Two cases with unusual mycetoma localizations in upper respiratory system.

Fungus balls or mycetomas are extramucosal and noninvasive accumulations of degenerating fungal hyphae. In head and neck they may localized most frequently in the paranasal sinuses, especially in the maxillary sinus. These indolent infections are mostly caused by Aspergillus spp. In this article, we present two rare fungus ball cases: one occurring in an automastoidectomy cavity of a temporal bone and the other in a concha bullosa. Typically, both patients admitted with vague symptoms consistent with chronic infection resistant to conventional antibacterial medication.

Etiological agents of community-acquired pneumonia in adult patients in Turkey; a multicentric, cross-sectional study.

This cross-sectional study was intended to investigate the etiology of community-acquired pneumonia (CAP) in adult patients receiving no prior antibiotic therapy. Etiological agents were identified in 137 (62.8%) of 218 patients, the most frequent being Streptococcus pneumoniae (14.7%), Mycoplasma pneumoniae (13.8%) and respiratory syncytial virus (10.1%). A single pathogen was detected in 50.9% of cases and mixed pathogens in 11.9%. Typical pathogens were determined in 35.8% of cases, atypical pathogens in 20.2% and viral pathogens in 20.6%. Chronic obstructive pulmonary disease was a common (42.7%) comorbidity. S. pneumoniae was the most common pathogen in adult patients with CAP. Atypical pathogens were more common in patients < 65 years old, M. pneumoniae being the most common in this age group. Our results suggest that initial empiric antibiotic treatment in patients with CAP should cover S. pneumoniae and M. pneumoniae in Turkey.

Molecular epidemiology of clinical Pseudomonas aeruginosa isolates carrying IMP-1 metallo-beta-lactamase gene in a University Hospital in Turkey.

Pseudomonas aeruginosa isolates carrying IMP- or VIM-type metallo-beta-lactamase (MBL) have been increasingly reported in hospitals worldwide. One hundred P. aeruginosa clinical isolates from unrelated inpatients hospitalized at a Turkish university hospital were screened for the presence of bla(IMP) and bla(VIM) genes by polymerase chain reaction (PCR). One (1%) isolate was found to carry a VIM-type MBL gene, whereas nine (9%) carried an IMP-1 MBL gene carried on a cassette inserted into a class 1 integron. Only four of the IMP producers were detected as MBL producers according to E-test MBL. Minimum inhibitory concentrations (MICs) of imipenem for the IMP-1 and VIM-type MBL-producers were highly variable (MIC values, 8-128 mug/ml). Imipenem resistance was not plasmid-mediated according to the transformation assays. Piperacillin/tazobactam was the only effective drug in antimicrobial susceptibility testing. No aztreonam-resistant IMP and VIM producers were detected to produce an extended-spectrum beta-lactamase (ESBL). Three class 1 integrons of approximately 2,300 bp, 1,800 bp, and 1,500 bp in size were detected in each of the nine IMP-positive isolates. Sequencing revealed three novel gene cassette arrays, aac(3)-1c-cmlA5, bla(IMP-1)-aadA7-like, and aacA7-smr-2-orfD. Enterobacterial repetitive intergenic consensus PCR (ERIC-PCR) indicated that a clonal spread of IMP-1-producers had occurred in this hospital.

Cerebellar abscess and meningitis, caused by Shewanella putrefaciens and Klebsiella pneumoniae, associated with chronic otitis media.

Shewanella putrefaciens is a facultatively anaerobic, non-motile, Gram-negative, non-fermentative bacterium. It is found in various environments and has been isolated worldwide. S. putrefaciens is a rare cause of brain abscesses and meningitis. This is a case report of a cerebellar abscess and meningitis caused by Shewanella putrefaciens and Klebsiella pneumoniae in a river trap fisherman.

Detection and prevalence of inducible clindamycin resistance in staphylococci.

