Empirical cefepime+vancomycin versus ceftazidime+vancomycin versus meropenem+vancomycin in the treatment of healthcare-associated meningitis: results of the multicenter ephesus study.

BACKGROUND: Herein, we analyzed the efficacy of main antibiotic therapy regimens in the treatment of healthcare-associated meningitis (HCAM). MATERIALS/METHODS: This retrospective cohort study was conducted in 18 tertiary-care academic hospitals Turkey, India, Egypt and Romania. We extracted data and outcomes of all patients with post-neurosurgical meningitis cases fulfilling the study inclusion criteria and treated with empirical therapy between December 2006-September 2018. RESULTS: Twenty patients in the cefepime + vancomycin-(CV) group, 31 patients in the ceftazidime + vancomycin-(CFV) group, and 119 patients in the meropenem + vancomycin-(MV) group met the inclusion criteria. The MV subgroup had a significantly higher mean Glasgow Coma Score, a higher rate of admission to the intensive care unit within the previous month, and a higher rate of antibiot herapy within the previous month before the meningitis episode (p < 0.05). Microbiological success on Day 3-5, end of treatment (EOT) clinical success (80% vs. 54.8%% vs 57.9%), and overall success (EOT success followed by one-month survival without relapse or reinfection 65% vs. 51.6% vs. 45.3%), EOT all cause mortality (ACM) and day 30 ACM (15% vs. 22.6% vs. 26%) did not differ significantly (p > 0.05) among the three cohorts. No regimen was effective against carbapenem-resistant bacteria, and vancomycin resulted in an EOT clinical success rate of 60.6% in the methicillin-resistant staphylococci or ampicillin-resistant enterococci subgroup (n = 34). CONCLUSIONS: Our study showed no significant difference in terms of clinical success and mortality among the three treatment options. All regimens were ineffective against carbapenem-resistant bacteria. Vancomycin was unsuccessful in approximately 40% of cases involving methicillin-resistant staphylococci or ampicillin-resistant enterococci.

[Investigation of bacterial and viral etiology in community acquired central nervous system infections with molecular methods]. / Toplum kökenli santral sinir sistemi enfeksiyonlarinda bakteriyel ve viral etiyolojinin moleküler yöntemlerle degerlendirilmesi.

In this multicenter prospective cohort study, it was aimed to evaluate the bacterial and viral etiology in community-acquired central nervous system infections by standart bacteriological culture and multiplex polymerase chain reaction (PCR) methods. Patients hospitalized with central nervous system infections between April 2012 and February 2014 were enrolled in the study. Demographic and clinical information of the patients were collected prospectively. Cerebrospinal fluid (CSF) samples of the patients were examined by standart bacteriological culture methods, bacterial multiplex PCR (Seeplex meningitis-B ACE Detection (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes, Group B streptococci) and viral multiplex PCR (Seeplex meningitis-V1 ACE Detection kits herpes simplex virus-1 (HSV1), herpes simplex virus-2 (HSV2), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein Barr virus (EBV) and human herpes virus 6 (HHV6)) (Seeplex meningitis-V2 ACE Detection kit (enteroviruses)). Patients were classified as purulent meningitis, aseptic meningitis and encephalitis according to their clinical, CSF (leukocyte level, predominant cell type, protein and glucose (blood/CSF) levels) and cranial imaging results. Patients who were infected with a pathogen other than the detection of the kit or diagnosed as chronic meningitis and other diseases during the follow up, were excluded from the study. A total of 79 patients (28 female, 51 male, aged 42.1 ± 18.5) fulfilled the study inclusion criteria. A total of 46 patients were classified in purulent meningitis group whereas 33 were in aseptic meningitis/encephalitis group. Pathogens were detected by multiplex PCR in 41 patients. CSF cultures were positive in 10 (21.7%) patients (nine S.pneumoniae, one H.influenzae) and PCR were positive for 27 (58.6%) patients in purulent meningitis group. In this group one type of bacteria were detected in 18 patients (14 S.pneumoniae, two N.meningitidis, one H.influenzae, one L.monocytogenes). Besides, it is noteworthy that multiple pathogens were detected such as bacteria-virus combination in eight patients and two different bacteria in one patient. In the aseptic meningitis/encephalitis group, pathogens were detected in 14 out of 33 patients; single type of viruses in 11 patients (seven enterovirus, two HSV1, one HSV2, one VZV) and two different viruses were determined in three patients. These data suggest that multiplex PCR methods may increase the isolation rate of pathogens in central nervous system infections. Existence of mixed pathogen growth is remarkable in our study. Further studies are needed for the clinical relevance of this result.

