Hydrocortisone may act through the angiotensin II receptor-2 level in patients with catecholamine-resistant septic shock.

BACKGROUND: This study aimed to compare the serum angiotensin II and its receptor levels (AT1, AT2) in septic patients with catecholamine-responsive or resistant. The effect of hydrocortisone treatment on angiotensin II levels in the catecholamine-resistant septic patients was evaluated. METHODS: This prospective observational study enrolled 40 patients diagnosed with septic shock based on sepsis-3 criteria. Patients were divided into two groups according to the noradrenalin infusion rate required to keep the mean arterial pressure above 65 mmHg: control group and hydrocortisone group (control group: below 0.5 µg/kg/min, hydrocortisone group: above 0.5 µg/kg/min). Serum angiotensin II, AT1, AT2 levels were measured at the time of diagnosis (A), one hour after hydrocortisone treatment (B), and three days later (C). RESULTS: In the catecholamine-resistant group, angiotensin II and AT1 levels were higher than the catecholamine-responder group in all periods. The sensitivity and specificity of AT-1 was observed to be high in all periods. AT2 levels decreased after hydrocortisone treatment in the catecholamine-resistant group and cut-off value was found 11%. CONCLUSIONS: It was concluded that angiotensin II and AT1 can be used as a biomarker of refractory septic shock and hydrocortisone may provide their blood pressure correcting effect by reducing AT2 level in these patients. AT2 can be a therapeutic target in the catecholamine-resistant septic shock patients.

Oral colonization of Acinetobacter baumannii in intensive care units: Risk factors, incidence, molecular epidemiology, association with the occur of pneumonia and sepsis, and infection control measures.

Objectives: Oral colonization of Acinetobacter baumannii can lead to infections such as pneumonia and sepsis. We aimed to evaluate oral colonization of hospitalized patients in ICUs and to examine risk factors for oral colonization, molecular epidemiology, and incidence of pneumonia and sepsis. Materials and Methods: The study began in February 2021. Oral cultures were taken. The microorganisms were identified by a Maldi-tof MS mass spectrometry device. Colistin resistance genes were investigated by polymerase chain reaction. Clonal relationships were determined by pulsed-field gel electrophoresis. Results: A. baumannii was found in 21 of 96 patients' oral cultures. Pneumonia and sepsis due to A. baumannii were detected in 14 and 5 patients, respectively. The mean growth time of A. baumannii from oral cultures was 11.8 days, and the meantime for the occurrence of pneumonia after oral growth was 5.2 days. We determined a plasmid mediated mcr-2 colistin resistance gene in a colistin susceptible A. baumannii strain. It is the first report of the plasmid mediated mcr-2 colistin resistance gene in our country. In total, fourteen different A. baumannii genotypes were determined in PFGE. It was determined that the effects of antibiotic use, oral motor dysfunction, mechanical ventilation, intubation, orogastric tube use, and total parenteral nutrition intake on oral colonization were statistically significant. Conclusion: Oral colonization of A. baumannii is a significant concern in ICUs. We believe that it is important to take oral cultures and follow the risk factors and take infection control measures to prevent oral colonization of resistant isolates in ICUs.

Angiotensin II and angiotensin II receptor 2 levels can predict shock and mortality in septic patients.

BACKGROUND: The aim of this study was to evaluate the place of angiotensin II and its receptors in the prognosis of septic patients. METHODS: Patients with sepsis and septic shock were included in the study group. The control group consisted of patients who were followed up in the ICU and had no sepsis/septic shock. Plasma angiotensin II, angiotensin receptor-1 and 2 (AT-1, AT-2) levels were evaluated first and third days. RESULTS: Angiotensin II levels were significantly lower in the septic shock and non-survivor. AT-1 levels were lower in all septic patients on the first day compared to the control. While AT-1 levels on the third day decreased in the septic shock group, it increased in the sepsis group. AT-2 levels were significantly higher in sepsis, and lower in septic shock compared to controls on the first day. Angiotensin II (95%, 82%) and AT-2 levels (100%, 87%) were observed to have high sensitivity and specificity in demonstrating the presence of shock in septic patients. Angiotensin II and AT-1/AT-2 ratios were observed to have high sensitivity and low specificity in the development of mortality. CONCLUSIONS: In septic patients, angiotensin II, AT-2 and AT-1/AT-2 levels can predict the probability of shock development and mortality.