Staphylococcus aureus and coagulase-negative staphylococci (CNS) are recognized as causing nosocomial and community-acquired infections in every region of the world. The resistance to antimicrobial agents among staphylococci is an increasing problem. Clindamycin (CL) is considered to be one of the alternative agents in these infections. This study demonstrates a simple, reliable method (double-disc diffusion test) for detecting inducible resistance to CL in erythromycin-resistance (ER-R) isolates of S. aureus and CNS. A total of 883 (52.3%) isolates of S. aureus and 804 (47.7%) isolates of CNS were selected from recent (2003-2005) clinical isolates recovered in the laboratory of the authors; duplicate isolates were not included. A total of 214 (12.6%) S. aureus and 308 (18.3%) CNS isolates were selected based on ER-R and CL sensitivity using standard National Committee for Clinical Laboratory Standards disc diffusion testing. A total of 1687 staphylococcal isolates were included, consisting of 27.5% meticillin-resistant S. aureus, 24.8% meticillin-sensitive S. aureus, 36.1% meticillin-resistant CNS and 11.6% meticillin-sensitive CNS isolates: 30.9% of staphylococcal isolates (214 S. aureus and 308 CNS) that were erythromycin resistant and CL sensitive were tested for inducible resistance using the D-test. A D-shaped zone around the CL was observed for 70.9% of staphylococcal isolates (81.8% of S. aureus isolates and 63.3% of CNS isolates) with an ER-R and a clindamycin-sensitive (CL-S) phenotype. The organism was positive for inducible clindamycin resistance (CL-R). There was a 21.9% level of inducible macrolide-lincosamide-streptogramin B resistance phenotype among all the staphylococcal isolates. When the S. aureus and CNS strains among all the staphylococcal isolates were compared statistically, inducible CL-R in CNS strains was determined to be 23% more positive (P=0.028, odds ratio 0.77, 95% confidence interval 0.61-0.98). When a statistical comparison was performed among ER-R but CL-S staphylococcal isolates inducible CL-R in S. aureus strains was determined to be 2.6 times more positive (P=0.000, odds ratio 2.6, 95% confidence interval 1.68-4.04). A simple, reliable method of detecting inducible resistance to CL in ER-R isolates of S. aureus and CNS is described. Clinical microbiology laboratories should use the double-disc diffusion test as standard practice with all ER-R staphylococci. CL should not be used in patients with infections caused by inducibly resistant staphylococcal isolates. Therapeutic failures may thus be avoided.

Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization.

BACKGROUND: Intravascular catheters are integral to the practice of modern medicine. Potential risk factors for catheter-related bloodstream infection (CRBSI) include underlying disease, method of catheter insertion, and duration and purpose of catheterization. The administration of parenteral nutrition (PN) through intravascular catheters increases CRBSI risks. The purpose of this study was to evaluate the risk factors of CRBSI in patients with PN administration. METHODS: This study was conducted at the Karadeniz Technical University Hospital between October 2003 and November 2004. All the patients to whom PN was administered through intravascular catheters were prospectively monitored for the presence of CRBSI and risk factors. RESULTS: During the study period, 111 intravascular catheters through which PN was administered were monitored for a total of 1646 catheter-days. CRBSI was determined in 31 cases, a CRBSI rate of 18.8 per 1,000 catheter-days. When risk factors affecting CRBSI were investigated using logistic regression, an increase in APACHE II score (OR, 1.10; 95% CI, 1.01-1.21; p = .012), prolongation of catheterization (OR, 1.08; 95% CI, 1.02-1.14; p = .004), catheterization in emergent conditions (OR, 5.45; 95% CI, 1.20-24.82; p = .016), and poor patient hygiene (OR, 4.38; 95% CI, 1.39-13.78; p = .019) were all determined to be independent risk factors. Proper implementation of hand hygiene and maximal barrier precautions during the insertion of catheters reduced CRBSI levels (OR, 0.28; 95% CI, 0.09-0.88; p = .003 and OR, 0.26; 95% CI, 0.08-0.93; p = .017, respectively). CONCLUSIONS: It was concluded that the duration of catheterization should be shortened; that the intravascular catheter, which is inserted in urgent situations, should be removed as soon as possible; and that maximal sterile barrier precautions should be taken and due attention should be paid to hand hygiene.

Occult anterior skull base defect without rhinorrhea as a cause of recurrent meningitis.

