Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study.

OBJECTIVE: We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia. METHODS: A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists. RESULTS: Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%). CONCLUSION: ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.

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.

Mediterranean spotted fever in the Trakya region of Turkey.

Mediterranean spotted fever (MSF) is caused by a tick-borne pathogen, Rickettsia conorii subsp. conorii, belonging to the spotted fever group (SFG) rickettsiae. The aim of the present study was to evaluate the cases with confirmed diagnosis of MSF from 2003 to 2009 in the Trakya region of Turkey. Patients with high fever, maculopapular rash (involving the palms or soles) and/or a black inoculation eschar at the site of the tick bite (tache noire) were included in the study. Before doxycycline treatment, skin biopsy specimens, preferably from the eschar or from the maculopapular rash, were obtained for DNA extraction. Immunofluorescence assay (IFA) was performed to detect IgM and IgG antibodies against R. conorii in acute and convalescent sera. Afterwards, a standard PCR reaction using primers suitable for hybridisation within the conserved region of genes coding for outer membrane protein A (ompA) and citrate synthase (gltA) and DNA sequencing were performed. There were 128 patients with confirmed MSF diagnosis. Using IFA, seroconversion or a fourfold or greater rise in titre was observed in 97 (77%) patients, whereas a single high titre was demonstrated in 16 (12.7%) patients. According to PCR analysis, 77 (72.6%) of 106 biopsy samples showed positive results. Of these, 58 (73%) of 79 biopsy specimens were from the eschar and 19 (70%) of 27 specimens were from the maculopapular rash. No significant difference was found between the rate of positive skin biopsies taken from the eschar and the maculopapular rash. DNA sequence analysis was performed to all PCR-positive cases, and R. conorii conorii (type strain: Malish, ATCC VR-613) was detected in each of them. MSF is prevalent, but has been underdiagnosed and underreported so far in Turkey. It is a potentially severe and even fatal disease resembling viral haemorrhagic fevers that has to be included in the differential diagnosis of febrile illness associated with thrombocytopenia, even in the absence of an eschar or a tick bite. While IFA allows for retrospective diagnosis in MSF, advanced molecular techniques provide the rapid detection of rickettsia in all skin samples, including eschar and maculopapular rash.

Negative serology: could exclude the diagnosis of brucellosis?

Two cases of brucellar spondylodiscitis of the lumbar area were presented. Although both cases showed typical radiological changes, serological tests could not detect Brucella agglutinating antibodies. One of the patients was bacteremic and Brucella spp. was identified from blood culture. In the second patient needle biopsy was required for definite diagnosis. Although small, serologic tests have a certain rate of false negative results in brucellosis. Thus, a negative serology should not exclude the diagnosis of brucellosis, as it is demonstrated in the current cases.

[Evaluation of epidemiological characteristics and risk factors of candidemia in adult patients in a tertiary-care hospital]. / Bir üçüncü basamak hastanesinde eriskin kandidemi olgularinin epidemiyolojik özellikleri ve risk faktörlerinin degerlendirilmesi.

