Unusual Diagnostic Presentation—A Case Report

by Victoria Birlutiu, Ioana Maria Cobirje and Rares-Mircea Birlutiu

Germs 2026, 16(3), 21; https://doi.org/10.3390/germs16030021 - 21 Aug 2026

Abstract

Background: Enterococcus faecalis is the third leading cause of infective endocarditis (IE) and remains the predominant enterococcal species involved in this condition, particularly among older patients with multiple comorbidities and healthcare-associated exposure. Its diagnosis may be challenging because the disease often follows a [...] Read more.

Background: Enterococcus faecalis is the third leading cause of infective endocarditis (IE) and remains the predominant enterococcal species involved in this condition, particularly among older patients with multiple comorbidities and healthcare-associated exposure. Its diagnosis may be challenging because the disease often follows a subacute course and may initially present with atypical extracardiac manifestations. Case presentation: We report the case of a 76-year-old man admitted with a 5-day history of fever, chills, profuse diaphoresis, myalgia, abdominal pain, and progressive confusion. On admission, he was febrile, hypotensive, disoriented, and presented with neck stiffness, a grade IV aortic murmur, suprapubic tenderness, hepatomegaly, and hemorrhagic lesions of the left hand. Initial transthoracic echocardiography did not reveal valvular vegetations. Cerebrospinal fluid analysis showed inflammatory changes with marked granulocytic predominance, whereas the multiplex PCR panel for meningitis/encephalitis pathogens and conventional cerebrospinal fluid cultures remained negative. In contrast, all blood cultures yielded E. faecalis. Repeat cranial computed tomography demonstrated a focal parasagittal frontal lesion involving the rostrum and genu of the corpus callosum, consistent with septic embolic involvement. Transesophageal echocardiography performed on hospital day 5 confirmed aortic valve IE, showing vegetative lesions on all cusps, the largest measuring approximately 8 mm, and severe aortic regurgitation. The clinical course was further complicated by cardiac decompensation and acute inflammatory involvement of the left knee, with synovial fluid analysis demonstrating a neutrophil-predominant inflammatory effusion, although cultures remained sterile. The patient received ampicillin plus vancomycin, followed by ampicillin plus linezolid after vancomycin-associated renal impairment. Follow-up blood cultures became negative after 3 weeks of treatment, but persistent severe aortic valve involvement required referral for cardiac surgical evaluation. The patient was readmitted to the cardiology department and subsequently developed multi-organ system failure, resulting in death one week after discharge. Conclusions: This case highlights the diagnostic complexity of. E. faecalis IE when meningocerebral and osteoarticular manifestations dominate the initial presentation, emphasizing the importance of repeated blood cultures and early transesophageal echocardiography. Full article

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13 pages, 1027 KB

Open AccessArticle

Changes in Patient Attitudes and Vaccination Intention After Pneumococcal Vaccination Counselling by Trained Family Physicians: A Multicentre Implementation Study in Romania

by Roxana Surugiu, Virginia-Maria Rădulescu, Anca Deleanu, Anca Lăcătuș, Mirela Mustață, Dana Fărcășanu, Iulia Vișinescu, Alexandra Aurora Dumitra and Gheorghe Gindrovel Dumitra

Germs 2026, 16(3), 20; https://doi.org/10.3390/germs16030020 - 13 Aug 2026

Abstract

Introduction: Improving adult pneumococcal vaccination is a public-health priority in Romania, and evidence regarding patient-level outcomes following different approaches to physician training remains limited. Materials and methods: This non-randomised, multicentre, quasi-experimental implementation study examined patient-level changes across three geographically distinct Romanian settings between [...] Read more.

Introduction: Improving adult pneumococcal vaccination is a public-health priority in Romania, and evidence regarding patient-level outcomes following different approaches to physician training remains limited. Materials and methods: This non-randomised, multicentre, quasi-experimental implementation study examined patient-level changes across three geographically distinct Romanian settings between August and November 2025. Physicians in Iași and Dolj counties received in-person training combining medical content with communication techniques based on motivational interviewing, whereas physicians in the webinar group received online medical training without a dedicated communication module. Eligible adult patients completed questionnaires before and after counselling and reported whether they had been vaccinated or had scheduled a vaccination appointment. Results: The analysis included 295 questionnaire pairs from patients nested within 29 physicians. Baseline attitudes differed markedly across settings (composite score of 5.64 in the webinar group, 5.29 in Dolj County, and 4.09 in Iași County; p < 0.001), as did strong baseline vaccination intention (75.6%, 48.1%, and 27.2%, respectively). Using a composite score comprising all seven attitude items, with item 7 reverse-coded and vaccination intention analysed separately, the cluster-robust group-by-time model indicated different mean changes between settings (global p = 0.001): +0.28 in the webinar group, +1.02 in Iași, and +0.60 in Dolj. Strong vaccination intention increased within each setting, but the magnitude of change did not differ between settings (group-by-time p = 0.929). The combined self-reported vaccination-or-scheduling outcome was observed in 81.5% of patients in the webinar group, 49.4% in Iași, and 73.3% in Dolj; after adjustment for baseline intention, there was no longer evidence of an overall group difference (p = 0.651). Discussion and conclusions: Because training approach, delivery modality, geographical setting, physician cohort, and patient population were not independently allocated, and because baseline levels differed markedly between settings, the findings should be interpreted as exploratory implementation patterns rather than causal comparative effects. Full article

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18 pages, 1661 KB

Open AccessReview

Clinical Features, Management, and Long-Term Outcomes of Chikungunya in Adult Populations: A Scoping Review

by Putu Cahyani Paramita Yoga, Agatha Viviane and Ni Putu Dila Iswarani Dewi

Germs 2026, 16(3), 19; https://doi.org/10.3390/germs16030019 - 11 Aug 2026

Abstract

Chikungunya poses a major clinical and public health challenge due to its wide range of manifestations and, consequently, frequent misdiagnoses. This pitfall may lead to compromised long-term outcomes when treatment is inadequate. This scoping review aims to summarize the clinical features, current management [...] Read more.

