Risk factors associated with fluconazole resistance in Candida parapsilosis candidemia: A case-case study.

BACKGROUND: Candida species are among the most important invasive pathogens in intensive care units (ICUs). Non-albicans species including Candida parapsilosis (C. parapsilosis) has increased in recent years. Fluconazole is the leading antifungal agent but resistance is a concern among C. parapsilosis species. OBJECTIVES: The aim of this study was to determine the factors associated with fluconazole resistance in patients with candidemia due to C. parapsilosis in ICUs. METHODS: This case-case study was conducted in a 750-bed, tertiary hospital between 2015 and 2021. Patients with fluconazole-resistant C. parapsilosis candidemia constituted the 'cases of interest' group and patients with fluconazole-susceptible C. parapsilosis candidemia constituted the 'comparison cases' group. Demographic and clinical data of the patients were recorded. Logistic regression analysis was performed using the backward elimination method to determine the independent predictors of fluconazole-resistant C. parapsilosis bloodstream infections. RESULTS: The study included 177 patients. In the cultures of these patients, 76 (43%) fluconazole-resistant, 13 (7.3%) fluconazole-reduced susceptible, and 88 (49.7%) fluconazole-susceptible isolates were found. In the regression analysis the risk factors for fluconazole-resistant C. parapsilosis bloodstream infection, malignancy, immunosuppressive treatment, history of intra-abdominal surgery, hypoalbunemia, previous fluconazole use, and SOFA score were found to be associated in univariate analysis. In multivariate regression analysis, history of intra-abdominal surgery (OR: 2.16; 95% CI: 1.05-4.44), hypoalbuminemia (OR: 2.56; 95% CI: 1.06-6.17) and previous fluconazole use (OR: 3.35; 95% CI: 1.02-11) were found to be independent predictors. CONCLUSIONS: In this study, a significant correlation was found between candidemia due to fluconazole-resistant C. parapsilosis in ICUs and intra-abdominal surgery, hypoalbuminemia, and previous fluconazole use. C. parapsilosis isolates and fluconazole resistance should be continuously monitored, strict infection control measures should be taken and antifungal stewardship programs should be implemented.

Evaluation of Depression, Anxiety, and Sleep Quality in Children Diagnosed With COVID-19.

ABSTRACT: COVID-19 has affected individuals of all age groups, both physically and mentally. We aimed to determine anxiety and depression in children diagnosed with COVID-19. Fifty children aged 8 to 18 years diagnosed with COVID-19 were included in the study. The children were evaluated the revised Child Anxiety and Depression Scale, STAI form TX-I (state anxiety inventory), and STAI form TX-II (trait anxiety inventory). Child Sleep Habits Questionnaire was applied for one of the parents according to three different periods. The periods were established as before the pandemic, during the illness-quarantine process, and after the quarantine. We observed the highest scores for depression-anxiety and the poorest sleep quality during the quarantine period. The scores for depression-anxiety were lower, and sleep quality scores were higher in the prepandemic period compared with after the quarantine period. Measures should be taken to protect mental health for children with COVID-19.

Comparison of Maternal, Perinatal, and Neonatal Outcomes of Asymptomatic and Symptomatic Pregnant Women with Coronavirus Disease-2019.

Objective: This study aimed to compare the postpartum outcomes of asymptomatic and symptomatic patients with coronavirus disease-2019 (COVID-19). Methods: This retrospective cohort study included pregnant women with COVID-19. Pregnant women were categorized into two sets as asymptomatic and symptomatic according to their clinics at the time of application. COVID-19 was diagnosed using the real-time reverse transcriptase-polymerase chain reaction on the oropharyngeal and nasopharyngeal swabs. Asymptomatic and symptomatic patients were compared in terms of maternal and perinatal outcomes. Results: Our study population consisted of 20 asymptomatic and 41 symptomatic patients with laboratory-confirmed COVID-19. The rate of primary cesarean section was more than twice in the symptomatic group (51.2%) than that of the asymptomatic group (20%) (p=0.019). Both groups are quite similar in terms of maternal [respiratory support, COVID-19- related treatment, and intensive care unit (ICU) admission], perinatal (preterm delivery, preterm premature rupture of membrane, preeclampsia, and mode of delivery), and neonatal outcomes [birth weight, Apgar scores, neonatal ICU (NICU) admission]. The rate of total cesarean section in the asymptomatic group (75%) was statistically similar to the symptomatic group (83%) (p=0.464). The NICU admission rate was found to be similar in the asymptomatic (54.2%) and symptomatic groups (50%) (p=0.858). However, NICU admissions were more frequent in the symptomatic group due to respiratory distress (p=0.032). The breastfeeding rate is higher in the asymptomatic pregnant group as expected (p=0.015). Additionally, the ferritin level was significantly lower in the asymptomatic group (p=0.006). Conclusions: The rate of primary cesarean section is quite high in symptomatic patients with COVID-19. Additionally, the total cesarean section rate was extremely high in both groups. We expected more adverse outcomes in symptomatic patients; however, we found similar maternal, perinatal, and neonatal outcomes between both groups.

