Comparison of colistin-carbapenem, colistin-sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections.

The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7%): colistin-carbapenem (CC), 69 (32.2%): colistin-sulbactam (CS), and 43 (20.1%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (p = 0.97) and microbiological (p = 0.92) outcomes and 14-day survival rates (p = 0.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (p > 0.05) and also for 14-day survival (p > 0.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (p = 0.02, p = 0.0001, p = 0.0001, p = 0.02, and p = 0.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (p < 0.0001, p < 0.0001, and p = 0.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.

Molecular epidemiology of the Bacillus anthracis isolates collected throughout Turkey from 1983 to 2011.

The main perspective of this study was to determine cross-transmissions amongst anthrax cases and provide detailed information regarding the genotypes of Bacillus anthracis isolates circulating in Turkey. A total of 251 B. anthracis isolates were obtained from human (93 isolates), animal (155 isolates), and environmental (three isolates) samples in various provinces of Turkey. All isolates were susceptible to quinolones, vancomycin, tigecycline, and linezolid, but not to ceftriaxone. Excluding human isolates, one of the animal isolates was found to be resistant to penicillin, erythromycin, and doxycycline. Multiple-locus variable-number tandem repeats analysis including 8 loci (MLVA8) revealed 12 genotypes, in which genotype 43 was observed at the highest frequency (41.8 %), followed by genotype 35 (25.5 %) and genotype 27 (10.4 %). Major subtype A3.a was the predominant cluster, including 86.8 % of the isolates. The MLVA25 analysis for the 251 isolates yielded 62 different genotypes, 33 of which had only one isolate, while the remaining 29 genotypes had 2 to 43 isolates, with a total of 218 isolates (86.9 %). These findings indicate very high cross-transmission rates within anthrax cases in Turkey. The genotypes diagnosed in Turkey are populated in the A major cluster. Penicillin prescribed as the first-choice antibiotic for the treatment of anthrax is still effective.

Naturally occurring cutaneous anthrax: antibiotic treatment and outcome.

OBJECTIVES: Cutaneous anthrax (CA) is the most common clinical presentation in human anthrax, but the duration of antibiotic therapy in naturally occurring CA is controversial. The aim of this study was to compare the clinical outcomes of patients receiving antibiotic treatment for either 3-5 days (group 1) or 7-10 days (group 2) in uncomplicated CA. METHODS: A total of 66 patients were enrolled; 29 (44%) in group 1 and 37 (56%) in group 2. Infections were classified as mild (n = 22, 33%) or severe (n = 44, 67%) CA. RESULTS: There were no significant differences between the groups in symptom resolution time, fever clearance time, healing of lesions, development and healing of eschars, requirement for surgical intervention or the development of complications. Both edema resolution time and duration of hospital stay were longer in group 2. There were no therapeutic failures, relapses or deaths in either group. Steroid therapy was used in 32% of patients with severe CA, but a beneficial effect on resolution of edema was not demonstrated. CONCLUSIONS: These results suggest that short-course antibiotic therapy is as effective as standard-duration therapy in uncomplicated CA and that steroid therapy may not be effective.

Evaluation of children with neurobrucellosis.

BACKGROUND: Brucellosis is an endemic disease in many areas throughout the world. Central nervous system involvement is a serious complication of brucellosis with a ratio of 4-11% of all patients. AIM: to describe our experience in diagnosis, treatment, and outcome of 25 pediatric patients with neurobrucellosis. PATIENTS AND METHODS: This study included a review of medical records of patients who were diagnosed with neurobrucellosis between March 2001 and March 2009. Patients who had both clinical findings consistent with neurobrucellosis and positive microbiologic/serologic examinations of CSF with abnormal CSF findings were enrolled in the study. RESULTS: The study included 25 patients between 1 and 15 years of age (mean 8.8 years), while 15 were males and 10 were females. Most of the patients (52 %) were in the age group of 5-9 years with male predominance. The distribution of cases showed density in June and February. The most commonly presented complaints were headache, fever and sweating while the most commonly observed findings were fever and meningeal irritation signs. All patients had positive cerebrospinal fluid agglutination test for brucellosis. Four different regimens were used based on ceftriaxone, doxycycline, cotrimoxasole, streptomycin, and rifampicin. One patient died, three patients were discharged with sequel, and the remaining patients (84 %) were discharged with full recovery. CONCLUSION: Clinicians, especially those providing health services in endemic areas like Turkey, should keep in mind that neurobrucellosis can be involved in patients with unexplained symptoms like memory impairment or in patients diagnosed with meningitis (Tab. 5, Fig, 2, Ref. 39).

Maternal and fetal outcomes of COVID-19, SARS, and MERS: a narrative review on the current knowledge.