[Evaluation of clinical and laboratory findings of adult visceral leishmaniasis cases]. / Eriskin viseral leysmanyaz olgularinin klinik ve laboratuvar bulgularinin degerlendirilmesi.

Visceral leishmaniasis (VL, kala-azar) is a zoonotic infection caused by Leishmania species which are transmitted to humans by the bites of infected female phlebotomine sandflies. Leishmania infantum is the responsible species of VL in Aegean, Mediterranean, and Central Anatolia regions of Turkey mainly observed sporadically in pediatric age groups. The aim of this study was to evaluate the clinical and laboratory findings of adult patients with VL who were admitted to our hospital. A total of 10 patients (3 female, 7 male; age range: 18-67 years, mean age: 39.3 ± 16.51) followed in the infectious diseases clinic of the hospital between 2000 and 2013 were evaluated retrospectively. The diagnosis of VL was based on the presence of appropriate clinical and physical examination, as well as biochemical findings, positive serological test results (indirect fluorescent antibody test, and rK39 rapid antigen test) and/or detection of amastigote forms of parasite in the bone marrow aspiration samples. Of the cases three were diagnosed with both bone marrow and serology positivity, five with bone marrow positivity and one of each only with liver biopsy and positive serology result. Time interval from onset of the symptoms until the establishment of the specific clinical diagnosis was ranged from 2 to 12 weeks. The most frequent initial symptoms were fever, fatigue and abdominal distension. None of the patients had immunosupressive conditions such as HIV infection, corticosteroid use, immunosupressive treatment, or transplantation. All the patients were from Aegean region and six were living in rural areas. In all cases, hepatosplenomegaly, increased erythrocyte sedimentation rate, albumin/globulin ratio inversion, anemia, leukopenia and among nine cases trombocytopenia were detected. In one case acute renal failure has been developed before treatment and the patient was admitted to dialysis program. Bacterial superinfection occurred in two cases. Patients were treated with either meglumine antimonate (Glucantime(®), 20 mg/kg/day, intramuscularly for 28 days) or liposomal amphotericin B (3 mg/kg/day, intravenously for the first 5 days, then on 14(th) and 21(st) days) according to the availability of drugs. During one year follow-up period all of the patients improved and no recurrence was seen in any patient. In conclusion, among adult patients with fever uncontrolled within 2-week course of ampiric antibiotic treatment without any infectious focus or malignancy, VL should also be considered.

[Molecular characterization of complex recombinant HIV-1 CRF06_cpx subtype detected in Turkey]. / Türkiye'de saptanan kompleks rekombinant HIV-1 CRF06_cpx alttipinin moleküler karakterizasyonu.

A major proportion of the global HIV infections is caused by group M of HIV-1 genotype and to date approximately nine subtypes (A, B, C, D, F, G, H, J, K) and 50 circulating recombinant forms (CRFs) have been recognized. Recombinants between different HIV-1 group M subtypes are designated as CRF. The extension 'cpx', for complex, is given if the CRF consists of contributions from three or more different subtypes but the composition of the subtype is not given. The objective of this study was to present, for the first time an HIV-1 positive married couple infected with CRF06_cpx subtype in Izmir, Turkey. A 39-year-old male patient who admitted to hospital with the complaints of oral candidiasis and zona, was found to be anti-HIV positive. CD4+ T lymphocyte count was 21 cells/mm3 and plasma HIV-1 RNA level was 56.380 copies/ml. He reported unprotected heterosexual contact with multiple partners including African women during his stay in Saudi Arabia between 1996 and 2002. After his diagnosis, his 37-year-old wife was screened for HIV infection and she was also found anti-HIV positive, with CD4+ T cell count of 122 cells/mm3. However, her results of basal plasma HIV-1 RNA could not be obtained because of an internal control error. HIV-1 strains were analysed for subtyping, recombination and drug resistance mutations with pol gene region sequencing. HIV-1 sequences were subtyped as CRF06_cpx after phylogenetic analysis using neighbor-joining method. According to the recombination analysis, HIV-1 pol gene regions consisted of group M subtype G, A, D, and B in the male patient and G K, A, F, and D in the female patient. While L10I + L33F mutation associated with protease inhibitor (PI) resistance was detected in both of the patients, K219N mutation associated with nucleoside reverse transcriptase inhibitor (NRTI) resistance was detected only in the male patient. In conclusion, HIV-1 molecular epidemiology studies are important tools for tracking transmission patterns and the spread of CRF. Global monitoring of CRF subtypes is also important to supply data for HIV vaccine development studies. On the other hand, the detection of HIV-1 primary resistance mutations in antiretroviral naive patients suggested that the resistance testing should be an integral part of the management of HIV infection.