The safety profile of favipiravir in COVID-19 patients with severe renal impairment.

OBJECTIVE: The safety profile of favipiravir in patients with severe renal impairment has not been investigated and available data are insufficient. The study aimed to compare the incidence of favipiravir-associated adverse events amongst patients with varying renal function statuses. METHODS: Records of 921 patients who were hospitalised for COVID-19 and had received at least 5 days of favipiravir treatment were retrospectively evaluated and 228 patients were included in the study. Patients' age, sex, comorbidities, estimated glomerular filtration rate (eGFR) and haematological and biochemical values were recorded. The incidence of adverse events was compared with the age, sex, comorbidities and eGFR of the patients. RESULTS: The mean age of the patients was 59.3 ± 15.6 years, and 38.2% of the patients were women. One hundred and thirty-one (57.5%) patients had experienced adverse events. These adverse effects consisted of ALT elevation (35.5%), AST elevation (21.5%), anaemia (16.2%), hyperuricaemia (10.5%), hepatocellular injury (9.2%), neutropenia (3.5%) and thrombocytopenia (2.6%). The incidence of adverse events was not significantly different when patients had eGFR >60 mL/min/1.73 m2 or eGFR 30-60 mL/min/1.73 m2 (P > .05), but significantly increased when the eGFR dropped to <30 (P < .05). The differences seen with hyperuricaemia and anaemia were significant (P < .05). CONCLUSION: Even though favipiravir appeared to be well tolerated in the individuals with renal failure in this study, its use in this population remains a challenge that requires more research and analysis.

Multisystem Inflammatory Syndrome in Adults (MIS-A) Associated with SARS-CoV-2 Infection in a Young Adult Case from Turkey.

Weeks and even months after recovering from the SARS-CoV-2 infection, clinically more severe cases are being reported, which are suggestive of COVID-19- related multisystemic inflammatory syndromes (MIS). Firstly on March 2020, this condition was reported to be COVID-19 related to children (MIS-C). Since June 2020, a syndrome similar to multisystem inflammatory syndrome in adults (MIS-A) came to be noticed in adults as well. We reported here a case of 24-year-old young woman who had gone to a hospital with abdominal pain and later developed a severe cough, followed by development of subconjunctival bleeding, pericardial effusion, pleural effusion, and intra-abdominal fluid that we deemed them to be acute multisystemic clinical symptoms, 47 days after she had undergone a COVID-19 infection of mild clinical severity. It should be kept in mind that a multisystemic inflammatory syndrome along with a delayed immune response during COVID-19 disease can be seen not only in children but also in young adults, and seemingly severe clinical and laboratory findings can improve by controlling the inflammatory process.

The Relationship between COVID-19 Severity and Bacillus Calmette-Guérin (BCG)/ Mycobacterium tuberculosis exposure history in healthcare workers: a multi-center study.

The COVID-19 pandemic has brought countries' health services into sharp focus. It was drawn to our group's attention that healthcare workers (HCWs) had a lower mortality rate against higher COVID-19 incidence compared to the general population in Turkey. Since risk of exposure to tuberculosis bacillus among healthcare workers are higher than the population, we aimed to investigate if there is a relationship between BCG and Mycobacterium tuberculosis exposure history with COVID-19 severity in infected HCWs. This study was conducted with 465 infected HCWs from thirty-three hospitals to assess the relationship between COVID-19 severity (according to their hospitalization status and the presence of radiological pneumonia) and BCG and Mycobacterium tuberculosis exposure history. HCWs who required hospital admission had significantly higher rates of chronic diseases, radiological pneumonia, and longer working hours in the clinics. Higher rates of history of contact and care to tuberculosis patients, history of tuberculosis, and BCG vaccine were observed in hospitalized HCWs. HCWs who had radiological pneumonia had a significantly increased ratio of history of care to tuberculosis patients and a higher family history of tuberculosis. The findings from our study suggest that the lower mortality rate despite the more severe disease course seen in infected HCWs might be due to frequent exposure to tuberculosis bacillus and the mortality-reducing effects of the BCG vaccine.

Investigation of SARS-CoV-2 RNA in milk produced by women with COVID-19 and follow-up of their infants: A preliminary study.