BACKGROUND: We present a case of recurrent meningitis in a patient with an occult skull base defect and without clinically or radiologically demonstrable rhinorrhea. CASE DESCRIPTION: A 34-year-old female patient presented with headache, fever, and cervical pain and was diagnosed with acute purulent meningitis. Her medical history revealed another meningitis episode following an upper respiratory tract infection 4 years before. She did not have any rhinorrhea complaint. Nasal endoscopy and computerized tomography with metrizamide failed to demonstrate any subclinical rhinorrhea. However, a bony defect in the cribriform plate and a submucosal nasoseptal collection of cerebrospinal fluid behind an intact septal nasal mucosa were detected in computerized tomography and magnetic resonance imaging studies. An endoscopic repair of the defect at the anterior cranial fossa was performed with a composite middle turbinate graft. CONCLUSION: We suggest that even if anamnesis and radiological evaluation do not confirm rhinorrhea, dehiscence of bony roof and additional submucosal collection of fluids should be investigated in patients with recurrent meningitis.

Post-ERCP bacteremia caused by Alcaligenes xylosoxidans in a patient with pancreas cancer.

Alcaligenes xylosoxidans is an aerobic, motile, oxidase and catalase positive, nonfermentative Gram negative bacillus. This bacterium has been isolated from intestine of humans and from various hospital or environmental water sources. A.xylosoxidans is both waterborne and results from the poor-hygienic conditions healthcare workers are in. In this case report, the bacteremia which appeared in a patient with pancreas cancer after ERCP was described.

[Liver abscess and infective endocarditis cases caused by Ruminococcus productus]. / Ruminococcus productus'un etken oldugu karaciger apsesi ve enfektif endokardit olgulari.

The genus Ruminococcus which are anaerobe Gram positive cocci, previously classified as Peptostreptococcus, may colonize the upper respiratory tract, gastrointestinal tract, vagina and skin of humans and animals. In this report a case of liver abscess and a case of infective endocarditis caused by Ruminoccocus productus, which is very rarely encountered in the clinical practice were presented. The first case was a 32 years old male who was admitted to the hospital in 2002, with the complaints of fever lasting for 20 days and pain while breathing. The abdominal ultrasonography revealed the presence of a liver abscess, and the drainage material from the abscess yielded Ruminococcus productus, identified in BACTEC 9200 (Becton Dickinson, Sparks, Md) anaerobe system. As the isolate was found to be sensitive to penicilin, the empirical gentamicin and ampicillin/sulbactam therapy was continued. The second case was a 25 years old male who was admitted to the hospital in 2005, with the signs of fever lasting for 3-4 months, chills, bone and joint pains. As multiple vegetations were detected in echocardiography, blood cultures were collected and empirical therapy with ceftriaxone and gentamicin was initiated with the preliminary diagnosis of infective endocarditis. Bacteria which were isolated from blood cultures by BACTEC 9200 system have been identified as R. productus. As this strain was also sensitive to penicillin, the empirical therapy was changed to penicilin and gentamicin. These two cases indicated that R. productus should be considered in complicated infections even if it is a rarely isolated species from the clinical samples.

Emergence of rifampicin resistance in methicillin-resistant Staphylococcus aureus isolated at a Turkish university hospital.

Twenty-three rifampicin-resistant methicillin-resistant Staphylococcus aureus (MRSA) isolated in three wards at a university hospital in Turkey between June, 2000, and February, 2001, were studied for their genetic relatedness using a combination of antibiogram, coagulase serotyping, coagulase gene polymorphism (coa-RFLP), and pulsed-field gel electrophoresis (PFGE). They all expressed high-level rifampicin resistance (MIC, >256 mg/L) and were resistant to gentamicin, kanamycin, amikacin, ciprofloxacin, tetracycline, and cadmium acetate and were susceptible to fusidic acid, vancomycin, trimethoprim, and mupirocin. They belonged to the same coagulase serotype (serotype IV) and had identical coa-RFLP patterns. In contrast, PFGE generated nine banding patterns designated type A, types A1-A5, B, C, and D. The most common PFGE pattern (type A) and its subtypes (types A1-A5) were seen in 20 (87%) of the 23 isolates in the three wards. The results demonstrated the acquisition of rifampicin resistance by different MRSA clones and the spread of one clone among patients in the three wards.

The influence of G-CSF addition to antibiotic treatment of experimental sepsis on pulmonary tissue.