Predictive Value of C-Reactive Protein to Albumin Ratio for Amputation Risk in Diabetic Foot Infection.

Diabetic foot infections are one of the complications of diabetes mellitus resulting in extremity amputation and mortality. This study aimed to examine the predictive value of the C-reactive protein (CRP) to albumin ratio (CAR) for amputation risk in diabetic foot infection. Data from 178 patients were retrospectively examined. We found the cut point value of 15.45 according to the receiver operating characteristic (ROC) curve to show the predictive value of CAR for amputation risk in the overall population. We then divided the patients into two groups low (<15.45, n = 96) and high risk (≥15.45, n = 82) according to their CAR value. Matching based on propensity scores produced 64 patients in each group and showed that the amputation rate was high in the high-risk groups (50 vs 25%, P = .003). In the multivariate analysis in the matching group, previous amputation, antibiotic therapy in the last 3 months, and CAR (Odds ratio [OR]: 1.30, 95%Confidence interval [CI]: 1.01-1.45, P < .001) were independent predictors of amputation. These parameters may be useful to predict amputation risk in these patient groups.

Are bacterial coinfections really rare in COVID-19 intensive care units?

OBJECTIVES: There are limited data about nosocomial coinfections of COVID-19 cases monitored in the intensive care unit. This study aims to investigate coinfections in COVID-19 patients followed in an intensive care unit of a university hospital. METHODS: This study analyzed retrospectively the data of coinfections of 351 COVID-19 patients in the period 28.02.2020-15.01.2021 in a tertiary care intensive care unit in a university hospital. RESULTS: Bacterial coinfections were present in 216 of the 351 cases. One hundred and thirty of these cases were evaluated as nosocomial infections. On the third day the Sequential Organ Failure Assessment Score, usage of invasive mechanical ventilation and presence of septic shock were significantly higher in the coinfected group. The neutrophil/lymphocyte ratio, polymorphonuclear leukocyte count, procalcitonin, ferritin, and blood urea nitrogen values were significantly higher in the coinfection group. White blood cells (WBC) (OR: 1.075, 95% CI 1.032-1.121, p = 0.001) and ICU hospitalization day (OR: 1.114, 95% CI 1.063-1.167, p < 0.001) were found to be independent risk factors for coinfection in the multivariate logistic regression analysis. The rates of hospitalization day on the day of arrival, the 21st day, as well as total mortality (p = 0.004), were significantly higher in the coinfected group. CONCLUSION: Bacterial coinfections of COVID-19 patients in the intensive care unit remain a problem. Identifying the infectious agent, classifying colonizations and infections, and using the proper treatment of antibiotics are of great importance in the case management of COVID-19 patients in the intensive care unit.

[Attitudes and side effects related to pandemic influenza A (H1N1) vaccination in healthcare personnel]. / Hastane Personeline Pandemik Influenza A (H1N1) Asi Uygulamasinin Ardindan Asilama Hakkindaki Görüsler ve Gözlenen Yan Etkiler.