OBJECTIVES: Studies have shown that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is primarily transmitted from person to person via airborne droplets. It is unclear whether it can be shed into human milk and transmitted to a child via breastfeeding. We investigated the presence of SARS-CoV-2 RNA in human milk samples of 15 mothers with coronavirus disease 19 (COVID-19) and in the throat swab samples of their infants. METHODS: This is a prospective observational study in which breast milk samples were collected from 15 mothers with COVID-19. The presence of SARS-CoV-2 RNA in the whole human milk samples of the patients was investigated using RT-qPCR. All of the infants underwent a clinical follow-up during their 14-day isolation and their throat swab samples were tested for SARS-CoV-2 RNA. RESULTS: Of 15 mothers with COVID-19, SARS-CoV-2 RNA was detected in milk samples from 4 mothers. The throat swab samples from these mothers' infants were found to be positive for SARS-CoV-2 RNA. Three of the four mothers were breastfeeding. In addition, during the 14-day isolation, all but three of the mothers breastfed their infants. Of the 12 breastfed infants, while the test for SARS-CoV-2 RNA in throat swab samples was negative in 6 of the infants, the other 6 infants, who had mild COVID-19 symptoms, tested positive for SARS-CoV-2 RNA. Clinical outcomes of all mothers and infants were uneventful. CONCLUSION: To our knowledge, this is the first case series with the largest number of cases with SARS-CoV-2 RNA positivity in human milk samples of mothers with COVID-19. However, we believe that the benefits of breastfeeding may outweigh the risk of SARS-CoV-2 infection in infants.

Relationship between hand hygiene and cutaneous findings during COVID-19 pandemic.

BACKGROUND: In the current situation of the COVID-19 pandemic, healthcare workers (HCWs) have to comply with hygiene conditions and use gloves more frequently and for a longer period of time than they would previously to avoid infection and prevent transmission. AIMS: We aimed to characterize the adverse skin reactions occurring after hand hygiene and glove use in HCWs in a tertiary university hospital to determine the possible causative factors and whether the use of these measures is affected. METHODS: Between April 15 and May 1, 2020, a cross-sectional survey was conducted, using online questionnaire, answered by HCWs in a tertiary university hospital. RESULTS: The increase in general hand-skin problems during the pandemic period was statistically significant (P = .004). The most common symptom was dryness. During the pandemic period, 67 (24.3%) HCWs thought that the conditions were caused by glove use, and 197 (71.4%) thought that they were due to alcohol-based hand antiseptics. The incidence of other hand-skin conditions except for vesicles was statistically higher in women than in men (P < .001). CONCLUSIONS: Increased number of hand-skin conditions during the pandemic should not be ignored, since hand hygiene and glove use are expected to increase.

A silent outbreak due to Klebsiella pneumoniae that co-produced NDM-1 and OXA-48 carbapenemases, and infection control measures.

OBJECTIVES: Infections due to carbapenemase-producing Klebsiella pneumoniae are associated with high morbidity and mortality. In this study, we report a hospital outbreak due to co-producing OXA-48 and NDM-1 K. pneumoniae clone. The aim of the study is to investigate the clonal relationship of strains, risk factors of outbreak and infection control measures. MATERIALS AND METHODS: Once an outbreak was suspected at the end of December 2017 in our intensive care unit (ICU), carbapenem resistance K. pneumoniae identified in patients' specimens. An outbreak analysis was begun to determine the risk factors and dissemination of the cases. A case-control study was conducted to determine the risk factors. To control the outbreak; tight contact prevention, good clean-up the medical devices and hospital environment, were done. Staff training programs such as hand hygiene, disinfection, wearing aprons, good cleaning were created. Carbapenem resistance genes determined by PCR. Clonal relationships of strains investigated by PFGE. RESULTS: We investigate 21 carbapenem-resistant K. pneumonia strains. Nine of them were found co-produced NDM-1 and OXA-48, 11 strains produced OXA-48, and one strain produced NDM-1. Seven strains of co-producing NDM-1 and OXA-48 were found clonally related with PFGE. We could not determine any risk factor except rectal colonization in the case-control study. CONCLUSION: The interventions that successfully controlled this outbreak were hand hygiene, tight contact prevention, good clean-up of the hospital environment and medical devices. As a result, we believe that it would be beneficial to take infection control measures to prevent the spread of these strains to the community and hospital settings.

Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: A single-center prospective cohort study.

INTRODUCTION: Surgical site infection (SSI) is an important cause of decreased graft survival, prolonged hospital stay, and higher costs following living donor liver transplantation. There are several risk factors for SSI. In this cohort study, we aimed to investigate the incidence of SSI at our center and the associated risk factors. MATERIALS AND METHODS: Adult right lobe living donor liver transplantations were included in this prospective cohort. Patients who died postoperatively within 3 days; patients with infected ascites or open abdomen, cadaveric, or pediatric transplants; and patients with biologic or cryopreserved vascular grafts were excluded. Patients' demographic characteristics and perioperative surgical findings were recorded. SSI follow-up was continued for 90 days. CDC-2017 criteria were used to diagnose SSI. In the presence of superficial, deep, and organ/space SSI, only the organ in the poorest condition was included in SSI evaluation. The patients were administered similar to antibiotic prophylaxes and immunosuppressive protocols. RESULTS: A total of 101 patients were enrolled in this study, of which 30 (29.7%) were diagnosed with SSI. Organ/space, only deep, and only superficial SSI were noted in 90% (27/30), 6.7% (2/30), and 3.3% (1/30) of the patients, respectively. Twenty-five of 30 patients with SSI had a remote site infection. One or more bacteria observed in cultures were obtained from 28 patients. A donor-recipient age difference of >10 years, cold ischemia lasting for ≥150 minutes, surgical duration of ≥600 minutes, intraoperative hemorrhage of ≥1000 mL, intraoperative blood transfusion, biliary leak or stricture, prolonged mechanical ventilation, prolonged intensive care unit and hospital stay, remote site infection, and the need for reoperation were associated with increased SSI incidence. Preoperative and intraoperative levels of blood glucose, albumin, and hemoglobin were not associated with SSI. A donor-recipient age difference of >10 years, remote site infection, and biliary leak were found to be independent risk factors for SSI. Hospital mortality with and without SSIs was 6.7% vs 4.4%, P = .61. DISCUSSION: Organ/space SSIs were the essential part of SSIs following right lobe living donor liver transplantations. Donor-recipient age gap, prolonged cold ischemia time, complicated surgery, and postoperative biliary complications were the main causes of SSIs. Although they did not increase the perioperative mortality, they promote increased rate of reoperations, remote infections, prolonged intensive care unit, and hospital stays.

[Co-production of OXA-48 and NDM-1 Carbapenemases in Providencia rettgeri: the first report]. / Providencia rettgeri'de OXA-48 ve NDM-1 karbapenemaz genlerinin birlikte üretimi: ilk bildirim.

Our country is the epicenter of the OXA-48-like carbapenemase-producing Klebsiella and Escherichia coli; and in the recent years, the concern has been increasing due to both spreading of this resistance to other members of Enterobacteriaceae family and acquiring other carbapenemases by the OXA-48-producing strains. In this study, OXA-48 and NDM-1 co-production was presented in Providencia rettgeri. Two P.rettgeri strains that were resistant to all antimicrobials except colistin and tigecyclin, were isolated from two patients in the burn unit of our hospital, including one from the urine sample of a 68 years female in April 2017, and the other from a burn wound swab of a 35 years old male, in November 2017. Minimal inhibitory concentrations (MICs) of the isolates for imipenem and meropenem were measured as ≥ 32 µg/ml; and for colistin and tigecyclin were 1 ve 0.5 µg/ml, respectively. Multiplex PCR analysis showed that both strains were carrying blaOXA-48 and blaNDM-1 carbapenemases, and blaTEM extended spectrum beta-lactamase genes. By using DNA sequence analysis, the TEM gene was typed as blaTEM-1. The Pulsed Field Gel Electrophoresis (PFGE) analysis indicated that these two strains which were consecutively isolated from two different patients in a single unit within about seven months were genetically indistinguishable. No significant data that could explain the spread of these isolates was obtained from our retrospective analysis of the medical records including the results of environmental surveillance cultures, and patients' history. Nevertheless, hospital infection control committee enforced the infection control measures in that unit, and no further isolation was observed within three months period following the last isolation, neither from environmental nor from clinical samples. With this study, it was emphasized that the co-production of OXA-48 and NDM-1 carbapenemases which was reported from only three Enterobacteriaceae species up to date was ongoing for spreading to other species by using horizontal route, and also showing a potential to be a growing problem in the hospitals, by clonal expansion (vertical route). Effectively using of the molecular epidemiological methods will provide useful data to better understand the transmission dynamics of such rare, but problematic species in hospitals.

Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization

ABSTRACT The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p < 005). On average, VAP occurred 17.33 ± 21.09 days in the case group and 10.43 ± 7.83 days in the control group (p = 0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.

Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization.

The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p<005). On average, VAP occurred 17.33±21.09 days in the case group and 10.43±7.83 days in the control group (p=0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.

Is airborne transmission of Acinetobacter baumannii possible: A prospective molecular epidemiologic study in a tertiary care hospital.

BACKGROUND: Understanding the dynamics of aerial spread of Acinetobacter may provide useful information for production of effective control measurements. We investigated genetic relationships between air and clinical isolates of Acinetobacter baumannii in an intensive care unit (ICU) setting. METHODS: We conducted a prospective surveillance study in a tertiary care hospital for 8 months. A total of 186 air samples were taken from 2 ICUs. Clonal characteristics of air isolates were compared with the prospective clinical strains and the previously isolated strains of ICU patients over a 23-month period. RESULTS: Twenty-six (11.4%) air samples yielded A baumannii, of which 24 (92.3%) isolates were carbapenem-resistant. The Acinetobacter concentration was the highest in bedside sampling areas of infected patients (0.39 CFU/m3). Air isolates were clustered in 13 genotypes, and 7 genotypes (including 18 air strains) were clonally related to the clinical strains of 9 ICU patients. One clone continued to be cultured over 27 days in ICU air, and air isolates could be clonally related to 7-week retrospective and approximately 15-week prospective clinical strains. CONCLUSIONS: The results of this study suggest that infected patients could spread significant amounts of Acinetobacter to ICU air. These strains could survive in air for some weeks and could likely still infect new patients after some months. Special control measurements may be required against the airborne spread of Acinetobacter in ICUs.

[Investigation of beta-lactamase genes and clonal relationship among the extended-spectrum beta-lactamase producing nosocomial Escherichia coli isolates]. / Genislemis spektrumlu beta-laktamaz üreten nozokomiyal Escherichia coli izolatlarinda beta-laktamaz gen oranlari ve klonal iliskinin arastirilmasi

Extended-spectrum beta-lactamase (ESBL) producing microorganisms currently cause a major problem. Among theseCTX-M beta-lactamase producing Escherichia coli has also disseminated worldwide as an important cause of both nosocomial and community-acquired infections. The aims of this study were to determine the prevalence of the beta-lactamase genes, antibiotic susceptibilities and clonal relationships of ESBL-producing nosocomial E.coli isolates. A total of 76 ESBL-producing E.coli strains isolated from urine (n= 26), blood (n= 25) and wound (n= 25) specimens of hospitalized patients identified as nosocomial infection agents according to the CDC criteria between June 2010-June 2011 were included in the study. Antibiotic susceptibilities of the isolates were detected by Kirby-Bauer disc diffusion method according to CLSI recommendations. ESBL production was tested by double disc diffusion method, and cefotaxime/cefotaxime-clavulanic acid E-test strips (AB Biodisk, Sweden) were used for indeterminate results. Presence of TEM, SHV, CTX-M, OXA-2 group, 0XA-10 group, PER, VEB and GES beta-lactamase genes were investigated by polymerase chain reaction (PCR) using specific primers. Pulsed-field gel electrophoresis (PFGE) method was used for the detection of clonal relationships among the strains. Most of the ESBL-producing E.coli strains were isolated from samples of inpatients in intensive care (35%), internal medicine (16%) and general surgery (13%) units. All of the 76 strains were found susceptible to imipenem, meropenem and amikacin; however all were resistant to cefotaxime and ceftriaxone. The susceptibility rates of the isolates to cefoxitin, ertapenem, cefoperazone/sulbactam, piperacillin-tazobactam, gentamicin, ciprofloxacin, cefepime, amoxicillin-clavulanic acid, aztreonam and ceftazidime were 96%, 83%, 63%, 61%, 50%, 41%, 25%, 21%, 20% and 18%, respectively. Among E.coli isolates, the frequency of CTX-M, TEM, OXA-2 group, PER, SHV and OXA-10 group beta-lactamase genes were found as 89.5%, 59.2%, 15.8%, 14.5%, 11.8% and 3.9%, respectively, while none of the isolates were positive for VEB and GES beta-lactamase genes. In 1 (1.3%) strain none of the investigated genes were detected. PCR analyses of the isolates revealed that 25 harbored CTX-M and TEM genes together, while 20 harbored only CTX-M and two harbored only TEM genes. Single SHV gene was not detected in any of the isolates. PFGE demonstrated no major clonal relationship between ESBL-producing isolates. This study indicated that CTX-M type enzymes were highly endemic among ESBL-producing nosocomial E.coli strains in our hospital, with the polyclonal spread of ESBL-producing bacteria without any dominant epidemic clone. In conclusion, it was considered that further studies are needed to explain the relationship between epidemic clones and plasmids with the use of plasmid analysis and multilocus sequence typing methods.