AIM: To investigate the effects of G-CSF addition to antibiotic treatment of experimental sepsis on pulmonary lung tissue. MATERIALS AND METHODS: Fifty Sprague-Dawley rats were used. The first four groups received a bolus intraperitoneal injection of Pseudomonas aeruginosa. The first group (Group SAG) received a combined therapy of imipenem and G-CSF, the second group (Group SA) received only imipenem, the third group (Group SG) received only G-CSF, and no antibiotic or G-CSF was given to the fourth group (Group S). The fifth group (Group C) served as the control. Survival rates, peripheral leukocyte counts (PLC) and absolute neutrophil counts (ANC) were obtained, and lung tissues were examined under light microscopy. RESULTS: Survival rates at the 120th hour were 100% in groups SAG, SA and C; 20% in group SG; and 0% in group S. PLC and ANC values reached their highest levels at the 36th hour in the SAG group and at the 60th hour in the SA group. Pulmonary architecture was better preserved in the SAG, SA and SG groups--in that order--than in the S group. CONCLUSION: Particularly in the early phase of infection, the administration of G-CSF in combination with antibiotics would be appropriate for maximizing the effect of antibiotics as soon as possible and for minimizing the damage caused by inflammation.

[Prospective evaluation of blood cultures in Medical Faculty Hospital of Blacksea Technical University]. / Karadeniz TEKNIK Universitesi Tip Fakültesi hastanesinde kan kültürlerinin prospektif olarak degerlendirilmesi.

In this study, the rate of blood culture contamination, bacterial pathogens and their antimicrobial susceptibilities causing nosocomial and community acquired bloodstream infections were investigated prospectively during the period February 2003 to February 2004. In the study period, among the 5994 blood culture samples obtained from 3114 patients, 1091 (18%) yielded positive results. Seventy-four of them (1.2%) were evaluated as false positive, 514 (9%) were pseudobacteremia or contamination. According to patients' clinical features, 503 (8%) blood culture samples were associated with blood stream infections, and 358 of them (71%) were primary episodes. Twohundred and ninetyfour of primary episodes (82%) were hospital acquired and 64 were community acquired bloodstream infections. Staphylococcus aureus was the most frequently isolated agent in the hospital and community acquired bloodstream infections at the rates of 16% and 20%, respectively. In hospital acquired blood stream infections, Escherichia coil (9%) and Pseudomonas aeruginosa (8%); in community acquired bloodstream infections Streptococcus spp (17%) and E. coli (15%) were the other most frequently isolated bacterial agents. Methicillin resistance of S. aureus isolates was determined as 54% in hospital acquired blood stream infections and 25% in community acquired blood stream infections.

A national survey of surgical antibiotic prophylaxis in Turkey.

OBJECTIVE: To assess the quality of antibiotic prophylaxis for clean and clean-contaminated elective surgical procedures. DESIGN: A cross-sectional, country-wide survey. SETTING: Thirty-six hospitals in 12 cities in Turkey. PARTICIPANTS: Four hundred thirty-nine surgeons from 6 different specialties who performed selected procedures of interest. METHODS: A random sample of surgeons from different hospitals was selected. A standardized data collection form was used to record the type of procedure, the names, doses, timing of the first doses, and duration of antibiotics, important decisive factors, and problems in the management of prophylactic antibiotic use for surgical procedures. RESULTS: Fifty-five percent of surgeons addressed completed the survey. For clean-contaminated procedures, 6% of surgeons did not use antibiotic prophylaxis, whereas 88% used more than a single dose. Inappropriate antibiotics were chosen for 32% of procedures. In 39% of procedures, the first dose of antibiotics was not administered during induction of anesthesia. Duration of prophylaxis was longer than 24 hours in 80% and longer than 48 hours in 46% of all procedures. Only 112 surgeons (26%) were using definitely appropriate prophylaxis in all ways. Multivariate analysis revealed that surgeons in university hospitals (OR, 2.353; CI95, 1.426-3.884; P = .001) and general surgeons (OR, 4.986; CI95, 2.890-8.604; P < .001) used antibiotic prophylaxis more appropriately. Patients not covered by health insurance (OR, 0.417; CI95 0.225-0.772; P < .001) were associated with inappropriate prophylaxis. CONCLUSION: Given the high frequency of antibiotics prescribed for surgical prophylaxis in Turkey, adherence to surgical prophylaxis guidelines is urgently needed.

