Multidrug resistance in pathogens of community-acquired urinary tract infections in Turkey: a multicentre prospective observational study

BACKGROUND: To have country-wide information about multidrug resistance (MDR) in isolates from community-acquired urinary tract infections (CAUTI) of Turkey, in terms of resistance rates and useful options. METHODS: We used a geocode standard, nomenclature of territorial units for statistics (NUTS), and a total of 1588 community-acquired isolates of 20 centres from 12 different NUTS regions between March 2019 and March 2020 were analysed. RESULTS: Of the 1588 culture growths, 1269 (79. 9%) were Escherichia coli and 152 (9.6%) were Klebsiella spp. Male sex, advancedage, and having two or more risk factors showed a statistically significant relation with MDR existence (p < 0.001, p: 0.014, p < 0.001, respectively) that increasing number of risk factors or degree of advancing in age directly affects the number of antibiotic groups detected to have resistance by pathogens. In total, MDR isolates corresponded to 36.1% of our CAUTI samples; MDR existence was 35.7% in E. coli isolates and 57.2% in Klebsiella spp. isolates. Our results did not show an association between resistance or MDR occurrence rates and NUTS regions. DISCUSSION: The necessity of urine culture in outpatient clinics should be taken into consideration, at least after evaluating risk factorsfor antibacterial resistance individually. Community-acquired UTIs should be followed up time- and region-dependently. Antibiotic stewardship programmes should be more widely and effectively administrated.

15-year evaluation of changes in the HBsAg positivity rate in pregnant women in Turkey: the prominent effect of national vaccination.

Background: The detection of hepatitis B surface antigen positivity in pregnant women before delivery is crucial to preventing mother-to-child transmission of hepatitis B virus. Aims: This study aimed to evaluate the status and rate of testing for hepatitis B surface antigen, rate of hepatitis B surface antigen positivity, hepatitis B surface antigen positivity distribution rate by age, and changes in hepatitis B surface antigen positivity rate in pregnant women over the study period. Methods: We conducted a multicentre, cross-sectional, descriptive study covering the period January 2005 to June 2019 for 2 145 668 pregnant women from 27 provinces in all 7 regions of Turkey, collected using Microsoft Excel before statistical analysis. Results: We found that 1 012 593 (47.1%) pregnant women were tested for hepatitis B surface antigen over the 15-year period, out of which 11 471 (1.1%) were hepatitis B surface antigen-positive. Overall, 97% of the hepatitis B surface antigen positive women were born before 1998, the year that national HBV vaccination was launched in Turkey. The rate of hepatitis B surface antigen positivity in that group was 1.1%, compared with 0.3% among women born after 1998. Conclusion: There was a downward trend in the hepatitis B surface antigen positivity rate among pregnant women in the younger age groups, especially among those born after universal hepatitis B vaccination was inaugurated, and low rate of HBsAg testing during pregnancy.

Vaccine hesitancy and refusal among parents: An international ID-IRI survey.

INTRODUCTION: Although vaccines are the safest and most effective means to prevent and control infectious diseases, the increasing rate of vaccine hesitancy and refusal (VHR) has become a worldwide concern. We aimed to find opinions of parents on vaccinating their children and contribute to available literature in order to support the fight against vaccine refusal by investigating the reasons for VHR on a global scale. METHODOLOGY: In this international cross-sectional multicenter study conducted by the Infectious Diseases International Research Initiative (ID-IRI), a questionnaire consisting of 20 questions was used to determine parents' attitudes towards vaccination of their children. RESULTS: Four thousand and twenty-nine (4,029) parents were included in the study and 2,863 (78.1%) were females. The overall VHR rate of the parents was found to be 13.7%. Nineteen-point three percent (19.3%) of the parents did not fully comply with the vaccination programs. The VHR rate was higher in high-income (HI) countries. Our study has shown that parents with disabled children and immunocompromised children, with low education levels, and those who use social media networks as sources of information for childhood immunizations had higher VHR rates (p < 0.05 for all). CONCLUSIONS: Seemingly all factors leading to VHR are related to training of the community and the sources of training. Thus, it is necessary to develop strategies at a global level and provide reliable knowledge to combat VHR.