Chikungunya poses a major clinical and public health challenge due to its wide range of manifestations and, consequently, frequent misdiagnoses. This pitfall may lead to compromised long-term outcomes when treatment is inadequate. This scoping review aims to summarize the clinical features, current management strategies, and long-term outcomes of chikungunya infection in adults. The review was designed and reported according to Joanna Briggs Institute (JBI) guidance and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) framework. Three main databases—PubMed, ScienceDirect, and Wiley Online Library—were searched, and additional gray literature from international and national health agencies was consulted. Nineteen studies met inclusion criteria. Chikungunya in adults commonly begins as an acute febrile illness with prominent musculoskeletal symptoms, but may evolve into a chronic, disabling disease, substantially impairing quality of life. Treatment is largely symptomatic for the acute phase, whereas chronic infections require long-term multidisciplinary care, supported by preventive measures through public health interventions. In summary, while most patients recover with appropriate care, a significant number of patients experience persistent sequelae requiring rehabilitation, continued clinical follow-up, and targeted preventive and public health actions. Full article

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17 pages, 453 KB

Open AccessReview

Genomic and Antigenic Evolution of Influenza A(H3N2) After the COVID-19 Era: A Scoping Review with Focus on J and K Subclades and Implications for Vaccine Effectiveness

by Angelo Cianciulli, Emanuela Santoro, Salvatore Esposito, Savino Quaglierella, Antonietta Pacifico, Michele Nappa, Domenico Fornino, Roberta Manente, Mario Capunzo and Giovanni Boccia

Germs 2026, 16(3), 18; https://doi.org/10.3390/germs16030018 - 16 Jul 2026

Abstract

Post-COVID-19, influenza A(H3N2) has re-emerged with accelerated genetic diversification. The rise in antigenically drifted subclades raises concerns regarding immune escape and vaccine mismatch. To synthesize the available evidence on the post-pandemic evolution of influenza A(H3N2), with particular attention to emerging subclades and their [...] Read more.

Post-COVID-19, influenza A(H3N2) has re-emerged with accelerated genetic diversification. The rise in antigenically drifted subclades raises concerns regarding immune escape and vaccine mismatch. To synthesize the available evidence on the post-pandemic evolution of influenza A(H3N2), with particular attention to emerging subclades and their potential public health implications, a scoping review (PRISMA-ScR) was conducted across six databases in January 2026, including studies on genomic surveillance, antigenic characterization, and vaccine effectiveness (VE). Twenty studies were included. While clade 2a.3a.1 (J lineage) predominated, reports highlighted the rapid emergence of the antigenically distinct K subclade (formerly J.2.4.1). Genetic and laboratory assays (HI/neutralization) confirmed immune escape and reduced vaccine match. Observational estimates indicated diminished VE against drifted strains, though no consistent increase in clinical severity was observed. Post-pandemic A(H3N2) is defined by rapid drift and diversification. Emerging variants like the K subclade challenge vaccine selection and seasonal preparedness. Integrated surveillance remains vital for timely vaccine updates and mitigating public health impact. Full article

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19 pages, 1625 KB

Open AccessArticle

Pre-Transplant Antibiotic Exposures and Intestinal Microbiome Diversity in Allo-HSCT Recipients: A Prospective Cohort Study

by Lavinia-Eugenia Lipan, Karina-Doris Vihta, Andra-Daniela Marcu, Irina Avramescu, Dumitru Jardan, Andi Palade, Anca Colita, Simona-Olimpia Dima, Ileana Constantinescu, Iuliana Iordan, Alexandra Marcoci, Oana-Gabriela Craciun, Cristina Negulescu and Alina Daniela Tănase

Germs 2026, 16(3), 17; https://doi.org/10.3390/germs16030017 - 14 Jul 2026

Abstract

Intestinal microbiome dysbiosis has been associated with transplant-related mortality and graft-versus-host disease in allo-HSCT patients. We assessed how pre-transplant antibiotic and antineoplastic exposures, together with multidrug-resistant colonization, are associated with baseline gut microbiome diversity at allo-HSCT. We conducted a prospective, single-center cohort study [...] Read more.

Intestinal microbiome dysbiosis has been associated with transplant-related mortality and graft-versus-host disease in allo-HSCT patients. We assessed how pre-transplant antibiotic and antineoplastic exposures, together with multidrug-resistant colonization, are associated with baseline gut microbiome diversity at allo-HSCT. We conducted a prospective, single-center cohort study at Fundeni Clinical Institute (Bucharest, Romania) between August 2024 and June 2025, enrolling 52 allo-HSCT recipients and 27 healthy controls. Fecal samples were collected before conditioning. Gut microbiome composition was assessed via 16S rRNA gene sequencing and analyzed using QIIME2 and R. Associations were evaluated using Wilcoxon test, multivariable linear regression, and PERMANOVA. Shannon diversity was significantly lower in patients (median 4.71, IQR 3.97–5.44) than in healthy controls (median 6.09, IQR 5.87–6.28; p < 0.001). In bivariate analyses, carbapenem (p adj = 0.02) and oxazolidinone exposure (p adj = 0.005) were associated with reduced diversity, while immunotherapy was associated with higher diversity (p adj = 0.042). Broad-spectrum penicillin (p adj = 0.062) and ESBL colonization (p adj = 0.066) did not reach significance. In the multivariable antibiotic model, although the overall model was statistically significant (model p = 0.039), no individual antibiotic class remained significantly associated with Shannon diversity after adjustment for co-exposures. Beta diversity differed modestly with carbapenem exposure (R² = 0.033, p = 0.019). Pre-transplant antibiotic exposures were associated with lower gut microbiome diversity at allo-HSCT admission, with patterns consistent with a cumulative rather than a class-specific association. These findings support antibiotic stewardship in pre-transplant care. Full article

