Military Medical Academy

Rotation advancement flaps are a challenge for dermatosurgery and in particular the severe clinical cases, mainly affecting skin tumors in the facial area or the so-called ˝high risk areas˝. The proximity of these areas to important vital structures (such as nerves and blood vessels) also determines the need for more precision when performing this type of manipulation. Teamwork and preoperative planning are crucial and provide a number of advantages in terms of the timely achievement of the therapeutic endpoints. We present two cases of patients with squamous cell carcinomas in the periocular and periorbital areas treated by rotation advancement flaps. The problems that may arise within these interventions and the prerequisites for the latter to be successful are discussed.

Myopia is a type of clinical refraction, a form of spherical refractive anomaly in which the eye has a relatively stronger refractive power for the corresponding length of the anteroposterior axis. The focus of this optical system is far in front of the retina. Myopia can be congenital or manifest later, most often at school age. It can be stationary or progressive. Progresive myopia is sight-threatening. The article discusses results from a screening program for myopia progression in Bulgarian schools between 2018-2023. The risk factors for myopia development have been outlined, and the ways of prophylaxis have been pointed out.

Background It has been observed that 5–8% of primary bariatric procedures result in inadequate treatment response, necessitating the need for revisional surgery. In this systematic review and meta-analysis, we aim to compare the effectiveness of single anastomosis duodeno-ileal bypass (SADI) and one anastomosis gastric bypass (OAGB) in addressing weight recurrence following sleeve gastrectomy. Methods We systematically searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases. Studies were considered eligible if they compared SADI with OAGB as revisional surgeries following sleeve gastrectomy. Results Our search strategy yielded four articles with a total of 309 patients. Regarding weight loss at 1 year of follow-up, SADI was favorable based on excess weight loss percentage (EWL%) and total weight loss percentage (TWL%). At 2 years of follow-up, EWL% did not show a statistically significant difference between the two operations although TWL% was higher in SADI group. Regarding postoperative bile reflux, the OAGB group had a significantly higher incidence of biliary reflux (OR 0.15; 95% CI 0.04 to 0.53; P = 0.003). Patients enrolled in SADI did not develop anastomotic ulcers according to the four studies included in the analysis. In contrast, seven patients in the OAGB group did develop anastomotic ulcers, but the difference was not statistically significant (OR 0.23; 95% CI 0.05 to 1.10; P = 0.07). Conclusion ADI is a feasible procedure with a favorable outcome compared to OAGB as a revisional surgery following sleeve gastrectomy regarding weight loss at 1 year with a lower incidence of postoperative biliary reflux.

Background Texture and color enhancement imaging (TXI) is a novel optical technology designed to improve visibility during endoscopy by highlighting subtle differences in morphology and color. This systematic review and meta-analysis aimed to determine whether TXI, compared to conventional white light imaging (WLI), can improve important colonoscopy quality indicators, specifically the adenoma detection rate (ADR) and adenomas per colonoscopy (APC). Methods We searched PubMed, EMBASE, and the Cochrane Central for studies comparing TXI to WLI in patients undergoing colonoscopy for any indication. Risk ratios (RR) and mean differences (MD) were computed using a random-effects model. Results We included 1541 patients from 3 studies, of which 2 were randomized controlled trials (RCTs). TXI was used in 775 (50.3%) patients. The indications for colonoscopy varied, including positive fecal immunochemical test (FIT), surveillance, and diagnostic workup for abdominal symptoms. In the pooled data, TXI significantly increased both ADR (57,8% versus 43.6%; RR 1.32 [95% CI, 1.20–1.46]; p < 0.001; I2 = 0%) and APC (MD 0.50 [95% CI, 0.37–0.64]; p < 0.001; I2 = 0%), compared to WLI. Furthermore, TXI was more effective at detecting nonpolypoid/flat adenomas, proximal/right-sided adenomas, and adenomas ≥ 10 mm in size. Colonoscopies with TXI had shorter withdrawal times. Conclusions Our meta-analysis demonstrates that TXI significantly improves the detection of colorectal adenomas in patients undergoing colonoscopy for various indications. TXI has the potential to improve the overall quality of colonoscopy and contribute to colorectal cancer prevention.