Investigation of atypical bacteria and virus antigens in respiratory tract infections by use of an immunofluorescence method.

In this study an immunofluorescence (IF) method was used to investigate the antigens of viruses and atypical bacteria in respiratory tract infections (RTI) in pediatric and adult age groups. In this prospective study of 2 years (1998-2000), IF was used to investigate the antigens of 7 viral and 3 atypical bacteria to be used for the etiological diagnosis of RTI. Sputum (33.6%) and nasopharyngeal aspirate specimens were obtained from pediatric patients (Group I, 76 cases) and adults (Group II, 135 cases) with RTI symptoms. Antigen detection rates were found to be 44.7% in Group I and 67.4% in Group II (P < 0.05). The following rates for specific antigens in Groups I and II, respectively, were as follows: Chlamydia pneumoniae, 17.1 and 13.3% (P > 0.05); Mycoplasma pneumoniae, 0 and 9.6% (P < 0.05); influenza A virus, 3.9 and 16.3% (P < 0.05); adenovirus, 3.9 and 14.8% (P < 0.05); parainfluenza virus type 1, 5.3 and 7.4% (P > 0.05); respiratory syncytial virus, 9.2 and 1.5% (P < 0.05); parainfluenza virus type 2, 3.9 and 3%(P > 0.05); and influenza B virus, 1.3 and 1.5% (P > 0.05). Mixed agents were found at a rate of 2.6 and 3.7% (P > 0.05) in Groups I and II, respectively. Parainfluenza virus type 3 and Legionella pneumophila antigens were not found. Since detecting etiological agents provides an important guide for determining the most appropriate antibiotic therapy, this IF method could be applied in clinical practice for arriving at a correct diagnosis and administration of effective treatment.

An epidemiological analysis of Stenotrophomonas maltophilia strains in a university hospital.

The aim of this investigation was to evaluate the epidemiology of Stenotrophomonas maltophilia in a university hospital of Turkey. From June 2000 to December 2001, S. maltophilia strains were collected, clinical presentations were noted, and MIC determinations were performed by means of E-test. Enterobacterial repetitive intergenic consensus sequences-PCR (ERIC-PCR) was used for molecular typing of the strains. Forty-four strains of S. maltophilia were isolated from 41 hospitalized patients in a teaching hospital. The majority of specimens were from the blood and respiratory tract. Antimicrobial sensitivities of these strains were as follows: 97.7 % trimethoprim-sulfamethoxazole, 15.9% ticarcillin, and 95.4% ticarcillin- clavulanate. The strains were evaluated using the ERIC-PCR method. It was of interest to note that epidemiological typing revealed three small outbreaks that were caused by a total of 12 strains. The remaining isolates generated singular DNA patterns. DNA amplification was possible in 38 isolates and yielded 26 different patterns in a period of 20 months, leading to the suggestion that commensal bacteria becomes selected in the presence of a suitable host.

The efficacy of ribavirin in the treatment of Crimean-Congo hemorrhagic fever in Eastern Black Sea region in Turkey.

BACKGROUND: The efficiency of ribavirin for treatment of Crimean-Congo hemorrhagic fever (CCHF) is unknown. In the literature, prospective randomized studies investigating the efficacy of ribavirin are not found. OBJECTIVES: To investigate the efficacy of ribavirin in treatment of patients with CCHF. STUDY DESIGN: In this prospective randomized cohort study 136 cases were included between June 2004 and August 2007. The diagnosis was confirmed in the CCHF reference laboratory of Refik Saydam National Hygiene Central Institute of the Turkish Ministry of Health. Patients either received ribavirin plus supportive treatment (Group A) (n=64) or only supportive treatment (Group B) (n=72). For the evaluation of efficacy of ribavirin, various parameters were compared between Group A and Group B. RESULTS: As well as the similarity of demographic features between the two groups, there were no statistical differences in incubation time; hospitalization time; patients requiring platelet replacement therapy; the time taken for platelet levels to return to normal levels and mortality. In Group B, the rate of tick contact was higher (p=0.03). In Group A, leukocyte levels took longer to return to the normal levels (p=0.02). CONCLUSION: In our study, there was no positive effect determined on clinical or laboratory parameters in CCHF patients treated with ribavirin, also it was observed that leukocyte levels took longer to return to normal (p=0.02) and, while not statistically significant, the longer period of hospitalization (p=0.09) needed was observed as a negative effect. Because of these reasons, it is thought that the use of ribavirin makes no significant contribution to the prognosis of the CCHF disease.