Nasopharyngeal carriage of Streptococcus pneumoniae in healthy children aged less than five years.

PURPOSE: In Turkey, pneumococcal conjugate vaccine (PCV) was introduced to the national immunization program as PCV7 in 2008, and was replaced with PCV13 in 2011. The aim of the study was to demonstrate the pneumococcal carriage rate and the serotype distribution in healthy children under 5 years in Turkey who were vaccinated with PCV13. METHODS: We conducted a cross-sectional study including the collection of questionnaire data and nasopharyngeal (NP) specimens among children aged <5 years from five centers from March 2019 to March 2020. Pneumococcal isolates were identified using optochin sensitivity and bile solubility. Serotyping was performed using a latex agglutination kit and Quellung reaction. RESULTS: NP swab samples were collected from 580 healthy children. The observed overall carriage rate was 17.8%. None of the hypothesised predictors of S. pneumoniae carriage, except maternal education level was statistically significant (p = 0.017). High maternal education level appeared to decrease the risk (lower vs. higher maternal education OR: 1.992 [95% CI; 1.089-3.643], p = 0.025). The overall NP S. pneumoniae carriage prevalence for the PCV13-vaccinated children was 17.8% (103/580). The most common serotypes detected were serotype 15B (n = 10, 9.7%), serotype 23F (n = 9, 8.7%), serotype 23A (n = 9, 8.7%), serotype 11A (n = 7, 6.7%), serotype 19F (n = 5, 4.8%) and serotype 15F (n = 5, 4.8%). Of the isolates, 28 (27.2%) were in PCV13 vaccine strains (VSs), and 75 (72.8%) strains were non-VS. The serotype coverage rate was 27.2% for PCV13. CONCLUSION: The overall S. pneumoniae carriage rate was higher than in earlier studies from Turkey. Post-vaccine era studies from around the world have reported a decrease in VS serotypes and a 'serotype replacement' to non-VS serotypes, as we determined in our study.

Seroprevalence of Toxoplasma gondii, Rubella virus and Cytomegalovirus among pregnant women and the importance of avidity assays.

OBJECTIVES: To determine the seroprevalence of Toxoplasma gondii (T. gondii), Rubella virus, and Cytomegalovirus (CMV) among pregnant women in Izmir, Turkey. METHODS: Medical records of pregnant women attending Izmir Tepecik Training and Research Hospital, Izmir, Turkey between January 2014 and January 2016 were analyzed in this retrospective cross-sectional study. The 7513 T. gondii IgM/IgG results, 7189 Rubella IgM/IgG results, 906 CMV IgM/IgG results and 146 avidity test results were evaluated. Specific IgM and IgG antibodies were detected by an automated chemiluminescent enzyme immunoassay method. Immunoglobulin G avidity tests were performed using a multiparametric immunoassay system. RESULTS: The rates of IgG positivity for T. gondii was 32.3%, Rubella virus 93.5%, and CMV 98.9%. Immunoglobulin M antibodies were found to be positive in 138 (1.9%) cases for T. gondii, 88 (1.2%) cases for Rubella, and 14 (1.5%) cases for CMV. Avidity tests were ordered from 146 of 218 patients who were found both IgM and IgG positive. Among 146 patients, 6 patients had a low avidity index (all for T. gondii), 11 patients showed borderline avidity, and 129 patients revealed high avidity. CONCLUSION: In our region, whereas the rates of IgG positivity for Rubella and CMV are high, most pregnant women were susceptible to T. gondii infections. In order to enhance the reliability of the serological diagnosis, avidity tests should be performed in all IgM positivities detected together with IgG positivity.

Antimicrobial susceptibilities of Escherichia coli isolates as agents of community-acquired urinary tract infection (2008-2014).