The introduction of antibiotics in the beginning of the 20th century was one of the most important scientific breakthroughs in history. However, in recent decades, the growing threat of antimicrobial resistance (AMR) has shown the limitations of the current research and development programs for new antimicrobial drugs. In the last decade, 20 antibiotics, 7 β-lactam/β-lactamase inhibitor (BL/BLI) combinations and 4 non-traditional antibacterial drugs have been launched worldwide. This study aimed to assess the time to patient access for new antibacterial drugs in countries in the European Union and the European Economic Area (EU/EEA). Time differences in marketing authorization from the U.S. Food and Drug Agency (FDA) and the European Medicines Agency (EMA) were also described, as well as the availability of each drug in the countries in the EU/EEA according to the national competent authorities. Substantial differences between countries were observed, with no or only one new drug available in some countries. Conclusions: Improving pricing and reimbursement timelines and fostering collaboration between national health authorities and market authorization holders can enhance timely and equitable patient access to new antibacterial treatments in Europe. Equitable and sustainable access to antibacterial drugs is a cornerstone in the battle against AMR.

Over the past three decades, there has been increasing interest in miniaturized percutaneous nephrolithotomy (mPCNL) techniques featuring smaller tracts as they offer potential solutions to mitigate complications associated with standard PCNL (sPCNL). However, despite this growing acceptance and recognition of its benefits, unresolved controversies and acknowledged limitations continue to impede widespread adoption due to a lack of consensus on optimal perioperative management strategies and procedural tips and tricks. In response to these challenges, an international panel comprising experts from the International Alliance of Urolithiasis (IAU) took on the task of compiling an expert consensus document on mPCNL procedures aimed at providing urologists with a comprehensive clinical framework for practice. This endeavor involved conducting a systematic literature review to identify research gaps (RGs), which formed the foundation for developing a structured questionnaire survey. Subsequently, a two-round modified Delphi survey was implemented, culminating in a group meeting to generate final evidence-based comments. All 64 experts completed the second-round survey, resulting in a response rate of 100.0%. Fifty-eight key questions were raised focusing on mPCNLs within 4 main domains, including general information (13 questions), preoperative work-up (13 questions), procedural tips and tricks (19 questions), and postoperative evaluation and follow-up (13 questions). Additionally, 9 questions evaluated the experts’ experience with PCNLs. Consensus was reached on 30 questions after the second-round survey, while professional statements for the remaining 28 key questions were provided after discussion in an online panel meeting. mPCNL, characterized by a tract smaller than 18 Fr and an innovative lithotripsy technique, has firmly established itself as a viable and effective approach for managing upper urinary tract stones in both adults and pediatrics. It offers several advantages over sPCNL including reduced bleeding, fewer requirements for nephrostomy tubes, decreased pain, and shorter hospital stays. The series of detailed techniques presented here serve as a comprehensive guide for urologists, aiming to improve their procedural understanding and optimize patient outcomes.

Modern skin cancer pathogenesis includes new concepts such as nitroso photocarcinogenesis and nitroso-mediated photosensitivity. The above 2 new concepts are in all likelihood also modeled/determined by photocarcinogens known as nitrosamines and/or NDSRIs available as contaminants in many drugs worldwide. The phototoxicity of nitrosamines is a known nonspecific property of them, for which evidence exists as far back as 1972. Current data from 2023/2024 are completely supportive of nitrosamines identified in drugs, with genotoxicity and phototoxicity proven once again. Regulators' data on polycontamination of a drug with up to several nitrosamines at the same time are of concern. The carcinogens/mutagens in question could also act as bi-/ polycarcinogens depending on whether they are metabolized or not. Permanent combined intake of potentially/actually nitrosamine-contaminated drugs appears to be key in the subsequent development of multiple cutaneous tumours, according to new findings in the literature. The localization of these tumours in areas exposed to intense solar radiation could also be seen as indirectly pointing to the presence of certain photosensitisers in the human body. Some of these nitrosamines are photocarcinogens and human carcinogens at the same time. The identification and specification of each of these genotoxic photosensitizers in drugs has yet to be further investigated in detail. The FDA identifies them currently as substances with carcinogenic potency. The clinicopathologic correlations published to date within the intake of potentially contaminated drugs are indicative of 1) the need to redefine skin cancer pathogenesis and 2) the subsequent possible introduction of complete elimination regimens against nitrosamines. We inform about another polymedication intake in a patient with arterial hypertension and diabetes mellitus, which includes the following medications: gliclazide 60 mg once daily and metformin hydrochloride 850 mg once daily, both since 24 years ; sotalol hydrochloride 80 mg since 2 years; bisoprolol fumarate 5 mg since 17 years; candesartan cilexetil/hydrochlorothiazide 16 mg/ 12.5 mg since 2 years; and lercanidipine hydrochloride 20 mg also since 2 years. Within this intake, it is notable that 1) all 6 of these drugs appear in the databases for possible availability as nitroso compounds, and that 2) this is the seventh consecutive keratinocyte tumor treated surgically (in this period). In the presented patient, surgical treatment was performed using a shark pedicle island flap for BCC of the nose, which is an ideal option for tumors with location in the alar or periralararea. An optimal postoperative outcome was achieved. This article focuses on the possible role of drug-mediated photo nitrosogenesis/ carcinogenesis of skin cancer by briefly reviewing and analyzing the available literature to date.