The aims of this study were to evaluate the attitudes towards H1N1 vaccination and to determine the safety and side effects following 2009 pandemic influenza A (H1N1) vaccination. Pandemic influenza vaccine had been administered to the healthcare personnel in our research and training hospital in December 2009. The rate being vaccinated was established as 40% (800/2000). Four months following vaccination, the opinions about vaccination were asked to the healthcare workers, and also side effects were questioned to the vaccinated group. Two different questionnaires (for vaccinated and unvaccinated subjects) were delivered to the volunteers who agreed to participate in the study. Demographic features, reasons related to being vaccinated or not, were questioned. The vaccinated group was also questioned for the presence of chronic diseases, previous vaccinations (pandemic/seasonal influenza), local or systemic reactions that develop after vaccination. A total of 332 volunteers participated in the questionnaire. Of them 247 (74.4%) were vaccinated and 85 (25.6%) were unvaccinated. Male/female ratio of the participants was 1.2, and 55.7% of them were older than 30-year-old. Most of the participants (82.8%) were highly educated (high school and faculty-graduated). Vaccination rates were found statistically significant in advanced age group compared to young adults (p= 0.042); in male gender compared to females (p= 0.001) and in parents compared to subjects who didn't have children (p= 0.021). Vaccination rates were observed to be higher (57.5%) in non-medical staff (cleaning employers, administrative personnel, etc.) than the physicians (29.1%) and nurses (13.4%), and the rate was also high (54.7%) in personnel who worked in intensive care units, emergency department and administrative units than the personnel who worked in the clinics of internal medicine (22.3%) and surgery (23.1%) (p= 0.001). The most important causes of rejecting vaccination were being afraid of the side effects (69.4%) and not believing the effectiveness of the vaccine (56.4%). The leading causes of accepting vaccination were worries about infecting their family (60.3%) and being in a risk group (54.3%). After vaccination, local reactions (pain, swelling and redness at the vaccination site) were described in 43.3% and systemic reactions (weakness, fatigue, muscle aches, influenza-like symptoms, etc.) were described in 43.7% of the subjects. Severe side effects such as vasculitis, neuritis, encephalomyelitis, Guillian-Barre syndrome and anaphylactic reaction were not observed in any of the vaccinated cases. It was detected that worries about the safety of vaccine had negative impact for vaccination. Since no serious side effects were detected related to vaccination, it was concluded that the vaccine was safe. In spite of the scientific proofs, negative concerns about the safety of the vaccines can unfavorably affect the vaccination campaigns and can jeopardize efforts of influenza control. As a result, data collection systems about the safety and side effects of the vaccine all over the country and regular reports about these data may more efficiently guide vaccination programs in the future.

Real-World Data from Turkey: Is Sofosbuvir/Ledipasvir With or Without Ribavirin Treatment for Chronic Hepatitis C Really Effective?

BACKGROUND: In this study, we aimed to investigate the efficacy and safety of sofosbuvir-based therapies in the treatment of chronic hepatitis C in real-world clinical practice. METHODS: Data from patients with chronic hepatitis C treated with SOF/LDV ± RBV or SOF/RBV in 31 centers across Turkey between April 1, 2017, and August 31, 2018, were recorded in a nationwide database among infectious disease specialists. Demographics, clinical, and virological outcomes were analyzed. RESULTS: A total of 552 patients were included in the study. The mean age of the patients was 51.28 ± 14.2, and 293 (55.8%) were female. The majority had HCV genotype 1b infection (65%), 75.04% of the patients underwent treatment, and non-cirrhosis was present at baseline in 381 patients (72.6%). SOF/LDV ± RBV treatment was given to 477 patients and 48 patients received SOF/RBV according to HCV genotype. The total SVR12 rate was 99% in all patients. Five patients experienced disease relapse during the study and all of them were genotype 2. In patients infected with HCV GT2, SVR12 was 77.3%. SVR was 100% in all patients infected with other HCV genotypes. All treatments were well tolerated by patients without causing severe adverse events. Side effects and side effects-associated treatment discontinuation rates were 28.2% and 0.4%, respectively. Weakness (13.7%) was the common side effect. CONCLUSION: The present real-world data of 525 patients with HCV genotypes 1, 1a, 1b, 3, 4, and 5 who underwent SOF/LDV ± RBV treatment in Turkey demonstrated a high efficacy and safety profile. HCV GT2 patients should be treated with more efficacious treatment.