Candida species which are currently the fourth most common cause of nosocomial bloodstream infections, are associated with a significant morbidity and mortality. The aim of this retrospective case-control study which included adult patients was to determine the epidemiology of candidemia and to evaluate risk factors for the development of candidemia and mortality at a tertiary-care education hospital over a 1-year period. A total of 38 candidemia cases (23 were male; age range: 17-82 yrs; mean age: 61.4 ± 13.5 years) were identified among 22.507 patients hospitalized during the study period (January 1-December 31, 2008) and the overall incidence was found as 16.8 per 10.000 hospital admissions. Control group (n= 36; 22 were male; mean age: 60.9 ± 16.3 years) was selected among patients who had no signs and symptoms of candidemia and had negative blood cultures during the study period. Thirty-six (95%) patients with candidemia were identified as nosocomial infection. The most frequently isolated species were C.albicans (55.2%) and C.parapsilosis (28.9%) and the primarily identified origin of infection was central venous catheter use (39%). Candida spp. Isolation was most frequent in patients hospitalized in intensive care units (13/38; 34.2%), followed by surgery (n= 8; 21%) and chest diseases (n= 5; 13). Univariate analysis revealed that presence of a central venous catheter [odds ratio (OR): 4.33; 95% confidence interval (CI): 1.63-11.47, p= 0.003] and the length of hospitalization (OR: 0.97; CI: 0.94-1.00, p= 0.01) were the most frequently associated factors with an increased risk of candidemia compared to controls. However, multivariate analysis exhibited presence of a central venous catheter (OR: 2.90; CI: 1.04 8.11, p= 0.04) as the only independent risk factor for the development of candidemia. Therapy was initiated with intravenous fluconazole (mean duration of therapy 13.2 ± 6.25 days) and in three patients following fluconazol use step-up therapy was initiated. Total mortality rate was 58% (22/38) in our case series. Risk factors for mortality due to candidemia in the univariate analysis were detected as no response to antifungal treatment (OR: 0.23; CI: 0.11-0.51, p< 0.001), underlying disease other than trauma (OR: 0.06; CI: 0.003-1.24, p= 0.02), and high Charlson index (OR: 0.60; CI: 0.38-0.93, p= 0.03), however those factors were not found significant by multivariate analysis. There was also a statistically significant correlation between Charlson index and treatment response (mean Charlson index was 3.5 ± 1.9 in therapy-responded patients and 4.8 ± 1.8 in non-responders; p= 0.03). Since the risk of developing candidemia was significantly higher in severely diseased patients using central venous catheter or with prolonged hospitalization, response to antifungal therapy may be insufficient, leading to higher mortality.

CTX-M type extended spectrum beta-lactamases in Escherichia coli isolates from community acquired upper urinary tract infections at a university in the European part of Turkey.

Extended spectrum beta-lactamase (ESBL) producing Escherichia coli has been an emerging etiologic agent in the community acquired infections. We investigated the occurrence of ESBL producing E. coli isolated from patients admitted with community acquired urinary tract infection (UTI) to the hospital of the Trakya University, Turkey during 2006. Eleven single patient isolates of E. coli harboring ESBL were identified among 30 E. coli isolated from patients admitted with symptoms corresponding to upper UTI. CTX-M type ESBLs were detected in all 11 ESBL-producers by isoelectric focusing and polymerase chain reaction screening. Sequence analysis revealed CTX-M-1 in one isolate, CTX-M-3 in three isolates and CTX-M-15 in seven isolates. ESBL-producing E. coli isolated from community acquired UTIs are widespread in the European part of Turkey.

[Staphylococcus aureus hepatic abscess associated with cervical lymphadenitis]. / Servikal lenfadenit esliginde gelisen Staphylococcus aureus'un etken oldugu karaciger apsesi.

Pyogenic liver abscesses usually develop secondary to biliary tract and intraabdominal infections and members of the Enterobacteriaceae family are usually implicated as the etiologic agents. In this report a case of hepatic abscess devoloped secondary to cervical lymphadenitis caused by Staphylococcus aureus, was presented. Twenty-one years old male patient was admitted to the hospital with complaints of fever, swelling and pain at the right side of the neck and difficulty in swallowing. Physical examination revealed painful submandibular lymphadenopathy with hyperemia. Upon demonstration of cystic lymphadenopathy by magnetic resonance imaging of the neck, the mass was aspirated. Gram-positive cocci with abundant leucocytes were detected in Gram stained smears of the aspiration material and methicillin-susceptible S. aureus (MSSA) was identified in the culture. Treatment with ampicillin/sulbactam (4 x 1.5 g/day) was initiated. However, since patient still had fever and abdominal pain, nausea and vomitting were also added to his complaints, abdominal ultrasonography and computerized tomography (CT) were done and abscesses were demonstrated in liver. The abscesses were drained under CT guidance and the fever of the patient resolved. Treatment with ampicillin/sulbactam was continued for 6 weeks. Although it was considered that the hematogenous spread of MSSA that led to cervical lymphadenitis caused the hepatic abscesses, the agent was neither isolated from the blood culture nor from the hepatic abscess material. It should always be taken into consideration that liver abscesses might accompany distant infections and antibiotic therapy alone might not be sufficient for the complete resolution of such infections.