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9 pages, 655 KB

Open AccessArticle

Comparable Treatment Efficacy of Switching to Dolutegravir/Lamivudine Versus Triple-Drug Antiretroviral Therapy in People with HIV After 2 Years of Follow-Up: The DUALING Prospective Nationwide Matched Cohort Study

by Ferdinand W. N. M. Wit, Marc van der Valk, Bart J. A. Rijnders and Casper Rokx

Germs 2026, 16(3), 16; https://doi.org/10.3390/germs16030016 - 2 Jul 2026

Abstract

Background: Demonstrating durable viral suppression after switching to dolutegravir/lamivudine in clinical practice solidifies its use. Methods: This was a prospective cohort (DUALING) study conducted in 24 Dutch HIV treatment centers. HIV-RNA-suppressed cases undergoing triple-drug antiretroviral therapy without prior virological failure or resistance who [...] Read more.

Background: Demonstrating durable viral suppression after switching to dolutegravir/lamivudine in clinical practice solidifies its use. Methods: This was a prospective cohort (DUALING) study conducted in 24 Dutch HIV treatment centers. HIV-RNA-suppressed cases undergoing triple-drug antiretroviral therapy without prior virological failure or resistance who switched to dolutegravir/lamivudine (cases) were 1:2 matched to controls, who remained on triple-drug antiretroviral therapy. Matching was stratified by dolutegravir use in the triple-drug antiretroviral therapy, and further by age, sex, HIV acquisition route, CD4⁺T-cell nadir, and HIV-RNA zenith. The primary endpoint was the treatment failure rate at 2 years, determined using intention-to-treat and on-treatment analyses with a 5% noninferiority margin. Results: The 2040 mostly male (84.3%) participants included 390 cases of dolutegravir-based triple-drug regimens with 680 controls, and 290 cases of non-dolutegravir-based triple-drug regimens with 580 controls. In the dolutegravir-based cases and controls, treatment failure occurred in 12.6% and 23.3% of patients in the intention-to-treat analysis (difference: −10.7%, 95%CI: −15.3% to −6.1%) and 2.6% and 2.4% of patients in the on-treatment analysis (difference: +0.2%, 95%CI −1.9% to +2.3%). The treatment failure risk in non-dolutegravir-based cases and controls was 15.2% and 19.9% in the intention-to-treat analysis (difference: −4.7, 95%CI: −10.0% to +0.6%) and 1.2% and 1.9% in the on-treatment analysis (difference +0.7%, 95%CI −2.6% to +1.1%). Therapy modifications unrelated to virological failure explained the higher treatment failure rate in the intention-to-treat analysis. In dolutegravir/lamivudine cases, a shorter time of prior triple-drug antiretroviral therapy, age < 50 years, and non-Western origin were associated with treatment failure in the multivariable analysis. Viral blips occurred in 6.8% of cases and 5.1% of controls. In the post hoc analysis, discontinuing tenofovir disoproxil fumarate-based triple-drug antiretroviral therapy led to weight gain in people with (+2.7 kg) and without (+2.3 kg) prior dolutegravir use. Conclusions: In this nationwide clinical practice study, switching to dolutegravir/lamivudine was noninferior to continuing triple-drug antiretroviral therapy after 2 years of follow-up. Full article

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21 pages, 1118 KB

Open AccessReview

Beliefs, Attitudes and Behaviors of Healthcare Professionals Regarding Seasonal Influenza Vaccination: An Umbrella Review

by Isidoros Kougioumtzoglou, Nikos Maniadakis, Dimitrios Kouvelas, Evangelia-Georgia Kostaki, Nikos Selekos, Areti-Dimitra Koulouvari and Areti Lagiou

Germs 2026, 16(3), 15; https://doi.org/10.3390/germs16030015 - 26 Jun 2026

Abstract

Background: Seasonal influenza remains a major public health challenge worldwide, causing significant morbidity each year and imposing substantial burdens on individuals, healthcare systems, and national economies. Vaccination is considered the most effective available strategy for prevention; however, uptake rates vary considerably across countries, [...] Read more.