Prevalence and associated factors of thrombocytopenia among human immunodeficiency virus-infected patients at a tertiary care hospital in Izmir, Turkey.

BACKGROUND/AIM: The aim of this study was to determine the prevalence and associated factors of thrombocytopenia in human immunodeficiency virus (HIV)-infected patients. MATERIALS AND METHODS: A cross-sectional study was conducted in a tertiary care hospital in Izmir, Turkey. All HIV-infected patients admitted to the Department of Infectious Diseases and Clinical Microbiology between 2006 and 2011 were recruited. Patients with thrombocytopenia at any time point were defined as the case group and the remaining patients were defined as the control group. RESULTS: The frequency of thrombocytopenia was 35.8%. Thrombocytopenia was more frequent in patients with acquired immune deficiency syndrome (AIDS) than in patients without AIDS (P < 0.05) and in antiretroviral-naive patients than in patients on combination antiretroviral therapy (cART) or those who had ever used cART in the past (P < 0.05). Additionally, rates of tuberculosis infection, prophylactic use of trimethoprim-sulfamethoxazole (TMP/SMX), and being anti-HCV seropositive at any time point were higher in patients with thrombocytopenia than in the control group (P < 0.05), and the case group had lower CD4+ T lymphocytes at first admission (P < 0.05). CONCLUSION: The main finding was the clear association between thrombocytopenia and advanced and uncontrolled HIV infection. Tuberculosis and HCV coinfections were also identified as associated factors for thrombocytopenia.

Variables determining mortality in patients with Acinetobacter baumannii meningitis/ventriculitis treated with intrathecal colistin.

AIM: To examine the variables associated with mortality in patients with Acinetobacter baumannii-related central nervous system infections treated with intrathecal colistin. MATERIALS AND METHODS: This multi-centre retrospective case control study included patients from 11 centres in Turkey, as well as cases found during a literature review. Only patients with CNS infections caused by multidrug-resistant or extensively drug-resistant Acinetobacter baumannii treated with intrathecal colistin were included in this study. The variables associated with mortality were determined by dividing the patients into groups who died or survived during hospitalisation, and who died or survived from Acinetobacter meningitis. RESULTS: Among the 77 cases enrolled in the study, 35 were found through a literature review and 42 were cases from our centres. Forty-four cases (57.1%) were male and the median age was 48 years (range: 20-78 years). Thirty-seven patients (48%) died during hospitalisation. The variables associated with increased all-cause mortality during hospitalisation included old age (odds ratio, 1.035; 95% confidence interval (CI), 1.004-1.067; p=0.026) and failure to provide cerebrospinal fluid sterilisation (odds ratio, 0.264; 95% confidence interval, 0.097-0.724; p=0.01). There is a trend (P=0.062) towards higher mortality with using of meropenem during meningitis treatment. Fifteen cases (19%) died from meningitis. There were no significant predictors of meningitis-related mortality. CONCLUSIONS: The mortality rate for central nervous system infections caused by multidrug-resistant or extensively drug-resistant Acinetobacter baumannii is high. Old age and failure to provide CSF sterilisation are associated with increased mortality during hospitalisation.

Evaluation of Dual Therapy in Real Life Setting in Treatment-Naïve Turkish Patients with HCV Infection: A Multicenter, Retrospective Study.