Antibiotic use and Influencing Factors Among Hospitalized Patients with COVID-19: A Multicenter Point-Prevalence Study from Turkey

Background: Broad-spectrum empirical antimicrobials are frequently prescribed for patients with coronavirus disease 2019 (COVID-19) despite the lack of evidence for bacterial coinfection. Aims: We aimed to cross-sectionally determine the frequency of antibiotics use, type of antibiotics prescribed, and the factors influencing antibiotics use in hospitalized patients with COVID-19 confirmed by polymerase chain reaction. Study Design: The study was a national, multicenter, retrospective, and single-day point prevalence study. Methods: This was a national, multicenter, retrospective, and single-day point-prevalence study, conducted in the 24-h period between 00:00 and 24:00 on November 18, 2020, during the start of the second COVID-19 peak in Turkey. Results: A total of 1500 patients hospitalized with a diagnosis of COVID-19 were included in the study. The mean age ± standard deviation of the patients was 65.0 ± 15.5, and 56.2% (n = 843) of these patients were men. Of these hospitalized patients, 11.9% (n = 178) were undergoing invasive mechanical ventilation or ECMO. It was observed that 1118 (74.5%) patients were receiving antibiotics, of which 416 (37.2%) were prescribed a combination of antibiotics. In total, 71.2% of the patients had neither a clinical diagnosis nor microbiological evidence for prescribing antibiotics. In the multivariate logistic regression analysis, hospitalization in a state hospital (p < 0.001), requiring any supplemental oxygen (p = 0.005), presence of moderate/diffuse lung involvement (p < 0.001), C-reactive protein > 10 ULT coefficient (p < 0.001), lymphocyte count < 800 (p = 0.007), and clinical diagnosis and/or confirmation by culture (p < 0.001) were found to be independent factors associated with increased antibiotic use. Conclusion: The necessity of empirical antibiotics use in patients with COVID-19 should be reconsidered according to their clinical, imaging, and laboratory findings.

Healthcare personnel's attitude and coverage about tetanus vaccination in Turkey: a multicenter study.

The tetanus vaccine is not routinely given to Turkish adults. Protective tetanus immunity decreases with age. Health-care personnel (HCPs), who are role models in the field of health, are a target group in order to achieve a higher rate of tetanus vaccination in the community. This study was designed to evaluate attitudes and coverage regarding tetanus vaccination among a large sample of Turkish HCPs. This cross-sectional epidemiologic study was conducted from July to August 2019. A questionnaire was sent to HCPs using social media. Of the 10,644 HCPs included in the study, 65% were female. Overall, the tetanus vaccination coverage (TVC) among HCPs was 78.5% (95% CI: 77.7%-79.3%). TVC was significantly higher among physicians [83.4% (95% CI: 82%-84.6%); p < .001] compared with all other HCPs except nurses. Older age (≥40 years) and length of professional experience were significantly correlated with TVC. Of the 8353 HCPs who received tetanus vaccines during their lifetime, 73.03% received tetanus vaccination in the past 10 years. The self-vaccination rate for protection against tetanus was 13.1%. Acute injuries (25.42%) and pregnancy (23.9%) were the most common reasons for having the tetanus vaccine. One-third (33.7%) of HCPs did not have information about whether pregnant women could receive tetanus vaccinations. This survey study provided excellent baseline information about HCPs' coverage rates and attitudes regarding tetanus vaccination. The present results suggested that tetanus boosters for HCPs should be established as soon as possible, and revealed that the HCPs younger than 30 years with relatively less professional experience and all other HCPs except nurses and physicians should be identified as the target population for future intervention programs.

Evaluation of testing and vaccination status of healthcare workers in Turkey for hepatitis A: A multicenter study.

BACKGROUND: This study aimed to investigate the prevalence of the disease and testing and vaccination status of healthcare workers in terms of hepatitis A infection as well as their awareness. This study is a multicenter descriptive study performed with healthcare workers. MATERIAL AND METHODS: Testing status for hepatitis A, awareness of the results and vaccination status of healthcare workers were compared. RESULTS: Of the 12,476 healthcare workers participating in the study, only 65% (8,115 healthcare workers) had awareness of hepatitis A test results. Of the participants, 6,481 (66.3 %) stated that they were not vaccinated against hepatitis A. Vaccination rates against hepatitis A decreased with increasing age (P < .01). The rates of vaccination in all departments where participants worked were above 60% (P < .05). While the rate of protection among those working in departments creating a risk for hepatitis A virus infection was higher, no difference among vaccination rates was observed compared with the other departments. CONCLUSION: Vaccination of seronegative individuals is the safest way for hepatitis A, which can progress to fulminant hepatitis at advanced ages. It must be aimed primarily to increase the awareness of healthcare professionals and to increase the vaccination rates for hepatitis B and hepatitis A for the prevention of viral hepatitis. In our study, the awareness level was found to be above 50%, and the vaccination level was 35%, which is a rate that must be increased.

Influenza vaccination rates, knowledge, attitudes and behaviours of healthcare workers in Turkey: A multicentre study.