Background: Seasonal influenza remains a major public health challenge worldwide, causing significant morbidity each year and imposing substantial burdens on individuals, healthcare systems, and national economies. Vaccination is considered the most effective available strategy for prevention; however, uptake rates vary considerably across countries, with many failing to achieve the recommended coverage levels. The aim of this umbrella review is to systematically synthesize and critically appraise the existing evidence on healthcare professionals’ beliefs, attitudes, and behaviors regarding seasonal influenza vaccination. Methods: This umbrella review was conducted in accordance with the PRISMA 2020 statement. A literature search was conducted in PubMed, the Cochrane Library, and Google Scholar. The following search terms were used: beliefs, attitudes, behaviors, influenza vaccination, flu vaccine, healthcare professionals and primary healthcare. The inclusion criteria were as follows: (1) Reviews, (2) Published after 1 January 2000, (3) English language, (4) Healthcare professionals as the target-population. Results: Twenty-five studies met the selection criteria and were included in this review. Twelve out of 25 studies were systematic reviews. Globally, vaccination uptake remains below recommended levels, with reported coverage ranging from approximately 2% to 44% in several settings, while rates can exceed 90% in countries with mandatory vaccination policies. North America demonstrates the highest vaccination coverage, while the lowest coverage is reported in Africa and South America. Overall, low- and middle-income countries show significantly lower vaccination behavior compared with high-income countries. Attitudes and beliefs appear to shape vaccination behavior in high-income countries. The main driver of acceptance is perceived protection of oneself and family, whereas hesitancy is mainly driven by concerns about side effects and vaccine safety. Across studies, non-physician healthcare professionals consistently demonstrated lower influenza vaccine acceptance compared with physicians, while pediatricians and general practitioners were found to receive the influenza vaccine more frequently. In addition, younger physicians and those with fewer years of professional experience showed higher vaccination coverage and a greater likelihood of recommending influenza vaccination to patients. Conclusions: Vaccination coverage, worldwide, is lower than what is recommended by the World Health Organization. Healthcare professionals working in hospital settings tend to be vaccinated at a higher rate compared with those working in primary care or community-based healthcare settings. The recommendations that healthcare professionals give are influenced by whether they accept influenza vaccines themselves. Beliefs and attitudes seem to influence behavior in countries where structural barriers, such as limited access to primary healthcare and socio-economic status are absent. Full article

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17 pages, 861 KB

Open AccessArticle

Preliminary Study on Prevalence of Obesity and Lifestyle Behaviors Among People Living with HIV in Romania: A Cross-Sectional Analysis

by Manuela Arbune, Alina Plesea-Condratovici, Anca Adriana Arbune, Lavinia-Alexandra Moroianu, Mariana Stuparu-Cretu and Catalin Plesea-Condratovici

Germs 2026, 16(2), 14; https://doi.org/10.3390/germs16020014 - 12 Jun 2026

Cited by 1

Abstract

Background/Objectives: Obesity is an increasing challenge among people living with HIV (PLWH). This study aimed to assess the prevalence of general and abdominal obesity and its association with lifestyle in adult Romanian PLWH, providing the first national data. Methods: A single-center, cross-sectional study [...] Read more.

Background/Objectives: Obesity is an increasing challenge among people living with HIV (PLWH). This study aimed to assess the prevalence of general and abdominal obesity and its association with lifestyle in adult Romanian PLWH, providing the first national data. Methods: A single-center, cross-sectional study involved 106 adult PLWH. Eating behavior was assessed using the Rapid Eating Assessment for Participants—Short Version (REAP-S) and physical activity with the General Practice Physical Activity Questionnaire (GPPAQ), both standardized and validated. Anthropometric, clinical, and virological data were collected from medical records and direct measurement. Results: Median age was 36 years [IQR 33–42], 83.3% were male, and 73.6% lived in urban areas. Median time since HIV diagnosis was 11 years, and 60.4% had AIDS-defining illness. General obesity (BMI ≥ 30 kg/m²) occurred in 17.9%, overweight in 29.2%, and high-risk abdominal obesity in 22.6%. Physical inactivity was reported by 20.8%. Multivariable analysis showed that being moderately or physically active was the only independent predictor of abdominal obesity (OR 0.19; 95% CI, 0.07–0.51; p = 0.001). Conclusions: In this young Romanian cohort of PLWH, physical activity reduces the risk of abdominal obesity, underscoring the need to integrate such interventions into the standard of care to reduce metabolic risk associated with HIV. Full article

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17 pages, 263 KB

Open AccessArticle

Bridging Knowledge–Practice Gaps in Syphilis Prevention: A Nationwide, Online Cross-Sectional Survey of Knowledge, Attitudes, Practices, and Policy Acceptance in Saudi Arabia

by Hind Muteb Albadrani

Germs 2026, 16(2), 13; https://doi.org/10.3390/germs16020013 - 11 May 2026

Cited by 1

Abstract

Introduction: Syphilis is a preventable sexually transmitted infection (STI) with severe health outcomes, yet it is not included in Saudi Arabia’s national premarital and antenatal STI screening programs. This study assessed knowledge, attitudes, and practices (KAP) toward syphilis in Saudi Arabia and identified [...] Read more.

Introduction: Syphilis is a preventable sexually transmitted infection (STI) with severe health outcomes, yet it is not included in Saudi Arabia’s national premarital and antenatal STI screening programs. This study assessed knowledge, attitudes, and practices (KAP) toward syphilis in Saudi Arabia and identified predictors of acceptance for including syphilis testing in such programs. Methods: A cross-sectional online survey was conducted among 935 participants aged ≥20 years. Data included sociodemographic characteristics and measures of KAP and screening acceptance. Continuous variables were summarized as medians (IQR) and categorical variables as frequencies and percentages, with bivariate and multivariate logistic regression used to identify predictors of screening acceptance. Results: Knowledge and preventive practices were low, while attitudes were predominantly neutral (median attitude score: 34 IQR 32–38). Although intentions for personal testing were low (17%), support for syphilis testing in premarital (60.8%) and antenatal (48.9%) programs was considerable. Employment in the health sector, older age, and positive attitudes predicted acceptance of screening policies. Knowledge and practice showed a weak correlation (r = 0.14), whereas knowledge and attitude were moderately correlated (r = 0.55). Conclusion: KAP toward syphilis is influenced by specific sociodemographic factors. Although acceptance of screening is high at the policy level, individual-level preventive behaviors remain low. Full article