BACKGROUND: Before the introduction of direct-acting antivirals in the treatment of chronic hepatitis C patients, the combination of peginterferon alpha and ribavirin was the standard therapy. Observational studies that investigated sustained virological response (SVR) rates by these drugs yielded different outcomes. AIMS: The goal of the study was to demonstrate real life data concerning SVR rate achieved by peginterferon alpha plus ribavirin in patients who were treatment-naïve. STUDY DESIGN: A multicenter, retrospective observational study. METHODS: The study was conducted retrospectively on 1214 treatment naïve-patients, being treated with peginterferon alpha-2a or 2b plus ribavirin in respect of the current guidelines between 2005 and 2013. The patients' data were collected from 22 centers via a standard form, which has been prepared for this study. The data included demographic and clinical characteristics (gender, age, body weight, initial Hepatitis C virus RNA (HCV RNA) level, disease staging) as well as course of treatment (duration of treatment, outcomes, discontinuations and adverse events). Renal insufficiency, decompensated liver disease, history of transplantation, immunosuppressive therapy or autoimmune liver disease were exclusion criteria for the study. Treatment efficacy was assessed according to the patient's demographic characteristics, baseline viral load, genotype, and fibrosis scores. RESULTS: The mean age of the patients was 50.74 (±0.64) years. Most of them were infected with genotype 1 (91.8%). SVR was achieved in 761 (62.7%) patients. SVR rate was 59.1% in genotype 1, 89.4% in genotype 2, 93.8% in genotype 3, and 33.3% in genotype 4 patients. Patients with lower viral load yielded higher SVR (65.8% vs. 58.4%, p=0.09). SVR rates according to histologic severity were found to be 69.3%, 66.3%, 59.9%, 47.3%, and 45.5% in patients with fibrosis stage 0, 1, 2, 3 and 4, respectively. The predictors of SVR were male gender, genotype 2/3, age less than 45 years, low fibrosis stage, low baseline viral load and presence of early virological response. SVR rates to each peginterferon were found to be similar in genotype 1/4 although SVR rates were found to be higher for peginterferon alpha-2b in patients with genotype 2/3. The number of patients who failed to complete treatment due to adverse effects was 33 (2.7%). The number of patients failed to complete treatment due to adverse effects was 33 (2.7%). CONCLUSION: Our findings showed that the rate of SVR to dual therapy was higher in treatment-naïve Turkish patients than that reported in randomized controlled trials. Also peginterferon alpha-2a and alpha-2b were found to be similar in terms of SVR in genotype 1 patients.

Comparison of colistin monotherapy and non-colistin combinations in the treatment of multi-drug resistant Acinetobacter spp. bloodstream infections: a multicenter retrospective analysis.

OBJECTIVES: To compare the efficacy of colistin (COL) monotherapy versus non-COL based combinations in the treatment of bloodstream infections (BSIs) due to multidrug resistant Acinetobacter spp.(MDR-A). MATERIALS AND METHODS: Retrospective data of 107 MDR-A BSI cases from 27 tertiary centers in Turkey were included. PRIMARY END-POINT: 14-day mortality. SECONDARY END-POINTS: Microbial eradication and clinical improvement. RESULTS: Thirty-six patients in the COL monotherapy (CM) group and 71 in the non-COL based combinations (NCC) group were included in the study. Mean age was 59.98 ± 20 years (range: 18-89) and 50.5% were male. Median duration of follow-up was 40 days (range: 9-297). The 14-day survival rates were 52.8% in CM and 47.23% in NCC group (P = 0.36). Microbiological eradication was achieved in 69% of CM and 83% of NCC group (P = 0.13). Treatment failure was detected in 22.9% of cases in both CM and NCC groups. Univariate analysis revealed that mean age (P = 0.001), Charlson comorbidity index (P = 0.03), duration of hospital stay before MDR-A BSI (P = 0.04), Pitt bacteremia score (P = 0.043) and Acute Physiology and Chronic Health Evaluation II score (P = 0.05) were significant in terms of 14-day mortality. Advanced age (P = 0.01) and duration of hospital stay before MDR-A BSI (P = 0.04) were independently associated with 14-day mortality in multivariate analysis. CONCLUSION: No significant difference was detected between CM and non-COL based combinations in the treatment of MDR-A BSIs in terms of efficacy and 14-day mortality.

Gemella morbillorum Endocarditis.

Infective endocarditis caused by Gemella morbillorum is a rare disease. In this report 67-year-old male patient with G. morbillorum endocarditis was presented. The patient was hospitalized as he had a fever of unknown origin and in the two of the three sets of blood cultures taken at the first day of hospitalization G. morbillorum was identified. The transthoracic echogram revealed 14 × 10 mm vegetation on the aortic noncoronary cuspis. After 4 weeks of antibiotic therapy, the case was referred to the clinic of cardiovascular surgery for valve surgery.