OBJECTIVE: Coronavirus infections, including SARS, MERS and COVID-19 have significant impact on global health as well as on pregnancies. The aim of this review was to enlighten and summarize the cumulative knowledge regarding the relationship between Coronavirus outbreaks and pregnancy. MATERIALS AND METHODS: Literature search was commenced in order to analyze the maternofetal effects of Coronavirus outbreaks. RESULTS: Fever and cough are the most common presenting symptoms of COVID-19 which mostly affects pregnant women in their 3rd trimester with a maternal mortality rate of  0-77%  and fetal and neonatal mortality rates of 1.2%. Fetal demise is common in critically ill pregnant. Pregnancy seems as a worsening factor for SARS and MERS epidemics and both infections affect prominently 3rd trimester pregnancies, although abortion (57%) is a significant risk for cases of early pregnancy. Clinical course of COVID-19, SARS and MERS may be rapid and worse in pregnant women than non-pregnant individuals. Cesarean section is the choice of delivery in most reported women due to mostly obstetrical reasons, although vaginal delivery seems not a worsening factor for the disease. CONCLUSIONS: COVID-19, SARS and MERS have significant detrimental effect on pregnancy. Rapid intervention, treatment, and intensive care support are essential for infected pregnant. Timely delivery is important in order to avoid intrauterine fetal death.

Cutaneous anthrax in Eastern Turkey: a review of 85 cases.

BACKGROUND: Anthrax is a zoonotic disease diminishing worldwide. Although a very rare disease in developed countries, anthrax is still endemic in developing countries. AIM: To evaluate the clinical history and features, treatment and outcome of our patients with anthrax and emphasize the importance of the disease in our region. METHOD: In this study, the records of all patients diagnosed with cutaneous anthrax admitted to Yüzüncü Yil University Medical Faculty between March 2002 and March 2007, were reviewed, and data on age, gender, occupation, clinical symptoms and findings, location and type of lesions, clinical history, laboratory findings, treatment and outcome were recorded. RESULTS: There were 85 patients [46 (54.1%) male, 39 (45.9%) female; mean age 30.6 years, range 6-72]. All the patients had a history of contact with infected animals or animal products. The infectious agent was found using direct examination of Gram-stained smears from 17 patients (20%), and Bacillus anthracis was isolated from vesicle fluid cultures from 11 patients (12.9%). Diagnosis was based on clinical findings in the remaining 57 patients (67.1%). All patients, except for two with respiratory tract obstruction, made a full recovery. CONCLUSION: Anthrax continues to be an endemic disease in Turkey, and should be considered in patients with a relevant contact history having a painless ulcer and vesicular skin lesions surrounded by a zone of oedema. Gram staining and simple culture methods are useful aids to diagnosis, but diagnosis may have to be based on clinical grounds in the majority of patients.

[A case of brucellosis presenting as high titer negative result by standard tube agglutination test]. / Standart tüp aglütnasyon testinde yüksek titrede negatiflik saptanan bir bruselloz olgusu.

Since prozone is a well known phenomenon in the serologic diagnosis of Brucella infections, it is necessary to prepare higher serum dilutions in the standard tube agglutination (STA) test for the brucellosis suspected patients. However, due to limited economical support, the serum dilutions generally last at 1/320-1/640 titers in some laboratories in Turkey. In this report, a brucellosis case whose STA test was found negative until the titer of 1/1280, has been presented. A 36-year-old female was admitted to our hospital with the complaints of fever, sweating, fatigue, generalized arthralgia and weight loss, lasting for 45 days. Hepatosplenomegaly was detected in the physical examination, and laboratory tests yielded anemia, leucopenia, elevated erythrocyte sedimentation rate and high C-reactive protein levels. Although brucellosis was suspected, Brucella STA test was found negative at 1/640 titer. On the sixth day of admission, Brucella melitensis was isolated from her blood culture. Since a positive result at 1/40 titer was detected in Brucella STA test with the use of Coombs antiserum, the patient's serum was retested at higher dilutions than 1/640, and positive result was obtained starting from 1/1280 dilution and extended to 1/5120 titer. The patient was treated with rifampin and doxycyline and discharged with complete cure. In conclusion, in countries endemic for brucellosis, STA test should be performed at 1/1280 or higher titrations in suspected patients especially in the presence of negative culture results, for the prevention of false negative results due to prozone phenomenon.

[Antibiotic resistance rates of Shigella species isolated from stool cultures in the years 1999-2003]. / Diski kültürlerinden 1999-2003 yillari arasinda izole edilen Shigella türleri ve antibiyotiklere direnç oranlari.

In this study, species distribution, seasonal isolation rates and antibiotic susceptibilitiy patterns of 115 Shigella spp, isolated from 5396 stool samples in our microbiology laboratory between 1999 and 2003, were investigated. Of the isolates, 96 (83.5%) were S. sonnei, 15 (13%) were S. flexneri, 3 (2.6%) were S. dysenteriae and 1 (1.9%) was S. boydii. Maximum isolation rates were observed at summer and fall seasons, especially in August, September and November (24%, 40%, 17%, respectively). The resistance rates against trimetoprime-sulphametoxasole and ampicillin were 79.1% and 19.1%, respectively. The rate of co-resistance against these two drugs was 12.2 percent. No isolate was found to be resistant to ciprofloxacin. Only one S. sonnei isolate had extended spectrum beta-lactamase detected by double-disk synergy test. In conclusion, ciprofloxacin is the drug of choice for empirical treatment of shigellosis. However, to avoid the loss of this choice, ampicillin which still has an high effectivity rate, should be preferred for the treatment of shigellosis with the guidence of antibiogram results. On the other hand, emergence of ESBL production among Shigella spp. after Salmonella spp. should warn us about the unexpected results of inappropriate antibiotic therapy.