Background Probiotics have been used to prevent antibiotic-associated diarrhea (AAD), but practical guidelines are sparse. This trial evaluated the efficacy and safety of a high-dose, multi-strain probiotic mix (Sinquanon®), specially designed for prevention of AAD in adults. Methods A Phase IV, multi-center, randomized, double-blind, placebo-controlled, parallel-group clinical trial was conducted over 5 months. Participants receiving broad-spectrum antibiotics were administered the specialized probiotic mix or placebo from the first dose of antibiotics until 14 days after the last antibiotic dose. The primary outcome measure was the incidence of AAD. Results In total, 564 participants were randomized (probiotic mix: 285; placebo: 279), of which 9 participants discontinued the trial early (probiotic mix: 3; placebo:6), had no efficacy data, and were excluded from the efficacy analysis. The 555 remaining participants completed the trial and were included in the efficacy analysis (probiotic mix: 282; placebo: 273). AAD occurred less frequently in the studied probiotic mix versus placebo group (9.2% versus 25.3%, p<0.001), resulting in an absolute risk reduction of 16% and a number needed to treat of 6 (95% CI: 4.55-10.49). A significant improvement in the average gastrointestinal quality of life in the studied probiotic mix versus placebo group was also observed. There were no clinically relevant differences in the incidence of adverse events between the studied probiotic mix and the placebo group. Conclusions The specially designed high-dose, multi-strain probiotic mix (Sinquanon®) demonstrated to be beneficial compared with placebo in the prevention of AAD in adults who received broad-spectrum antibiotics. ClinicalTrials.gov Identifier NCT05607056.

The insertion of pedicle screws is one of the most common procedures in neurosurgical spinal interventions. It has been used for the fixation and immobilization of spinal segments secondary to trauma or as part of complex spinal reconstruction for vertebral metastatic disease, degenerative disease, or infection. However, increasing rates of pedicle screw use may also be the cause of more frequent revision surgery. The stabilization system may become loosened or defective, which could cause instability of the segment, severe neurological deficit, and intense pain. In addition to this, the screws may be removed in case of satisfactory consolidation depending on the individual decision of the surgeon. Despite the widespread use of pedicle screw fixation, there is limited research regarding the precise circumstances that may cause the need to remove the stabilization system. To our knowledge, this is the first research item to review the causes and the exact time for removal of inserted pedicle screws, as well as to outline techniques for the explantation and the possible short- and long-term outcomes after the procedure.

Background One of the most important surgical steps during thyroidectomy is the safe ligation of vessels. In fact, it is crucial to avoid postoperative bleeding and nerves’ injury. The “clamp and tie” technique was first introduced in the 19 th century. Since then, a lot of other techniques have been adopted to facilitate the safe ligation and sectioning of thyroidal vessels; however, one of the most relevant advances is the introduction of energy-based devices (EBDs), which occurred three decades ago. Purpose The aim of this systematic review and meta-analysis is to evaluate the safety and effectiveness of sutureless FOCUS harmonic scalpel (second generation EBDs) versus conventional clamps-and-tie technique) in total thyroidectomy. Results This systematic review and meta-analysis represent the largest comparison in literature between the thyroidectomy procedure with the second-generation Advanced Harmonic Scalpel Ultrasonic Focus (UAS FOCUS) versus the conventional Clamp-and-Tie (CT) technique: as a matter of fact, it includes 43 randomized controlled trials (RCTs) and a total of 10.361 patients. The incidence of transient recurrent laryngeal nerve was statistically lower in patients undergoing UAS (3.99%) rather than CT (5.23%) (RR 0.79, 95% CI 0.63 to 0.99). The incidence of transient hypocalcemia was 11.3% in patients who underwent thyroidectomy with UAS FOCUS and 15.4% in those who underwent thyroidectomy with CT. Conclusion Sutureless EBD is associated with a lower risk of damage to the laryngeal nerves and parathyroid glands. The rate of hypocalcemia and nerve paresis is indeed lower due to less thermic damage. Sutureless EBD can also diminish the rate of postoperative bleeding and cervical hematoma, a rare but potentially fatal complication.