29 pages, 2393 KB

Open AccessReview

Decoding Norovirus Biology: Insights into Epidemiology, Structural Dynamics, Host Interactions, and Viral Replication

by Mudra Sikenis, Bhavna Prajapati, Ashutosh Kumar Singh, Karmveer Yadav, Ashish Kumar Vyas, Narapity Pathirannehalage Sunil-Chandra, Akansha Tandekar, Surya Singh, Tarun Patil, Subhabrata Kar, Rajnarayan R. Tiwari and Ram Kumar Nema

Germs 2026, 16(2), 12; https://doi.org/10.3390/germs16020012 - 11 May 2026

Abstract

Norovirus is the leading cause of acute infectious gastroenteritis in the world and accounts for a significant proportion of outbreaks at the food-borne and person-to-person levels. Due to their low infectious dose, persistence in the environment, and broad genetic diversity, they can quickly [...] Read more.

Norovirus is the leading cause of acute infectious gastroenteritis in the world and accounts for a significant proportion of outbreaks at the food-borne and person-to-person levels. Due to their low infectious dose, persistence in the environment, and broad genetic diversity, they can quickly spread and reappear in even the most diverse populations. This review integrates current knowledge on the epidemiology of noroviruses, genomic organization, structural biology, virus–host interactions, and replication mechanisms, with a focus on factors that determine virus evolution and strain dominance. Literature has been systematically searched in the PubMed and Scopus databases to incorporate recent experimental and epidemiological findings. Analysis of global surveillance data indicates ongoing genetic diversification of circulating strains, with periodic replacement of major variants, particularly the GII.4 lineage. Variability of the capsid and recognition of histo-blood Group Antigens strongly affects the host’s susceptibility, viral attachment and immune escape. The capsid consists of most of the viral protein complexes. The structural proteins VP1 and VP2 are responsible for determining the contours of the capsid and antigenic specificity. Non-structural proteins are responsible for coordinating the genome replication and the modification of host cell pathways to favor the production of the virus. Eliminating these gaps by means of integrated genomic surveillance and functional studies will provide insight into the evolution of norovirus and help to develop broadly effective vaccines and antiviral strategies. Full article

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3 pages, 161 KB

Open AccessEditorial

Editorial Judgment in Infectious Diseases

by Terenzio Cosio

Germs 2026, 16(2), 11; https://doi.org/10.3390/germs16020011 - 7 May 2026

Abstract

Infectious diseases have become increasingly dependent on diagnostic systems, whose reach have expanded, largely through advances in clinical microbiology, far more quickly than efforts to verify the reliability and accurate interpretation of their findings [...] Full article

10 pages, 474 KB

Open AccessArticle

The Characteristics of the Main Nontuberculous Mycobacteria Species Among Patients with HIV at a Single Center in Poland

by Jakub Młoźniak, Adam Szymański, Gabriela Stondzik, Dagny Clea Krankowska, Tomasz Mikuła, Agnieszka Lembas, Joanna Kozłowska, Regina Podlasin, Magdalena Thompson, Grażyna Cholewińska, Aleksandra Chylak-Nowosielska, Anna Zabost, Ewa Augustynowicz-Kopeć and Alicja Wiercińska-Drapało

Germs 2026, 16(2), 10; https://doi.org/10.3390/germs16020010 - 9 Apr 2026

Abstract

Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms capable of causing diverse clinical manifestations. Their epidemiology among people with HIV remains insufficiently characterized. This study examined the epidemiology of NTM among people with HIV admitted to the Hospital for Infectious Diseases in Warsaw between [...] Read more.

Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms capable of causing diverse clinical manifestations. Their epidemiology among people with HIV remains insufficiently characterized. This study examined the epidemiology of NTM among people with HIV admitted to the Hospital for Infectious Diseases in Warsaw between 2017 and 2023. Data on CD4+ T-cell counts, type of NTM involvement, species identification, and antimicrobial resistance were obtained from medical records. In the analyzed group the median of the CD4+ T-cell count was 25 cells/mm³ (IQR 65 cells/mm³). Late HIV diagnosis was observed in n = 45/50 (90.0%) patients. NTM colonization was identified in n = 20 (33.9%) patients, while n = 39 (66.1%) had active NTM disease, including pulmonary (53.9%), disseminated (41.0%), and extrapulmonary (5.1%) forms. Mycobacterium kansasii was the most common species among colonized patients, n = 7/24 (29.2%), whereas Mycobacterium avium predominated among patients with NTM disease, n = 30/42 (71.4%). Among patients with NTM disease, in vitro resistance to at least one antimicrobial agent was observed in 80.0% of M. avium isolates. High levels of resistance of M. avium were noted for ethambutol (n = 8/8, 100%), moxifloxacin (n = 16/22, 72.8%) and linezolid (n = 9/21, 42.9%). Proper identification of Mycobacterium species and its antibiotic resistance might be helpful in selecting effective antimicrobial therapy. Early HIV diagnosis is needed to prevent NTM disease. Full article

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18 pages, 1742 KB

Open AccessArticle

Microbial Contamination in Hard-Shell Capsule Traditional Medicines and Health Supplements in Malaysia: GMP Regulatory Oversight and Encapsulation Practices

by Muhammad Amirul Amil, Jun Hao Koo, Xin Yun Yah, Norizzati Adila Salam and Muhammad Mawardi Zakaria

Germs 2026, 16(2), 9; https://doi.org/10.3390/germs16020009 - 9 Apr 2026

Abstract

Introduction: The growing demand for traditional medicines and health supplements (TMHS) in Malaysia has raised concerns regarding microbial contamination in hard-shell capsule products. Despite regulatory oversight, recurring recalls highlight persistent non-compliance with Good Manufacturing Practice (GMP) standards. This study examines the risks [...] Read more.