Mortality indicators in pneumococcal meningitis: therapeutic implications.

BACKGROUND: The aim of this study was to delineate mortality indicators in pneumococcal meningitis with special emphasis on therapeutic implications. METHODS: This retrospective, multicenter cohort study involved a 15-year period (1998-2012). Culture-positive cases (n=306) were included solely from 38 centers. RESULTS: Fifty-eight patients received ceftriaxone plus vancomycin empirically. The rest were given a third-generation cephalosporin alone. Overall, 246 (79.1%) isolates were found to be penicillin-susceptible, 38 (12.2%) strains were penicillin-resistant, and 22 (7.1%) were oxacillin-resistant (without further minimum inhibitory concentration testing for penicillin). Being a critical case (odds ratio (OR) 7.089, 95% confidence interval (CI) 3.230-15.557) and age over 50 years (OR 3.908, 95% CI 1.820-8.390) were independent predictors of mortality, while infection with a penicillin-susceptible isolate (OR 0.441, 95% CI 0.195-0.996) was found to be protective. Empirical vancomycin use did not provide significant benefit (OR 2.159, 95% CI 0.949-4.912). CONCLUSIONS: Ceftriaxone alone is not adequate in the management of pneumococcal meningitis due to penicillin-resistant pneumococci, which is a major concern worldwide. Although vancomycin showed a trend towards improving the prognosis of pneumococcal meningitis, significant correlation in statistical terms could not be established in this study. Thus, further studies are needed for the optimization of pneumococcal meningitis treatment.

Withdrawal of Staphylococcus aureus from intensive care units in Turkey.

BACKGROUND: In the past, Staphylococcus aureus infections have displayed various patterns of epidemiologic curves in hospitals, particularly in intensive care units (ICUs). This study aimed to characterize the current trend in a nationwide survey of ICUs in Turkey. METHODS: A total of 88 ICUs from 36 Turkish tertiary hospitals were included in this retrospective study, which was performed during the first 3 months of both 2008 (period [P] 1) and 2011 (P2). A P value ≤.01 was considered significant. RESULTS: Although overall rates of hospital-acquired infection (HAI) and device-associated infection densities were similar in P1 and P2, the densities of HAIs due to S aureus and methicillin-resistant S aureus (MRSA) were significantly lower in P2 (P < .0001). However, the proportion of HAIs due to Acinetobacter was significantly higher in P2 (P < .0001). CONCLUSIONS: The incidence of S aureus infections is declining rapidly in Turkish ICUs, with potential impacts on empirical treatment strategies in these ICUs.

An uncommon case of acute brucellosis presenting with severe thrombocytopenia.

A 49-year-old man was admitted to the hospital with complaints of fatigue, epistaxis and a skin rash. The whole blood count revealed isolated thrombocytopenia (4,000/mL), and the patient was admitted to the hematology department with a diagnosis of immune thrombocytopenia. He did not respond to steroid treatment for 15 days, and a subfebrile fever developed during this period. A diagnosis of acute brucellosis was considered due to positive serological tests and a blood culture positive for Brucella spp. After starting doxycycline and rifampicin therapy, the patient's thrombocyte count increased to 15,000/mL on the third day, to 41,000/mL on the sixth day and was normal on the 21st day of treatment. A diagnosis of brucellosis must be considered in patients presenting with severe and isolated thrombocytopenia in countries where brucellosis is endemic.