AIM: Influenza vaccination is the most effective method in prevention of influenza disease and its complications. Our study aimed to investigate the rates of vaccination and the behaviours and attitudes against the vaccine in healthcare workers in Turkey. METHODS: This multicentre national survey is a descriptive study in which 12 475 healthcare workers. Healthcare workers were asked to answer the questionnaire consisting of 12 questions via the survey. RESULTS: It was found that 6.7% of the healthcare workers regularly got vaccinated each year and that 55% had never had the influenza vaccine before. The biggest obstacle against getting vaccinated was determined as not believing in the necessity of the vaccine (53.1%). CONCLUSION: The rates of influenza vaccination in healthcare workers in Turkey are quite low. False knowledge and attitudes on the vaccine and disease are seen as the most important reasons to decline vaccination. It is important to detect reasons for anti-vaccination and set a course in order to increase the rates of vaccination.

The Effect of Alpha Lipoic Acid on Cerebrospinal Fluid Biochemistry and Brain Edema After Experimental Traumatic Brain Injury.

AIM: To investigate the effect of alpha lipoic acid on cerebrospinal fluid (CSF) osmolarity and brain tissue water ratio in a rabbit model of traumatic brain injury. MATERIAL AND METHODS: Using a previously established model of traumatic brain injury using liquid nitrogen, 36 New Zealand rabbits were randomized into six groups (three treatment groups, a no trauma/no treatment group, a trauma/no treatment group, and a no trauma/treatment group). The treatment groups were administered intravenous alpha lipoic acid at different times of the experiment. Cerebrospinal fluid was obtained 96 hours after injury/treatment via cisterna magna puncture; glucose, blood urea nitrogen, and sodium levels were measured and osmolarity was calculated. Brain tissue water ratio was determined using wet and dry brain weights. The therapeutic effect of alpha lipoic acid was evaluated by comparing cerebrospinal fluid osmolarity and brain tissue water ratio between study groups. RESULTS: Based on cerebrospinal fluid osmolarity values, alpha lipoic acid treatment effectiveness was greatest in the group that received 3 doses after trauma. CONCLUSION: Alpha lipoic acid is effictive in the treatment of brain edema after experimental traumatic brain injury.

The Role of Ciprofloxacin Resistance and Extended-spectrum beta-lactamase (ESBL) Positivity in Infective Complications Following Prostate Biopsy.

PURPOSE: To evaluate ciprofloxacin resistance (CR) and extended-spectrum beta-lactamase (ESBL) positivity in the rectal flora, antibiotic prophylaxis received, and post-biopsy infectious complications in patients undergoing prostate biopsy. MATERIAL & METHODS: Rectal swab samples collected from 99 patients suspected of prostate cancer two days before prostate biopsy were tested for microbial susceptibility and ESBL production. All patients were given standard ciprofloxacin and ornidazole prophylaxis. Ten days post-biopsy, the patients were contacted by phone and asked about the presence of fever and/or symptoms of urinary tract infection. RESULTS: Escherichia coli (E.coli) was the most common isolate detected in 82 (75%) of the rectal swab samples. Ciprofloxacin resistance was detected in 33% and ESBL positivity in 22% of the isolated E.coli strains. No microorganisms other than E.coli were detected in blood, urine, and rectal swab cultures of patients who developed post-biopsy complications. CR E.coli strains also showed resistance to other antimicrobial agents. The lowest resistance rates were to amikacin (n = 2, 7.4%) and nitrofurantoin (n = 1, 3.7%). Seven patients (7.6%) developed infectious complications. There was no significant difference in probability of hospitalization between patients with CR strains (14.3%) and those with ciprofloxacin-susceptible strains (14.3% vs. 4.7%; p = 0.194). However, strains that were both CR and ESBL-positive were associated with significantly higher probability of hospitalization compared to ciprofloxacin-susceptible strains (28.6% vs. 3.8%; p = 0.009). CONCLUSION: The higher rate of infectious complications with CR and ESBL-positive strains suggests that the agents used for antibiotic prophylaxis should be reevaluated. It is important to consider local resistance data when using extended-spectrum agents to treat patients presenting with post-biopsy infectious complications.

The Role of Cerebrospinal Fluid Biomarkers in the Diagnosis of Post-Neurosurgical Meningitis.

