Ophthalmologic Examination and Echocardiography Should be the Essential Components of Candidemia Bundle.

Objective: Candidemia is the most common form of invasive candidiasis, and it is associated with end-organ involvement, prolonged hospitalization, increased mortality, and higher healthcare costs. Candidemia can lead to metastatic heart and ocular infections. This study aimed to define the incidence, characteristics, and mortality of candidemia episodes and compare the data with our center's previous results. Materials and Methods: In this single-center retrospective observational study, we enrolled 250 patients over 18 years diagnosed with candidemia between January 2015 and December 2020. We obtained patients' demographic, clinical, laboratory, and therapeutic data from medical records. An ophthalmologic examination and screening with echocardiography were carried out within the first week after candidemia diagnosis. Results: There were 275 candidemia episodes from 250 patients. The incidence of candidemia was 2.8/1000 admissions and 5.68/ 10,000 inpatient days, higher than our previous results (1.23/1000 and 3.29/10,000). The median age was 65 (interquartile range [IQR]=52-75) years. Malignancies were the most frequent comorbidity (50%). The most common type was Candida albicans (n=115, 41.8%). Candida glabrata (n=61, 22.2%) was common, particularly in surgical patients, patients with malignancy, and critically ill patients. There was Infectious disease consultation in 93.3% (257) episodes.The ophthalmoscopic examination was made in 145 episodes (52.7%), and ophthalmitis was detected in 16 (11.0%). Echocardiography was performed in 139 (50.5%) episodes; one case had an endocarditis diagnosis. The 30-day mortality was 44.7% (n=123). Mortality rates in C. glabrata and Candida krusei infections were higher (54.1% and 66.7). The factors related to mortality were intensive care unit requirement (p=0.0001), chronic liver disease (p=0.005), corticosteroid usage (p=0.0001), previous antibiotic usage (p=0.013), multiple antibiotic usage ( p=0.020), and CVC related candidemia (p=0.010). Conclusion: Because of the life-threatening complications such as endocarditis, increased mortality rates, and higher healthcare costs, systematic and comprehensive candidemia bundle applications would be effective strategies for providing an effective antifungal stewardship program.

Effect of initial antifungal therapy on mortality among patients with bloodstream infections with different Candida species and resistance to antifungal agents: A multicentre observational study by the Turkish Fungal Infections Study Group.

This study aimed to describe the effect of initial antifungal therapy on patient mortality and to detail the current distribution and resistance patterns of Candida spp. among patients with candidaemia. A prospective observational study was performed among consecutive patients with candidaemia from 10 Turkish medical centres between January 2015 and November 2018. The primary outcome was 10-day mortality. Species were identified using MALDI-TOF/MS. A total of 342 patients with candidaemia were included, of which 175 (51.2%) were male and 68 (19.9%) were aged <18 years. The most common species were Candida albicans (47.4%), Candida parapsilosis (26.6%), Candida tropicalis (9.6%) and Candida glabrata (7.6%). Among all Candida spp., the 10-day case fatality rate (CFR) was 32.2%. The CFR was highest in patients with C. albicans (57.3%) and lowest in patients with C. parapsilosis (21.8%). The resistance rate to fluconazole was 13% in C. parapsilosis, with no significant effect on mortality. No resistance to echinocandins was detected. In the multivariate analysis, being in the ICU [OR = 2.1 (95% CI 1.32-3.57); P = 0.002], renal failure [OR = 2.4 (1.41-3.97); P = 0.001], total parenteral nutrition [OR = 2 (1.22-3.47); P = 0.006], C. albicans infection [OR = 1.7 (1.06-2.82); P = 0.027] and echinocandin as primary agent [OR = 0.6 (0.36-0.99); P = 0.047] were significantly associated with mortality. Candidaemia is a deadly infection. Fluconazole resistance is emerging, although it was not significantly related to mortality. Using an echinocandin as the primary agent could be life-saving.

Consensus Report on Diagnosis, Treatment and Prevention of Infective Endocarditis by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Clinical Microbiology and Infectious Diseases (KLIMIK), Turkish Society of Cardiology (TSC), Turkish Society of Nuclear Medicine (TSNM), Turkish Society of Radiology (TSR), Turkish Dental Association (TDA) and Federation of Turkish Pathology Societies (TURKPATH) Cardiovascular System Study Group.

Infective endocarditis (IE) is rare, but associated with significant morbidity and mortality rates. Estimates of the incidence of IE in Turkey are compromised by the absence of population-based prospective studies. Due to the frequent presence of predisposing cardiac conditions and higher rates of nosocomial bacteremia in highrisk groups, the incidence of IE is expected to be higher in Turkey. Additionally, while IE generally affects older people in developed countries, it still affects young people in Turkey. In order to reduce the mortality and morbidity, it is critical to diagnose the IE to determine the causative agent and to start treatment rapidly. However, most of the patients cannot be diagnosed in their first visits, about half of them can be diagnosed after three months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of identification of causative organisms is significantly lower in Turkey than in developed countries. Furthermore, most of the centers do not perform some essential microbiological diagnostic tests as a routine practice. Some antimicrobials that are recommended as the first-line of treatment for IE, particularly antistaphylococcal penicillins, are not available in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. Physicians can follow patients with IE in many specialties. Diagnosis and treatment processes of IE should be standardized at every stage so that management of IE, a setting in which many physicians are involved, can always be in line with current recommendations. Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the light of current information and local data in Turkey.