[Retrospective evaluation of the cases prediagnosed as viral encephalitis in Trace University Hospital between the period of 2000-2005]. / Trakya üniversitesi tip fakültesi hastanesinde 2000-2005 yillari arasinda viral ensefalit ön tanili olgularin retrospektif degerlendirilmesi.

In this study, a total of 17 adult patients ((> or =18 years old; 12 male, 5 female) with encephalitis followed up in neurology and infectious diseases clinics of Trace University Hospital between the years 2000-2005 were retrospectively analyzed. The most common signs and symptoms were confusion (n: 13; 76.4%), nausea and vomiting (n: 13; 76.4%), disorientation (n: 12; 70%), fever and headache (n: 11; 64.7%), amnesia (n: 10; 58.8%), convulsions (n: 9; 52.9%), agitation (n: 7; 41%), dysphasia and aphasia (n: 6; 35.2%), nuchal stiffness (n: 5; 29.4) and focal neurological signs (n: 1; 5.8%). Six of the patients were admitted to the hospital during summer, six during winter, four during spring and one during autumn. Eleven (64.7%) of the patients had electroencephalographic signs compatible with encephalitis. Encephalitis related signs were detected in 83.3% (10/12) of the patients by cranial magnetic resonance imaging and in 58.3% (7/12) by computerized tomography. Cerebrospinal fluid (CSF) examination revealed low glucose levels in 17.6% (3/17), high protein levels in 47% (8/17) and increased white blood cells with a predominance of lymphocytes in 41.2% (7/17) of the cases. CSF findings were within normal limits in 23.5% (4/17) of the patients. Empirical acyclovir treatment was given to all patients. One patient died at the acute phase of the infection while all the other 16 recovered. Since none of the CSF samples yielded bacterial growth, all of the patients were diagnosed as viral encephalitis. However, no investigation was performed to identify the viral etiology and this was the major limitation owing to the inadequacy of laboratory facilities during the study period and/or unawareness of the physicians about viral identification methods.

[Short communication: Evaluation of the flu vaccine administered to health care workers in Trakya University Hospital in 2006]. / Kisa bildiri: Trakya Universitesi Hastanesi saglik Calisanlarina 2006 yilinda uygulanan grip asisinin degerlendirilmesi.

After the detection of human cases of highly pathogenic avian influenza A (H5N1) virus in Eastern Turkey in January 2006, Turkish Ministry of Health has had declared "National Plans of Activity for Pandemic Influenza". All health-care facilities were recommended to develop contingency plans. Then the essential activities were started in August 2006 in Trakya University, Faculty of Medicine (Edirne, Trace region of Turkey), and institutional education about pandemic influenza and preventive measures was implemented to health care workers (HCWs). In November 2006, health care workers were offered inactivated flu vaccine (Vaxigrip, Sanofi Pasteur, France) supplied by the Ministry of Health. The aim of this questionary survey was to evaluate the visions and conceptions of health care workers about influenza vaccination during the vaccination campaign. All the participants were informed by using an information form including the indications, contraindications and possible adverse reactions of flu vaccine, and were requested to complete the questionnaire about influenza vaccination according to their own perception before vaccination. Vaccine recipients were also invited to the vaccination unit if they had any adverse reaction. A total of 1041 HCWs (560 female, 481 male; mean age: 32.8 +/- 8.2 years) completed the questionnaire. Of them 884 subjects (85%) have accepted to be vaccinated, while 157 subjects (15%) have not. It was determined that 72 HCWs (6.9%) had been administered flu vaccine in 2005, and 38 (3.7%) have had an underlying chronic disease requiring medical therapy. Six subjects (16%) with an underlying chronic disease were vaccinated in 2005, while 66 HCWs (6.6%) without any chronic disease received vaccination voluntarily. Seven workers (0.7%) declined vaccination as they defined hypersensitivity to egg, and 84 workers (8%) had influenza vaccine voluntarily before the campaign in 2006. Sixty six workers (6.3%) have refused to be vaccinated as they considered influenza vaccination ineffective to protect against flu. Two workers (0.2%) had allergic skin reactions such as erythema and itching after vaccination. It can be concluded that influenza vaccination of the health care workers is a part of infection control policies and it is also a matter of patient safety. The implementation of necessary education programmes and attempts to emphasize the importance of vaccination of health care workers especially dealing with high risk patients, would be of crucial importance to decrease the morbidity and mortality due to influenza infections.