A new diagnostic scoring for discrimination of tuberculous and bacterial meningitis on the basis of clinical and laboratory findings.

OBJECTIVES: The aim of this study was to develop a new diagnostic index (DI) on the basis of clinical and laboratory findings including serum C-reactive protein (CRP) for tuberculous meningitis (TM) and bacterial meningitis (BM). SUBJECTS AND METHODS: During a 7-year period, 96 adult patients with meningitis (30 with TM and 66 with BM) were studied retrospectively. Multivariate logistic regression analysis was performed to investigate the diagnostic value of clinical and laboratory parameters as independent predictors on discrimination of tuberculous from BM patients. RESULTS: Six features predictive for diagnosis including age, CSF leukocyte count, PML dominance, length of illness, serum CRP level and blood WBC count were used. The DI model developed from these features had very high sensitivity and specificity rates of 100.0 and 95.4%, respectively. The sensitivity and specificity rates were 97.4 and 100%, respectively, in microbiologically proven cases. CONCLUSION: Our results suggested that this new DI which consists of simple clinical and laboratory parameters had the power to discriminate adult patients with documented tuberculous and BM (excluding Brucella meningitis). It should, however, be tested in prospective studies.

[Investigation of the susceptibilities of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella spp. strains to ertapenem and other carbapenems]. / Genislemis Spektrumlu Beta-Laktamaz Üreten Escherichia coli ve Klebsiella spp. Suslarinin Ertapenem ve Diger Karbapenemlere Karsi Duyarliliklarinin Arastirilmasi

Infections caused by extended-spectrum beta-lactamase (ESBL) producing Escherichia coli and Klebsiella spp. constitute severe problems. Carbapenems are commonly used to treat these infections. However, infections caused by carbapenem-resistant gram-negative bacteria show an increasing trend recently. The aim of this study was to investigate the susceptibilities of ESBL-producing E.coli and Klebsiella spp. to ertapenem and other carbapenems. A total of 239 E.coli, 28 K.pneumoniae and 11 K.oxytoca strains isolated from clinical specimens (208 urine, 16 blood, 26 wound, 17 sterile body fluids, four tracheal aspirates and seven others) of hospitalized patients and outpatients between January 2007-February 2008, were included to the study. The isolates were identified by conventional methods, and antibiotic susceptibility tests were performed by Kirby Bauer disc diffusion method according to Clinical and Laboratory Standards Institute (CLSI) standards. ESBL production was tested by double disk diffusion method. When ESBL production was indeterminate, cefotaxime-clavulanic acid E test (BioMerieux, France) was used. According to the CLSI standards modified Hodge test was performed for carbapenem resistant isolates and minimal inhibitory concentration (MIC) values were detected for ertapenem (Etest®, BioMerieux, France), imipenem and meropenem (M.I.C. Evaluator Strips, Oxoid, UK). All of the isolates were found susceptible to amikacin (278/278; 100%), whereas the susceptibility rates for imipenem/meropenem and ertapenem were 99.3% (276/278) and 98.6% (274/278), respectively. When evaluated individually, ertapenem susceptibilities of E.coli, K.pneumoniae and K.oxytoca strains were 99.2%, 96.4% and 90.9%, respectively, while these rates were 100%, 96.4% and 90.9%, respectively, for imipenem/meropenem. Carbapenem resistance was detected in two E.coli, one K.oxytoca and one K.pneumoniae isolates. While two Klebsiella spp. Isolates were resistant to all of the tested carbapenems (MIC > 32 µg/ml), two E.coli isolates were resistant to ertapenem (MIC > 32 µg/ml) but susceptible to imipenem (MIC= 0.25 µg/ml) and meropenem (MIC= 0.5 µg/ml). Carbapenemase production was demonstrated by modified Hodge test in all of the carbapenem-resistant isolates. In conclusion, ESBL-producing gram-negative isolates should be routinely tested with a screening method for carbapenemase activity and confirmation tests should be performed in suspected cases.