Characteristics and analysis of risk factors for mortality in infective endocarditis.

OBJECTIVE: The aim of our study was to establish the etiology of and risk factors for infective endocarditis (IE) and determine the prognostic factors for adverse outcome during hospital admission in a Turkish population. MATERIAL AND METHODS: Between January 2002 and January 2004, the clinical and laboratory features of 112 consecutive adult patients (>18 years) with diagnosis of IE who were referred to the infectious diseases clinics/departments of 17 teaching hospitals in Turkey were evaluated. Cases of IE were defined according to the modified Duke Criteria. Mortality was defined as death occurring within 30 days or during hospital stay period. Univariate and multivariate analyses were performed to predict the factors related to fatal outcome. RESULTS: A total of 112 consecutive patients presented with 101 definite and 11 probable IE episodes were defined according to the modified Duke Criteria. The mean age was 45.2+/-19.9. Fifty percent of the patients were male. Ninety (60.4%) of the 112 patients had risk factors for IE and 48 (42.9%) of them had >or=2 risk factors. On the other hand, 49.1% of patients had cardiac risk factors. Blood cultures were positive in 94 (83.9%) cases. Staphylococci were the most common agents (50.0%), followed by streptococci (28.7%) and enterococci (16.0%). Native cardiac valves were detected in 93 (83%) of the episodes of suspected IE. Valvular involvement was present in 103 (92%) patients; the mitral valve, alone or in combination with other valves, was affected in 70 (62.5%) of the patients. Echocardiography detected vegetations in 105 patients (93.8%). The mortality rate was 28.6%. Three factors were independently associated with mortality: haemodialysis OR: 14.5 (95% CI: 1.5-138.2), mobile vegetation OR: 4.8 (95% CI: 1.5-15.4) and mental alteration OR: 4.1 (95% CI: 1.1-15.6). CONCLUSION: Mortality is still high in IE. Our data indicate that patients with altered mental status, mobile vegetation, or on haemodialysis had poorer prognosis.

The effect of a restriction policy on the antimicrobial consumption in Turkey: a country-wide study.

BACKGROUND: The total annual expenditure of antimicrobials in Turkey in 2002 was 24% of all drug spending. In order to reduce the cost of drug expenditure, the Turkish government introduced a new restriction policy on the prescription of antimicrobials in June 2003. This new policy is based on the justification that the physicians specializing in infectious diseases should be primarily responsible for the prescription of antimicrobials. OBJECTIVES: Compare and contrast the usage of antimicrobials at hospitals before and after the implementation of the new restriction policy. METHODS: The data was collected from the same departments in two different periods in 2003 at 15 hospitals throughout Turkey. The first set of data was collected a few days before the new policy was implemented in May 2003 and the second data set 6 months after that. Antimicrobial usage was calculated as defined daily doses (DDDs) per 100 patient days according to ATC-DDD index. The change in antimicrobial consumption was determined by comparing the mean DDD values before and after the implementation of the new policy. RESULTS: Before the intervention, the mean antimicrobial use density was 71.56 DDD/100 patients-day at the hospitals in the study. Six months after the implementation, the mean antimicrobial use density was 52.64 DDD/100 patients-day. There was a 26.4% decrease in the antimicrobial usage between that prior to and that after the intervention (P < 0.025). CONCLUSIONS: The study shows that the implementation of the new policy resulted in a significant reduction in the prescription of antimicrobials.

Oropharyngeal tuberculosis causing severe odynophagia and dysphagia.

Oropharyngeal tuberculosis is a rare disease and is usually secondary to laryngeal involvement in pulmonary tuberculosis. The major symptom in such patients is sore throat. Here, we report a case of tuberculosis of the posterior oropharyngeal wall without laryngeal involvement and causing severe dysphagia and odynophagia without esophageal or mediastinal involvement. The unusual presentation of extrapulmonary tuberculosis is emphasized, and its diagnosis and treatment are discussed.