Prospective evaluation of rickettsioses in the Trakya (European) region of Turkey and atypic presentations of Rickettsia conorii.

In 2004 between the months of May-November, 11 patients with spotted fever group (SFG) rickettsioses were admitted to the Trakya University Hospital in Edirne, Turkey. SFG rickettsioses were diagnosed clinically. Before treatment, punch biopsy from skin lesions, especially from the eschar, was performed. Serum specimens were tested by IFA using a panel of nine rickettsial antigens, including SFG rickettsiae and R. typhi. Western blotting and standard PCR were also performed. The average age of the 11 patients (4 male and 7 female) was 51 years. All the patients had high fever; 10 (91%) had maculopapular rash; 8 (73%) had rash in the palms or on the soles. Five patients had a unique eschar; two had double eschars (64%). Two patients presented with multiple organ failure and one of them died. All the patients had significant antibody titers against SFG rickettsiae. PCR experiments of skin biopsies were positive in six (60%) of 10 skin biopsy samples and DNA sequencing of the positive PCR products gave 100% homology with Rickettsia conorii Malish 7 for opmA and gltA. Trakya Region in an endemic area for rickettsioses. In this series, three patients presented with life-threatening diseases and one of them died. This patient was the first fatal case (2.8%). Atypic and serous life-threatening presentations of rickettsioses must be kept in mind for the differential diagnosis of febrile disease in Turkey.

Meningitis due to bacillus anthracis.

The first case of haemorrhagic meningitis due to Bacillus anthracis in the European part of Turkey is reported here. B. anthracis, sensitive to penicillin, was isolated from the cerebrospinal fluid and blood cultures. Although appropriate therapy was administered, the patient died two days after hospitalization.

Antituberculosis drug resistance and associated risk factors in the European section of Turkey.

BACKGROUND: We carried out this study in order to establish the prevalence of antituberculosis drug resistance in Mycobacterium tuberculosis strains and to determine risk factors for the development of resistance in Trakya region of Turkey. METHODS: Pattern of drug resistance in 214 M. tuberculosis isolates from patients with tuberculosis treated at the regional tuberculosis dispensaries were included in the study. RESULTS: Isolates of 105 (49.1%) were resistant to only one drug, and 62 (29.0%) were resistant to more than one drug. The total resistance rates to streptomycin, isoniazid, rifampicin, ethambutol and isoniazid + rifampicin were 29.0%, 27.1%, 21.5%, 10.3% and 11.6%, respectively. The secondary resistance rates in all drugs and combinations were higher than primary resistance rates (p<0.001). Step wise logistic regression revealed that (i) non-compliance with treatment increases the chances of development of resistance by 15 times [p<0.00001, 95% confidence intervals (95% CI) : 4.16 to 56.70], and (ii) a regimen of inadequate treatment increases the chance of development of drug resistance by 10.5 times (p<0.01, 95% CI=2.66 to 49.80). CONCLUSIONS: We propose that specially trained physicians should institute antituberculosis therapy and medication should be practiced under direct observation in this region.

[Species and biovar distribution of Brucella isolates in Trakya University Hospital between 1997-2002]. / Trakya Universitesi Hastanesinde 1997-2002 yillari arasinda saptanan Brucella izolatlarinin tür ve biyovar dagilimi.