AIM: To measure cytokine and lactate levels in the cerebrospinal fluid (CSF) of patients with suspected post-neurosurgical meningitis. MATERIAL AND METHODS: Interleukin (IL)-8,-12, and -13, interferon (IFN) gamma, and lactate concentrations were determined in the CSF of patients diagnosed with meningitis, who were undergoing follow-up after neurosurgical procedures at the Neurosurgery Clinic between May 2016 and November 2017. The demographic, clinical, biochemical, CSF cell count, CSF biochemistry, and CSF culture results of 119 patients were recorded. RESULTS: The study group consisted of 39 patients diagnosed with post-neurosurgical meningitis. The control group comprised of 80 patients without pleocytosis, who had undergone lumbar puncture due to various indications. In the study group, 59% of the patients had fever, 66.7% had deterioration in the level of consciousness, and 35.9% had neck stiffness. The levels of IL-8 (96.5 ng/L vs. 86.6 ng/L, p < 0.001), IL-12 (10.1 ng/L vs. 3 ng/L, p < 0.001), and lactate (5.9 mmol/L vs. 2.1 mmol/L, p < 0.001) were higher in the CSF of the patient group compared to the control group. However, IL-13 (32.7 ng/L vs. 42.5 ng/L, p=0.003) and IFN gamma (73.3 ng/L vs. 260.4 ng/L, p < 0.001) levels were lower in patients compared to controls. The mortality rate in post-neurosurgical meningitis patients was estimated to be 35.9%. CONCLUSION: Post-neurosurgical meningitis prolongs the duration of hospital stay and causes long-term sequelae. Therefore, measurement of CSF cytokine and lactate levels alongside meningitis diagnostic processes may facilitate early and accurate diagnosis. Measuring CSF lactate is inexpensive and cost effective, particularly in post-neurosurgical patients.

Evaluation of Post-operative Meningitis: Comparison of Meningitis Caused by Acinetobacter spp. and Other Possible Causes.

AIM: To analyse postoperative meningitis (POM) after craniotomy, and to compare the clinical characteristics, treatment outcomes and mortality rates of POM that were caused by Acinetobacter spp. or other possible causes. MATERIAL AND METHODS: In this study, POM cases in our hospital between 2008 and 2016 were retrospectively reviewed. Cases were divided into three groups; Acinetobacter spp. meningitis (case group), non-Acinetobacter bacterial meningitis (control group 1) and culture negative meningitis (control group 2). Demographic, clinical, laboratory features, treatment modalities and mortality rates were compared between case and control groups. RESULTS: A total of 112 patients with POM were included in the study. Cerebrospinal fluid (CSF) culture results were negative in 50 (44.6%) patients; bacteria were isolated from CSF of 62 (55.3%) patients. Acinetobacter spp. was isolated from 28 (45%) patients, while bacteria other than Acinetobacter spp. were detected in 34 (55%) patients. No significant differences were observed between case and control groups in terms of age, gender, comorbidity and operation type. For the case group, change of treatment according to culture result was significantly different from control groups (p < 0.001). Mortality was 55.6% in the case group, 24.2% in control group 1 (p=0.013), and 24% in control group 2 (p=0.006). In multivariate analysis, isolation of Acinetobacter spp. from CSF culture [OR < sub > adj < /sub > 5.2, 95% confidence interval (CI):1.2-22.0, p=0.026] and inappropriate treatment (OR < sub > adj < /sub > 15.7, 95%CI:3.6-68.9, p < 0.001) were determined to be independent risk factors for mortality. CONCLUSION: Postoperative meningitis, especially caused by Acinetobacter spp., and its inappropriate empirical treatment are associated with high mortality.

Reactivation rates in patients using biological agents, with resolved HBV infection or isolated anti-HBc IgG positivity.

BACKGROUND/AIMS: Tumor necrosis factor-α (TNF-α) inhibitors and ustekunimab are widely used in autoimmune diseases. It is known that these biological agents cause the reactivation of hepatitis B virus (HBV). There is no standardized strategy to prevent the reactivation in patients with evidence of a previous HBV infection. In our study, anti-HBc IgG-positive patients who received a biological agent were evaluated in terms of HBV reactivation. MATERIALS AND METHODS: Patients who were followed up for the use of biological agents in our clinic were evaluated retrospectively. Patients with isolated anti-HBc IgG positivity were included in the study. The HBV reactivation data were recorded from the patients' files retrospectively. RESULTS: Two hundred and seventy-eight patients who received biological treatment were evaluated. Twenty-nine patients with isolated anti-HBc IgG positivity or resolved HBV infection were included in the study. The HBV reactivation was seen in 5 patients (17.2%). Of these patients, 3 were using adalimumab, 1 infliximab, and 1 ustekunimab. It was controlled by antiviral therapy that was started in the early period. CONCLUSION: Drugs that block TNF-α and ustekunimab cause an increase in viral replication. In literature, the HBV reactivation rate was approximately 1% in HBsAg-negative, anti-HBC IgG-positive cases, whereas it was found to be as high as 17.2% in our study. Patients receiving the immunomodulator therapy should be evaluated for HBV serology before treatment and carefully monitored for HBV reactivation during and after treatment.