Introduction: The growing demand for traditional medicines and health supplements (TMHS) in Malaysia has raised concerns regarding microbial contamination in hard-shell capsule products. Despite regulatory oversight, recurring recalls highlight persistent non-compliance with Good Manufacturing Practice (GMP) standards. This study examines the risks of microbial contamination, recall patterns, and encapsulation practices among TMHS hard-shell capsule manufacturers in Malaysia. Methods: A cross-sectional approach was employed, comprising a review of regulatory guidelines, analysis of NPRA recall data from 2020 to 2024, and a structured survey of 86 TMHS manufacturers on equipment and production parameters. Results: Review of GMP guidance indicated that greater automation and reduced manual handling in capsule-filling processes help minimise microbial contamination. In line with this, TMHS products were recalled at a rate of 4.73%, more than 4 times the pharmaceutical recall rate (1.09%). Among the 245 TMHS recalls, 68 involved hard-shell capsule products that failed microbial testing, primarily total aerobic microbial count (73.53%). Additionally, manufacturers with 50–100 registered products had significantly higher odds of recall (OR = 10.0, 95% CI: 2.35–42.47). However, no significant associations were found between recall status and equipment type, capsule size, or production frequency. Conclusions: Microbial contamination remains a critical issue in TMHS hard-shell capsule products. Regulatory efforts should focus on medium-scale manufacturers and reinforce risk-based GMP adherence to enhance product safety and public health protection. Full article

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11 pages, 889 KB

Open AccessReview

A National Multidisciplinary Consensus to Develop an HIV Pre-Exposure Prophylaxis (PrEP) Referral Framework in Romania

by Oana Săndulescu, Anca Streinu-Cercel, Cătălina Poiană, Viorel Jinga, Beatrice Mahler, Gheorghe Gindrovel Dumitra, Sandra Adalgiza Alexiu, Simona Negreș, Cristina-Elena Zbârcea, George-Sorin Țiplică, Mihai Mitran, Robert Stoica, Mariana Mărdărescu, Șerban Benea, Adrian Gabriel Marinescu, Victor Daniel Miron, Elena Mătăsaru, Odette Chirilă, Sorin Petrea, Iulian Petre, Mihai Lixandru and Adrian Streinu-Cercel Show full author list Hide full author list

Germs 2026, 16(1), 8; https://doi.org/10.3390/germs16010008 - 17 Mar 2026

Abstract

Background: Despite major advances in antiretroviral therapy, HIV transmission remains an important public health challenge. Pre-exposure prophylaxis (PrEP) is a highly effective prevention strategy, offering a significant opportunity to further reduce new HIV infections through expanded access and optimized implementation. Methods: [...] Read more.

Background: Despite major advances in antiretroviral therapy, HIV transmission remains an important public health challenge. Pre-exposure prophylaxis (PrEP) is a highly effective prevention strategy, offering a significant opportunity to further reduce new HIV infections through expanded access and optimized implementation. Methods: A national multidisciplinary consensus process was conducted to define principles and operational pathways for PrEP referral and linkage in Romania. Experts from different medical fields, professional societies, academic institutions, and community-based organizations participated in structured discussions. Results: The consensus highlighted relevant knowledge gaps related to HIV prevention and PrEP among specialists working outside the field of infectious diseases, including difficulty recognizing risk factors for HIV, uncertainty about next steps after identifying risk factors, and uneasiness discussing sexual health. The consensus also emphasized a shared commitment of these professional societies to address these gaps through pragmatic, specialty-adapted training. Key priorities included improved HIV risk recognition in routine care, development of communication skills, and clear referral pathways to PrEP services. Existing barriers were also discussed, underscoring the importance of multidisciplinary networks and community engagement. Conclusions: This consensus provides a structured, context-adapted framework to support the upcoming nationwide implementation of PrEP in Romania. By strengthening provider education, clarifying clinical pathways, and fostering interdisciplinary collaboration, it offers a foundation for equitable and sustainable HIV prevention. Full article

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18 pages, 1682 KB

Open AccessSystematic Review

Comparative Effectiveness and Safety of Monotherapy and Defined Combination Regimens for Stenotrophomonas maltophilia. Infections: A Network Meta-Analysis

by Ming-Ying Ai and Wei-Lun Chang

Germs 2026, 16(1), 7; https://doi.org/10.3390/germs16010007 - 2 Mar 2026

Cited by 1

Abstract

Background: Stenotrophomonas maltophilia is a multidrug-resistant pathogen with limited therapeutic options that predominantly affects critically ill and immunocompromised patients. Trimethoprim–sulfamethoxazole (TMP/SMX) remains the conventional first-line therapy; however, emerging resistance and toxicity concerns necessitate alternative regimens. This study represents, to our knowledge, the first [...] Read more.