The aim of this study was to evaluate the species and biovar distribution of Brucella spp. isolated from blood cultures in Clinical Microbiology Laboratory of Trakya University Hospital, between 1997-2002. A total of 48 Brucella spp. have been isolated from 14.815 patients (0.3%), and the strains were identified according to CO2 requirement, H2S production, basic fuchsin and thionin sensitivity, lysis by Tbilisi phages, and presence of agglutination with monospecific A and M antisera. As a result, 47 (97.9%) isolates were identified as B. melitensis, and one as B. abortus (2.1%). Forty two (89.4%) of B. melitensis isolates were biovar 3, and five (10.6%) were biovar 1, while the single isolate of B. abortus was identified as an atypical strain.

The epidemiology of hepatitis a virus infection in children, in Edirne, Turkey.

Turkey is a middle endemic area with respect to Hepatitis A virus (HAV) infection. However, the frequency of this infection varies due to socio-economic differences in various regions. The aim of this study was to detect the most likely age of exposure to HAV and factors affecting infection rates among children living in Edirne. A sample of 645 children between the ages of 0-19 living in Edirne were tested for total anti-HAV levels using ELISA method. A questionnaire on socio-economic status (SES), possible risk factors, and place of residence was completed for each child. Anti-HAV seropositivity was found to be 4.4, 25, 37.3 and 43.2%, in 2-5, 6-10, 11-14 and 15-19 age groups, respectively. Seropositivity was found to be increasing with age (p < 0.05). According to logistic regression analysis results; mother's education, SES of family, history of hepatitis in primary family members and the number of brothers or sisters were determined as factors increasing the seropositivity of HAV. Furthermore, HAV infection risk was found to be a decreasing function of income that is higher the income less likely the infection. These results showed that HAV infection rate in Edirne is in middle endemicity and the most likely way of exposure is transmission from family members. Although it requires further cost-effectiveness studies, our results indicate that applying the HAV vaccination in early childhood would be beneficial to decrease the prevalence of the infection and prevent HAV epidemics.

A food-borne outbreak caused by Salmonella enteritidis.

This study was designed to define the epidemiology of a food-borne outbreak caused by Salmonella enteritidis that affected only one squadron of a military battalion located in the vicinity of the city of Edirne in Turkey. The outbreak was analyzed by a standard surveillance form of the Centers for Disease Control and Prevention. The relationship between the eaten foods and cases was analyzed by Fisher's exact chi-square test, and odds ratios were calculated by a case-control study. The outbreak affected 60 of 168 soldiers in the squadron, 16 of whom were hospitalized. S.enteritidis was cultured in stools from 13 of the hospitalized soldiers and from 3 soldiers who had prepared the food. All strains were completely susceptible to antibiotics; their plasmid profiles were also identical. The highest attack rate detected was 55.7% in an omelet eaten 24 hours before (p < 0.001). Furthermore, it was the riskiest food according to the case-control study (OR=7.88; 95% CI=3.68-16.89). The food samples were unobtainable because they had been discarded. All of the hospitalized cases recovered, and none of the control cultures of stools yielded the pathogen after three weeks. In conclusion, although our results didn't indicate the exact source of the outbreak microbiologically, the omelet was considered to be the source based on the epidemiological proofs.

Resistance to macrolides in Group A streptococci from the European section of Turkey: genetic and phenotypic characterization.

The aim of this study was to determine the susceptibilities to macrolides of Group A streptococcal isolates from the European section of Turkey. In the case of resistant isolates, the patterns and genetic mechanisms of erythromycin resistance were studied. Seven (2.7%) of the 260 isolates were resistant to erythromycin. Four of them showed the M phenotype and harboured mefA genes whereas three isolates showed the inducible macrolide, lincosamide and streptogramin B resistance phenotype and harboured ermTR genes. In the European section of Turkey, the current resistance rate of Group A streptococci to macrolides remains low.