The pathogenesis of cutaneous tumors has been known for decades yet remains largely unexplained or incompletely understood. The reason for this mystery lies in the concepts of photosensitivity and phototoxicity: how do they arise or what actually causes them? Recently published data in the medical literature link certain nitrosamines such as nitrosomorpholine, for example, to gene and phototoxicity in humans. A number of other nitrosamines analogous in action and structure are found as contaminants in about 300 of the most widely distributed pharmaceuticals worldwide: NDEA, NDMA, NMBA and many others. These contaminated drugs include beta blockers/ bisoprolol/, thiazide diuretics/ hydrochlorothiazide/, antiarrhythmics/ propafenone/, ACE inhibitors/ lisinopril/, but also a number of other drugs which are, according to the FDA, found to have contaminants with a certain carcinogenic potency ranging between 1 and 5. The phototoxicity and genotoxicity of these contaminants, attributed to the pathogenesis of skin tumors, still remain a mystery. The problems of the intake of the above-mentioned groups of drugs arise mainly on the basis of the official bulletins of the regulatory bodies, namely that: in practice, the intake of polymedication could in many cases also be considered as regular, permanent, long-term intake of contaminants/carcinogens/mutagens of heterogeneous type, also known as nitrosamines or NDSRIs. Nitrosamines are genome modifiers in humans and cause acquired mutations. Their concomitant administration in the context of standard, but currently not yet officially declared as contaminated polymedication, would be able to block certain tumor suppressor genes (p53) as well as activate RAS oncogenes. Or in practice- daily administration of a particular combination of drugs could activate the cascades of carcinogenesis regulating the genesis of skin cancer. Precisely because of this fact, it should not be surprising to anyone that the concurrent intake of the aforementioned drugs could also be associated with the clinical manifestation of multiple keratinocytic tumors. We describe a consecutive case of a patient who developed 4 keratinocytic tumors: 2 basal cell carcinomas, 1 keratoacanthoma, and 1 squamous cell carcinoma on a background of potentially contaminated polymedication with propafenone, lisinopril, hydrochlorothiazide, and bisoprolol. Recently published innovative international data on the topic are discussed in the context of concepts such as drug-mediated nitrosogenesis, photonitrosо-carcinogenesis and metabolic programming/ reprogramming of the tumor cell. PubMed Disclaimer

Lyme borreliosis is a frequently encountered tick-borne infection worldwide, caused by a spirochete from the Borrelia burgdorferi genoscpecies. In most cases, the initial sign of Lyme disease is the pathognomonic symptom - erythema migrans rash appearing at the site of the thick bite. Оther described cutaneous manifestations besides erythema migrans ‒ such as erythema nodosum (an acute nodular septal panniculitis), papular urticaria, granuloma annulare, psoriatic changes, lichen striatus et atrophicans, Henoch-Schönlein purpura, and morphea ‒ could potentially present as an initial/first sign of acute Borrelia burgdorferi infection. Serological testing for Lyme disease is only reliable after the initial stages of the disease. Additional PCR or serological examinations such as ELISA, immunoblot, indirect immunofluorescence examination could be performed. The diverse cutaneous manifestations of Lyme disease can lead to delays or ineffectiveness in treatment, as these symptoms may not be promptly identified as signs of the infection. Therefore, a comprehensive evaluation of the three key aspects - clinical findings, serology, and histology - is essential and should be considered collectively. We present a 78-year-old female with an acute form of Borrelia infection following a thick bite, manifesting as erythema nodosum on the lower extremities. Serology confirmed the presence of Borrelia infection, and the histological findings were indicative of erythema nodosum. The patient initially received anti-inflammatory and antibiotic medications. Reverse development of the nodules was observed after therapy with ceftriaxone, methylprednisolone, esomeprazole, and local dressings with povidone-iodine. For outpatient care, her regimen consisted of systemic reduction of the corticosteroid therapy, esomeprazole, and doxycycline. Due to the potential triggering of erythema nodosum by valsartan, it was recommended switching to an alternative medication. The rarity of erythema nodosum as an initial or first sign of acute Borrelia infection is being discussed.