Background: Stenotrophomonas maltophilia is a multidrug-resistant pathogen with limited therapeutic options that predominantly affects critically ill and immunocompromised patients. Trimethoprim–sulfamethoxazole (TMP/SMX) remains the conventional first-line therapy; however, emerging resistance and toxicity concerns necessitate alternative regimens. This study represents, to our knowledge, the first network meta-analysis (NMA) comparing the efficacy and safety of clearly defined monotherapy and combination antibiotic regimens for S. maltophilia infections. Materials and methods: A systematic search of PubMed, Cochrane Library, Web of Science, and ClinicalTrials.gov (inception to January 2026) identified eligible randomized-controlled studies and retrospective studies. Data were analyzed using a frequentist random-effects NMA with TMP/SMX as the reference. Evaluated regimens included TMP/SMX, fluoroquinolone (FQ), minocycline (MIN), TMP/SMX + FQ, TMP/SMX + MIN, FQ + MIN and FQ + other. Primary and secondary outcomes were all-cause mortality, clinical cure, and adverse effects. Results: Thirteen retrospective studies encompassing 2980 patients were included. Using TMP/SMX as the reference, network meta-analysis demonstrated heterogeneity in all-cause mortality across antimicrobial regimens. FQ and MIN monotherapies were associated with lower odds of mortality (effect sizes: 0.65, 95% CI: 0.49–0.85 and 0.50, 95% CI: 0.28–0.90), whereas combination therapy with TMP/SMX plus FQ was associated with higher mortality (effect size: 2.93, 95% CI: 1.18–7.31). Treatment ranking based on effect sizes suggested more favorable mortality profiles for MIN and FQ regimsens. No significant differences were observed in clinical cure, while FQ was associated with a lower incidence of adverse effects compared with TMP/SMX. Conclusions: This network meta-analysis suggests that FQ and MIN monotherapies may be associated with more favorable survival and tolerability compared with TMP/SMX monotherapy. No clear differences were observed for combination therapy relative to other active monotherapy options. Prospective randomized studies are required to validate these observations and to better inform the management of S. maltophilia infections. Full article

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9 pages, 218 KB

Open AccessArticle

The Use of Unproven Drugs for COVID-19 Treatment in People Living with HIV in Central and Eastern Europe

by Blazej Rozplochowski, Justyna D. Kowalska, Arjan Harxhi, Lukas Fleischhans, Sergii Antoniak, Deniz Gokengin, Anna Vassilenko, Kerstin Aimla, Raimonda Matulionyte, Antonios Papadopoulos, Nino Rukhadze, Botond Lakatos, Dalibor Sedlacek, Gordana Dragovic, Marta Vasylyev, David Jilich, Anatonija Verhaz, Nina Yancheva, Josip Begovac, Agata Skrzat-Klapaczynska and Cristiana Oprea Show full author list Hide full author list

Germs 2026, 16(1), 6; https://doi.org/10.3390/germs16010006 - 19 Feb 2026

Abstract

Early in 2020, the WHO recommended that existing drugs be evaluated as a repurposed resource to fight the SARS-CoV-2 pandemic. Here, we investigate the trends of using repurposed and off-label drugs among people living with HIV in Central and Eastern Europe (CEE). From [...] Read more.

Early in 2020, the WHO recommended that existing drugs be evaluated as a repurposed resource to fight the SARS-CoV-2 pandemic. Here, we investigate the trends of using repurposed and off-label drugs among people living with HIV in Central and Eastern Europe (CEE). From November 2020 to May 2021, data on the clinical outcomes of HIV-positive patients diagnosed with COVID-19 were collected on eCRFs (SurveyMonkey^® platform, Inc. San Mateo, CA, USA). Factors associated with the off-label drugs available at this time (chloroquine, hydroxychloroquine, favipiravir, oseltamivir, and lopinavir/ritonavir) were identified using logistic regression models. Of the 557 HIV-positive patients assessed with COVID-19 disease, 67 (12.0%) received off-label drugs, as well as 11.6% (16/138) of hospitalized and 12.2% (51/419) of ambulatory patients (p = 0.8564). In the adjusted logistic regression model, higher odds of off-label drug use were found in patients who had their diagnoses confirmed by an RT PCR test (aOR 5.08 [95%CI 1.17–22.0], p = 0.0396), and who came from a non-EU region (aOR 6.79 [95%CI 3.51–13.1], p < 0.0001). The only factor decreasing the odds of off-label drug use was co-infection (aOR 0.31 [95%CI 0.10–0.94], p < 0.0395). In a cohort of HIV patients from the CEE, 12% were prescribed off-label drugs for COVID-19. Symptomatic patients with confirmed SARS-CoV-2 infection or who were from non-EU countries were more likely to receive a repurposed drug. Drug repurposing is an immediate solution to emerging pandemics. All data regarding the safety and effectiveness of such use should be monitored, reported, and publicly available. Access patterns within and outside the EU should be analyzed to prevent potential inequalities in access to care during epidemics in European settings. Full article

9 pages, 606 KB

Open AccessBrief Report

Burkholderia cepacia Complex Comprising Divergent Strains Identified as a Dominant Cause of Pediatric Bloodstream Infections in Myanmar

by Thida San, Meiji Soe Aung, Nan Aye Aye Oo, Linn Linn Htun, Myat Myint Zu Aung, Lynn Waddy and Nobumichi Kobayashi

Germs 2026, 16(1), 5; https://doi.org/10.3390/germs16010005 - 9 Feb 2026

Abstract

Burkholderia cepacia complex (Bcc) consists of genetically diverse species having highly pathogenic potential to humans, causing nosocomial infections via environmental sources. In Myanmar, Bcc has been known as one of the common pathogens of infectious diseases, with relatively low prevalence. However, recently, an [...] Read more.