Epidemiology, species distribution, clinical characteristics and mortality of candidaemia in a tertiary care university hospital in Turkey, 2007-2014.

Candidaemia still continues to be a serious medical concern and the epidemiology of candidaemia varies according to geographical areas. We aim to determine the incidence, local epidemiology, Candida species distribution and crude mortality rates of candidaemia. We retrospectively evaluated candidaemia episodes in between January 2007 and August 2014. We compared demographic, clinical, microbiological findings and mortality rates of episodes caused by Candida albicans and non-albicans Candida species. Overall the candidaemia incidences were 1.23 episodes/1000 admissions. A significant negative slope among candidaemia episodes and years was determined. Overall C. albicans (54.6%) was the most common species followed by Candida glabrata, Candida tropicalis and Candida parapsilosis respectively. Preinfection hospital stay and length of hospital stay were statistically longer in patients with non-albicans Candida candidaemia than in patients with C. albicans candidaemia. The source of candidaemia was unknown in 52.5% of all episodes. Central venous catheters among non-albicans Candida candidaemia episodes and urinary system among C. albicans candidaemia episodes were common source of candidaemia compared to each other. Previous antifungal therapy preceding candidaemia and concomitant bacteraemia were significantly associated with non-albicans Candida candidaemia. Continuous local surveillance will preserve its pivotal importance in formulating empirical antifungal therapy and improving management of candidaemia.

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.

In vitro susceptibility of tigecycline against multidrug-resistant gram-negative strains: Etest versus agar dilution.

BACKGROUND AND AIM: Tigecycline is a semi-synthetic tetracycline with activity against most multidrug-resistant (MDR) bacteria. METHODS: We studied in vitro activity of tigecycline by agar dilution (AD) and Etest methods to evaluate their correlation. The study included 206 isolates of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli, Klebsiella pneumoniae and MDR Acinetobacter baumannii recovered from blood cultures of patients of Baskent University between 2008 and 2010. RESULTS: ESBL-producing E. coli had MIC50/MIC90 values of 0.5/0.5 µg/ml by AD and 0.25/0.5 µg/ml by Etest. ESBL-producing K. pneumoniae had MIC50/MIC90 values of 1/2 µg/ml by AD and 0.75/2 µg/ml by Etest, whereas MDR A. baumannii had MIC50/MIC90 values of 4/4 µg/ml by AD and 2/4 µg/ml by Etest. The correlation between AD and Etest was weak for ESBL-producing E. coli and strong for ESBL-producing K. pneumoniae and MDR A. baumannii. Tigecycline MIC values for ESBL-producing E. coli were lower than the tigecycline concentration, while they were higher than the concentrations attainable by treatment doses for A. baumannii. CONCLUSION: Tigecycline is an appropriate agent in the treatment of E. coli bacteremia, but it is not for treating A. baumannii bacteremia. Tigecycline could be used for K. pneumoniae bacteremia treatment after determining its MIC value. Determining the MIC value by gold-standard methods is more appropriate due to the correlation between Etest and AD at high MIC values.

Influence of febrile neutropenia period on plasma viscosity at malignancy.

Cancer, chemotherapy, and infections all together make changes in blood rheology and may affect the defense mechanisms by changing the thrombocyte function and endothelial cell. We have examined changes of blood rheology on plasma viscosity to put on probable following criteria for starting the treatment of febrile neutropenia immediately. A total of 27 postchemotherapy patients (16 males and 11 females) with febrile neutropenia diagnosed according to international guidelines have been included into the study. The plasma viscosity of the patients whose febrile neutropenia has been successfully treated was also measured to assess the impact of the duration of neutropenia on viscosity. The plasma viscosities of the patients were significantly higher during neutropenic episode than in nonneutropenic state (P = 0.006) except for alkaline phosphatase. All study parameters, particularly acute phase reactants, were statistically similar during both states. In the correlation of analysis with study parameters and stages, significant correlation was not observed between plasma viscosity alteration and leukocyte-neutrophil alteration, also other study parameters. We have demonstrated significantly elevated plasma viscosity in our patients during febrile neutropenic episode. Despite normal values of various parameters known to trigger plasma viscosity, particularly fibrinogen, it can be easily argued that the main mechanism may be the endothelial injury during infectious process and immune response mediated microcirculatory blood flow alterations.

Bloodstream Infections among Solid Organ Transplant Recipients: Eight Years' Experience from a Turkish University Hospital.