The aim of this study was to assess the prevalence of Coxiella burnetii infection among veterinary medicine students from two Bulgarian Universities, located in Sofia and Stara Zagora. Blood samples were collected from a total of 185 veterinary students for the detection of C. burnetii phase II antibodies and presence of DNA using an enzyme-linked immunosorbent assay (ELISA) and end-point PCR test. Out of all samples, 29.7% were positive for at least one C. burnetii phase II antibody marker or by the result of the PCR test. Veterinary students from Stara Zagora showed a significantly high seropositivity for Q fever (33.6%), as compared to the students in Sofia (23%; p < 0.05). Evidence of recent exposure with detection of anti-C. burnetii phase II IgM (+) antibodies was observed in 14.6% of the students under study. Seroprevalence among students in Stara Zagora was higher (15.3%). Anti-C. burnetii phase II IgG antibodies were detected in 21.6% of examined samples. Our study revealed a higher seropositivity among the male students (32.8%) as compared to females (16.0%; p < 0.05). The end-point PCR assay detected 5.9% blood samples as positive. The relative risk (RR) of Q fever exposure for male students was 40.7%, whereas it was 24.6% in females (p < 0.05). The findings from this study indicate that the C. burnetii infection is widely distributed amongst veterinary students in Bulgaria. This study emphasizes the need for improved safety protocols and infection control measures in veterinary training programs.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), a pneumonia with extremely heterogeneous clinical presentation, ranging from asymptomatic to severely ill patients. Previous studies have reported links between the presence of host genetic variants and the outcome of the COVID-19 infection. In our study, we used whole exome sequencing in a cohort of 444 SARS-CoV-2 patients, admitted to hospital in the period October-2020–April-2022, to search for associations between rare pathogenic/potentially pathogenic variants and COVID-19 progression. We used gene prioritization-based analysis in genes that have been reported by host genetic studies. Although we did not identify correlation between the presence of rare pathogenic variants and COVID-19 outcome, in critically ill patients we detected known mutations in a number of genes associated with severe disease related to cardiovascular disease, primary ciliary dyskinesia, cystic fibrosis, DNA damage repair response, coagulation, primary immune disorder, hemoglobin subunit β, and others. Additionally, we report 93 novel pathogenic variants found in severely infected patients who required intubation or died. A network analysis showed main component, consisting of 13 highly interconnected genes related to epithelial cilium. In conclusion, we have detected rare pathogenic host variants that may have influenced the COVID-19 outcome in Bulgarian patients.

Purpose We aimed to investigate controversial pediatric urolithiasis issues systematically, integrating expert consensus and comprehensive guidelines reviews. Methods Two semi-structured online focus group meetings were conducted to discuss the study’s need and content, review current literature, and prepare the initial survey. Data were collected through surveys and focus group discussions. Existing guidelines were reviewed, and a second survey was conducted using the Delphi method to validate findings and facilitate consensus. The primary outcome measures investigated controversial issues, integrating expert consensus and guideline reviews. Results Experts from 15 countries participated, including 20 with 16+ years of experience, 2 with 11–15 years, and 4 with 6–10 years. The initial survey identified nine main themes, emphasizing the need for standardized diagnostic and treatment protocols and tailored treatments. Inter-rater reliability was high, with controversies in treatment approaches (score 4.6, 92% agreement), follow-up protocols (score 4.8, 100% agreement), and diagnostic criteria (score 4.6, 92% agreement). The second survey underscored the critical need for consensus on identification, diagnostic criteria (score 4.6, 92% agreement), and standardized follow-up protocols (score 4.8, 100% agreement). Conclusion The importance of personalized treatment in pediatric urolithiasis is clear. Prioritizing low-radiation diagnostic tools, effectively managing residual stone fragments, and standardized follow-up protocols are crucial for improving patient outcomes. Integrating new technologies while ensuring safety and reliability is also essential. Harmonizing guidelines across regions can provide consistent and effective management. Future efforts should focus on collaborative research, specialized training, and the integration of new technologies in treatment protocols.