Burkholderia cepacia complex (Bcc) consists of genetically diverse species having highly pathogenic potential to humans, causing nosocomial infections via environmental sources. In Myanmar, Bcc has been known as one of the common pathogens of infectious diseases, with relatively low prevalence. However, recently, an increase in isolation from bloodstream infections was noted in a pediatric hospital in Yangon. From December 2023 to June 2025, among the organisms isolated from blood samples (n = 586), Bcc was the most dominant species (n = 178, 30.4%), followed by Klebsiella pneumoniae (16.4%) and Candida spp. (12.7%). Species of Bcc and their genetic types were identified by sequence analysis of partial recA and gyrB genes. Based on the recA sequence, Bcc isolates were identified as B. cepacia (49%), B. cenocepacia (43%), and B. contaminans (7%), having 10, 3, and 2 recA-allelic types, respectively. Similarly, sequences of gyrB revealed the three Bcc species with multiple allelic types. Ceftazidime MIC > 32 mg/L and meropenem MIC > 16 mg/L were found in 38% and 34% of Bcc isolates, respectively. These findings indicated that Bcc, comprising three species with genetically diverse clones, has become the main cause of bloodstream infections in the pediatric hospital in Myanmar. Full article

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13 pages, 257 KB

Open AccessArticle

Factors Associated with Transfer to Intensive Care in Younger Adults Hospitalized with COVID-19

by Philip Tenchev, Emilia Naseva and Nina Yancheva

Germs 2026, 16(1), 4; https://doi.org/10.3390/germs16010004 - 30 Jan 2026

Abstract

Background/Objectives: While COVID-19 severity is strongly associated with older age, younger adults may also develop complications. This study investigated factors associated with transfer to ICU in hospitalized younger adults during May–December 2021. Materials and methods: Eighty-six consecutive patients aged ≥18 and <50 years [...] Read more.

Background/Objectives: While COVID-19 severity is strongly associated with older age, younger adults may also develop complications. This study investigated factors associated with transfer to ICU in hospitalized younger adults during May–December 2021. Materials and methods: Eighty-six consecutive patients aged ≥18 and <50 years were admitted to the University Multi-profile Hospital for Active Treatment of Infectious and Parasitic Diseases “Prof. Ivan Kirov”, Sofia, Bulgaria between 12 May 2021, and 7 December 2021. Results: Among 86 patients (median age 40 years; 55.8% female), common symptoms included fever (89.5%), cough (91.9%), headache (76.7%), and gastrointestinal symptoms (83.7%). Laboratory abnormalities were frequent: lymphopenia (median 0.94 × 10⁹/L), elevated CRP (28.9 mg/L), LDH (333 U/L), and ferritin (198.5 µg/L). Severe andcritical disease occurred in 17.5% of cases, with 43% requiring oxygen therapy. In descriptive/univariate analyses, ICU transfer was more frequent among patients with hypoxemia (SaO₂ < 90%) and higher CRP, D-dimer, vomiting and ferritin. In a Firth penalized logistic regression model (rare-event setting), endocrine/metabolic comorbidity showed a directionally consistent association with ICU transfer; gastrointestinal comorbidity signals were not interpretable because of extremely small cell counts. Conclusions: Younger adults usually present with mild to moderate COVID-19; however, a substantial minority develop severe illness. Hypoxemia and elevated inflammatory and coagulation markers were consistently associated with worse outcomes. Endocrine/metabolic comorbidity showed the most consistent association with transfer to ICU in this cohort, although all comorbidity estimates should be interpreted cautiously, given the small number of events. Full article

8 pages, 227 KB

Open AccessArticle

Comparative Analysis of Direct Hospital Costs for Community Acquired Viral Gastroenteritis in Children Under 60 Months in Brasov, Romania

by Ioana Arbanaș, Gabriela Coja, Vlad Monescu, Bianca Elena Popovici, Ileana-Raluca Lixandru and Oana Falup-Pecurariu

Germs 2026, 16(1), 3; https://doi.org/10.3390/germs16010003 - 19 Jan 2026

Abstract

Background/Objectives: Viral gastroenteritis leads to a broad range of hospitalization costs globally in children, depending on the region. To our knowledge, no recent studies have examined the hospitalization cost associated with viral gastroenteritis in Romania. The aim of this study is to determine [...] Read more.

Background/Objectives: Viral gastroenteritis leads to a broad range of hospitalization costs globally in children, depending on the region. To our knowledge, no recent studies have examined the hospitalization cost associated with viral gastroenteritis in Romania. The aim of this study is to determine the direct hospitalization cost of community-acquired viral gastroenteritis (rotavirus, adenovirus and norovirus) in children admitted to Children’s Clinical Hospital of Brașov, Romania, for one year. Methods: All children aged 0–60 months hospitalized for a stool sample positive for rotavirus, adenovirus or norovirus during January 2023 and December 2023 were included in this study. Hospital-acquired gastroenteritis, gastrointestinal coinfections or children with acute coinfection were excluded. The stool specimens were tested using the immunochromatography method. Results: Out of the total of 282 children, 218 children presented rotavirus gastroenteritis, 35 children presented adenovirus gastroenteritis and 29 children presented norovirus gastroenteritis. Regarding patient characteristics, a higher proportion of boys than girls was observed in all three comparison groups, the average age for children with rotavirus was 22.2 months vs. norovirus and adenovirus, and children presented an average age of 16.4 months. Average hospitalization length of stay for rotavirus was 4.64 (±1.95) days, for adenovirus it was 4.54 (±1.52) days and for norovirus it was 4.75 (±1.93) days. Direct hospitalization costs did not differ between rotavirus, adenovirus, and norovirus infections (Kruskal–Wallis H(2) = 0.145, p = 0.930). Conclusions: In this single-center study, rotavirus remained the most frequent cause of viral gastroenteritis requiring hospitalization in young children, followed by adenovirus and norovirus. Although the average length of stay was similar across groups, hospitalization costs varied, with rotavirus-associated cases showing the highest mean expenses and widest cost variability. Full article

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