BACKGROUND: Bloodstream infections (BSI) are frequently seen after solid organ transplantation. The incidence of bloodstream infections differs among the types of transplantation. The microbiological features and antimicrobial resistance patterns change from centre to centre. AIMS: To evaluate the incidence and spectrum of aetiological agents of bloodstream infections among solid organ transplantation recipients. STUDY DESIGN: Retrospective descriptive study. METHODS: Medical records of solid organ transplant recipients in the period between January 1(st) 2004 and August 15(th) 2012 were assessed retrospectively. The study population comprised 927 (64 heart, 556 kidney, 307 liver) consecutive recipients. Bloodstream infections were divided into three groups according to the onset time of bloodstream infections after transplantation: early, mid-term and late. The incidence and microbiological features of bloodstream infections were evaluated. RESULTS: The number of bloodstream infection episodes was 317 in 191 recipients which was distributed as 228 (72%) in liver, 70 (22%) in kidney and 19 (6%) in heart transplantation. Ninety-eight 98 (30.9%) of the episodes were diagnosed within the early period, 134 (42.3%) within the mid-term and 85 (26.8%) in the late period. Early and mid-term bloodstream infections were seen statistically more often in liver than in kidney or heart transplantation (p=0.01 and p=0.031, respectively). Late bloodstream infections were also common in liver transplant recipients which was not statistically significant (p=0.229). CONCLUSION: Liver transplant recipients are at the highest risk for developing BSI after transplantation in early, mid-term and late periods.

[A fatal case of West Nile virus encephalitis]. / Ölümcül Seyreden Bati Nil Virusu Ensefaliti Olgusu.

Although West Nile virus (WNV) serologic evidence has been well demonstrated throghout Turkey in the last 40 years; the first symptomatic WNV infection was reported in 2009 and increased number of cases were reported during August 2010. In that period WNV encephalitis was diagnosed serologically (WNV IgM positivity in serum sample detected by ELISA and IFA) and confirmed by plaque reduction neutralization test in a 76-year-old man who was admitted to Baskent University Faculty of Medicine with complaints of fever, impaired consciousness and generalized tremors. Despite all supportive treatment, he died on the 9th day of hospitalization. In this report, detailed clinical course, laboratory features and diagnosis of this mortal case of WNV encephalitis were described. WNV encephalitis should be considered in the differential diagnosis of patients with fever of unknown origin and loss of consciousness especially in summer and early fall in Turkey.

A Rare Cause of Endocarditis: Streptococcus pyogenes.

Although group A ß-hemolytic streptococcus is an uncommon cause of infective endocarditis, an increase in the incidence of invasive group A streptococcus infections including bacteremia has been reported in the last two decades. Herein we report Streptococcus pyogenes endocarditis in a previously healthy adult patient who was hospitalized to investigate the etiology of fever. Because of a suspicion of a new vegetation appeared in the second (aortic) valve in the 14(th) day of high dose penicillin G treatment, the mitral and aortic valves were replaced by mechanical prosthesis on the 22(nd) day of treatment. He was discharged from hospital after the 6 week course of antibiotic treatment.

The effect of a nationwide antibiotic restriction policy on antibiotic usage in a stem cell transplantation unit.

The Turkish Ministry of Health has released a regulation in February 2003 in order to decrease, first the antibiotic expenses and second, inappropriate use of antimicrobial agents. The aim of this study is to assess the impact of this nationwide antibiotic restriction (NAR) in the most active stem cell transplantation unit (SCTU) in Turkey. All patients followed up in SCTU and had received antimicrobial therapy in the period of four months before and after NAR were evaluated retrospectively. The appropriateness of antimicrobial treatments was assessed by two ID specialists and one ID professor. Disagreements between investigators were solved by discussion and review of published guidelines. There were 10 and 25 patients who were on antimicrobial therapy in the 1st (before NAR) and 2nd (after NAR) group, respectively. Seventeen of the patients had undergone allogeneic stem cell transplantation, while 6 were allogeneic bone marrow recipients and 12 were autologous peripheral stem cell recipients. The antibiotic days per patient was 33.4 and 19.4 in the first and second groups respectively (p=0.036). Although it was not significant, the appropriateness of antibiotic regimens used in the second group was higher than the first group (OR: 5, CI: 0.9-26.4, p= 0.059). The significantly lower antibiotic day per patient in the 2nd group may be the result of collaboration between infectious diseases and hematology physicians settled after NAR in our hospital. NAR had reduced the antimicrobial use in our unit mainly by providing collaboration between infectious diseases and hematology departments.

[Prolonged hepatitis A: three case reports]. / Uzamis hepatit A: üç olgu raporu.

In this report, three patients, admitted to Ankara University Faculty of Medicine, Ibni Sina Hospital, Clinical Bacteriology and Infectious Diseases Department, with the diagnosis of acute viral hepatitis A have been discussed because of their clinical and/or biochemical relapses. Following conservative treatment and bedrest, the liver transaminases decrease to nearly normal levels but a second peak was observed later in three of the cases. Other viral, metabolic and autoimmune factors which could lead to the increase of liver transaminases were ruled out. Anti-HAV IgM antibodies became negative in 2 to 4 months later, and liver enzymes returned to normal in 4 to 5 months after onset of their illnesses. As a result, it was concluded that conservative follow-up and therapy would be sufficient since the prognosis of A hepatitis is usually benign even if it relapsed.