[Short communication: prevalence of extended spectrum beta-lactamases in gram negative rods: data of 2001-2004 period]. / Kisa bildiri: gram negatif çomaklarda genis spektrumlu beta-laktamaz sikligi: 2001-2004 yili verileri.

This study was undertaken to determine the prevalence of extended spectrum beta-lactamase (ESBL) production by Gram negative rods (GNRs) isolated from various clinical specimens (3.240 urine, 336 pus, 277 feces, 83 blood, 38 sputum) sent to our hospital laboratory, between 2001-2004. Of isolated bacteria 71.4% were identified as Escherichia coli, 11.1% were Klebsiella spp, 4.2% were Salmonella spp, 3.7% were Pseudomonas spp, 3.5% were Proteus spp, 2.9% were Shigella spp, 2.3% were Enterobacter spp, 0.5% were Acinetobacter spp, 0.12% of each Serratia spp, and Stenotrophomonas maltophilia, 0.1% were Citrobacter spp, and one of each Providencia spp and Pantoeae spp. (0.02%). ESBL production were screened by using the double disk synergy test. Of a total of 3.974 isolates, 269 (6.8%) were found to be ESBL producers. Klebsiella spp had the highest rate (14.3%) which was followed by Enterobacter spp (8.6%) and E.coli (6.7%). All of the S.maltophilia isolates were resistant to carbapenems. One of the Shigella spp was found to be an ESBL producer, being the first case from Turkey and the fifth from the world. There was statistically significant difference in distribution of ESBL producing isolates between hospitalized (16%) and non-hospitalized patients (5%) (p<0.01). A significant increase in ESBL production rates (from 3.8% in 2001 to 10.6% in 2004) was observed over time (p<0.05). The increasing trend (about 300% in four years) in ESBL production rates, should be considered as an indicator for expansion propensity and speed of the threat against the effective treatment of infections, and possible preventive strategies should be established.

Diagnosis of chronic brucellar meningitis and meningoencephalitis: the results of the Istanbul-2 study.

No detailed data exist in the literature on the accurate diagnosis of chronic brucellar meningitis or meningoencephalitis. A multicentre retrospective chart review was performed at 19 health centres to determine sensitivities of the diagnostic tests. This study included 177 patients. The mean values of CSF biochemical test results were as follows: CSF protein, 330.64 ± 493.28 mg/dL; CSF/ blood-glucose ratio, 0.35 ± 0.16; CSF sodium, 140.61 ± 8.14 mMt; CSF leucocyte count, 215.99 ± 306.87. The sensitivities of the tests were as follows: serum standard tube agglutination (STA), 94%; cerebrospinal fluid (CSF) STA, 78%; serum Rose Bengal test (RBT), 96%; CSF RBT, 71%; automated blood culture, 37%; automated CSF culture, 25%; conventional CSF culture, 9%. The clinician should use every possible means to diagnose chronic neurobrucellosis. The high seropositivitiy in brucellar blood tests must facilitate the use of blood serology. Although STA should be preferred over RBT in CSF in probable neurobrucellosis other than the acute form of the disease, RBT is not as weak as expected. Moreover, automated culture systems should be applied when CSF culture is needed.

A brucellosis case presenting with mass formation suggestive for tumor in soft tissue.

We report here a 70-year-old female patient who was diagnosed with brucellosis and presented with mass formation resembling a tumor. The mass was protuberant, 10 cm from the skin surface with a diameter of 15 cm, located at the inferior-lateral region of the left scapula. Brucella melitensis was yielded from culture of mass fluid. The patient responded to ceftriaxone, rifampin and doxycycline therapy and recovered without any sequela at the end of surgery and 3 months of medical treatment.

Comparison of intramuscular and intradermal applications of hepatitis B vaccine in hemodialysis patients.

This study compared the application of intramuscular recombinant hepatitis B vaccine in hemodialysis patients with the application of accelerated intradermal recombinant hepatitis B vaccine, which can be applied with one-tenth of the standard dose. Sixty seronegative patients for hepatitis B were randomly separated into two groups. Twenty mug of the recombinant hepatitis B vaccine was intramuscularly applied at 0-, 1-, 2-, and 6-month intervals to the first group (32 cases). One more dose was applied at month 12 to those whose anti-HBs titers remained below 100 mIU/mL at month 7. The same vaccine was intradermally applied at 2 microg dose six times with one-month intervals to the second group (28 cases). Vaccine applications were continued in those whose anti-HBs titers remained below 100 mIU/mL at month 7 until antibody titers reached above this value or until the dose number became 12. Measurements of antibody titers were repeated at month 13 in both groups. As a result, in the vaccination of hemodialysis patients against hepatitis B, the accelerated ID application of hepatitis B vaccine with a dose reduced to one-tenth is more cost-effective than the standard dose vaccination schedules. Especially for hemodialysis patients, the time has come for routine application of ID hepatitis B vaccine as an alternative vaccination method.