Oxidative stress is a major source of ROS-mediated damage to macromolecules, tissues, and the whole body. It is an important marker in the severe picture of pathological conditions. The discovery of free radicals in biological systems gives a “start” to studying various pathological processes related to the development and progression of many diseases. From this moment on, the enrichment of knowledge about the participation of free radicals and free-radical processes in the pathogenesis of cardiovascular, neurodegenerative, and endocrine diseases, inflammatory conditions, and infections, including COVID-19, is increasing exponentially. Excessive inflammatory responses and abnormal reactive oxygen species (ROS) levels may disrupt mitochondrial dynamics, increasing the risk of cell damage. In addition, low serum albumin levels and changes in the normal physiological balance between reduced and oxidized albumin can be a serious prerequisite for impaired antioxidant capacity of the body, worsening the condition in patients. This review presents the interrelationship between oxidative stress, inflammation, and low albumin levels, which are hallmarks of COVID-19.

Cardiovascular disease is not only the leading cause of mortality in Bulgaria, but the associated mortality rate is twice the European Union average, so screening programmes that identify subjects with elevated blood pressure (BP) are of utmost importance. May Measurement Month (MMM) is an annual global initiative that began in 2017 that aims to raise awareness of high BP. Bulgaria first joined the third campaign of MMM in 2019, and an overview of the results of Bulgarian participation in MMM21 is presented in this paper. Hypertension was defined as receiving BP-lowering medications or having a systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. Statistical analysis followed the standard MMM protocol. In Bulgaria, 155 screening sites were set up in primary and secondary care facilities, in pharmacies, and outdoor spaces across 16 administrative districts. Out of 3908 individuals screened, 2896 participants (74.1%) had hypertension. Of 2896 participants with hypertension, 76.4% were on treatment of whom 48.5% had controlled BP (<140/90 mmHg). Out of 1696 participants not on antihypertensive medication, 684 (40.3%) had elevated BP. Men were found to have higher rates of undiagnosed hypertension and lower rates of control than women. By identifying almost two-thirds of the whole screened cohort with the possibility of newly diagnosed or uncontrolled hypertension, our results confirm the importance of BP screening.

The rapid spread of carbapenemase-producing strains has led to increased levels of resistance among Gram-negative bacteria, especially enterobacteria. The current study aimed to collect and genetically characterize the colistin-and carbapenem-resistant isolates, obtained in one of the biggest hospitals (Military Medical Academy) in Sofia, Bulgaria. Clonal relatedness was detected by RAPD and MLST. Carbapenemases, ESBLs, and mgrB were investigated by PCR amplification and sequencing, replicon typing, and 16S rRNA methyltransferases with PCRs. Fourteen colistin-and carbapenem-resistant K. pneumoniae isolates were detected over five months. Six car-bapenem-resistant and colistin-susceptible isolates were also included. The current work revealed a complete change in the spectrum of carbapenemases in Bulgaria. blaNDM-5 was the only NDM variant, and it was always combined with blaOXA-232. The coexistence of blaOXA-232 and blaNDM-5 was observed in 10/14 (72%) of colistin-and carbapenem-resistant K. pneumoniae isolates and three colistin-susceptible isolates. All blaNDM-5-and blaOXA-232-positive isolates belonged to the ST6260 (ST101-like) MLST type. They showed great mgrB variability and had a higher mortality rate. In addition, we observed blaOXA-232 ST14 isolates and KPC-2-producing ST101, ST16, and ST258 isolates. The colistin-and carbapenem-resistant isolates were susceptible only to cefiderocol for blaNDM-5-and blaOXA-232-positive isolates and to cefiderocol and ceftazidime/avibactam for blaOXA-232-or blaKPC-2-positive isolates. All blaOXA-232-positive isolates carried rmtB methylase and the colE re-plicon type. The extremely limited choice of appropriate treatment for patients infected with such isolates and their faster distribution highlight the need for urgent measures to control this situation .