OBJECTIVE: Urinary tract infections (UTIs) are among the most frequently seen community-acquired infections worldwide. E. coli causes 90% of urinary system infections. To guide the empirical therapy, the resistance pattern of E. coli responsible for community-acquired UTI was evaluated throughout a seven-year period in this study. MATERIAL AND METHODS: The urine cultures of patients with urinary tract infections admitted to outpatient clinics between 1(st) January 2008 and 31(st) December 2014 were analyzed. Presence of ≥10(5) colony-forming units/mL in urine culture media was considered as significant for UTI. Isolated bacteria were identified by standard laboratory techniques or automated system VITEK2 (BioMerieux, France) and BD PhoenixTM 100 (BD, USA), as required. Antibiotic susceptibility testing was performed by Kirby-Bauer disk diffusion method using Clinical Laboratory Standard Institute (CLSI) criteria. RESULTS: A total of 13281 uropathogens were isolated. Overall E. coli accounted for 8975 (67%) of all isolates. Resistance rates of E. coli to antimicrobial agents was demonstrated to be as follows: ampicillin 66.9%, cefazolin 30.9%, cefuroxime 30.9%, ceftazidime 14.9%, cefotaxime 28%, cefepime 12%, amoxicillin-clavulanic acid 36.9%, trimethoprim-sulfamethoxazole (TMP-SXT) 20%, ciprofloxacin 49.9%, amikacin 0.3%, gentamycin 24%, nitrofurantoin 0.9%, and fosfomycin 4.3%. There was no resistance to imipenem nor meropenem. The frequency of ESBL-producing E. coli strains was 24%. CONCLUSION: It is concluded that fosfomycin and nitrofurantoin are appropriate empirical therapy for community-acquired UTI empirical therapy, but the fluoroquinolones and the TMP-SXT shall not be used in the emprical treatment of UTI at this stage. In conclusion, as resistance rates show regional differences, it is necessary to regularly examine regional resistance rates to determine the appropriate empiric antibiotic treatment and national antibiotic usage policies must be reorganized according to data obtained from these studies.

Evaluation of the in vitro colistin susceptibility of Pseudomonas aeruginosa and Acinetobacter baumannii strains at a tertiary care centre in Western Turkey.

Multidrug-resistant gram-negative bacteria are an important issue in intensive care units worldwide. Colistin, one of the earliest polymyxin antibiotics, was once widely used for the treatment of gram-negative bacterial infections. However, its use is now limited due to concerns over nephrotoxicity. The appearance of multidrug-resistant species, including A. baumannii and P. aeruginosa, has led to the re-emergence of this class of drugs. The aim of this study was to evaluate the susceptibility of A. baumannii and P. aeruginosa isolates to colistin and other antibiotics. The antimicrobial susceptibility of A. baumannii and P. aeruginosa isolates to colistin and other antibiotics was evaluated between January 2011 and October 2012 at Tepecik Education and Research Hospital in Izmir, Turkey. Clinical isolates were identified using an automatized Vitek 2.0 system. Colistin susceptibility was measured by E-test; the susceptibility profiles of other antibiotics were evaluated using the Kirby Bauer disk-diffusion method. A total of 149 isolates were included in the study, consisting of 98 A. baumannii and 51 P. aeruginosa isolates. The MICs of colistin against A. baumannii were 0.125-2.0 mcg/mL, and 0.25-2.0 mcg/mL against P. aeruginosa; all multidrug-resistant strains examined in this study were susceptible to colistin. Recently, colistin has re-emerged as an effective treatment for infections due to multidrug-resistant A. baumannii, P. aeruginosa, and Klebsiella pneumoniae. All isolates examined in this study were susceptible to colistin, suggesting it could be a viable alternative for the treatment of infections with multidrug-resistant strains.

[Evaluation of vancomycin-resistant Enterococcus cases at a tertiary level hospital in Izmir, Turkey]. / Izmir'de Üçüncü Basamak Bir Hastanede Görülen Vankomisine Dirençli Enterokok Olgularinin Degerlendirilmesi.

Vancomycin-resistant enterocococci (VRE) are common pathogens that may lead to infection in intensive care units. VRE strains that colonize the hospital environment can stay alive for a long time on fomites and can easily be spread by the hands of hospital staff and by the instruments. The aim of this study was to evaluate the epidemic and sporadic VRE cases, following an epidemic at anesthesiology intensive care unit (ICU). The records of the patients hospitalized at anesthesiology ICU between October 2010-June 2011 were evaluated retrospectively. The hospitalized patients with VRE positive culture reports were included in this study. Rectal swab samples of the patients and environmental surveillance cultures were inoculated on sheep blood agar and enterococcosel agar media and incubated for 24-48 hours. The isolated strains were identified by conventional methods and automatized Vitek 2.0 system (BioMérieux, France). The molecular detection of VRE was performed by real-time polymerase chain reaction (Cepheid GeneXpert System, USA). A total of 19 VRE colonised or infected cases (11 male, 8 female; age range: 18-96 years, mean age: 60 years) that were detected sporadically or during the epidemic, were included in this study. Ten (52.6%) cases were evaluated as colonization (seven rectal, two urinary and one both urinary and rectal colonisation). Nine patients were considered as infected (five bacteremia, three catheter infections and one urinary tract infection). Five of the nine patients directly progressed to infection. Four of the nine patients progressed to infection after rectal colonization. Eight of the infected cases were treated with daptomycin and one case with linezolid. Five of the infected and treated cases died and the rate of mortality was determined as 55.6%. PCR was applied to the samples of eight cases and vanA was detected in seven of these. VRE were not grown in two of the PCR positive samples and one PCR positive sample did not yield VRE growth in culture. VRE were detected from the samples obtained from patients' monitors, infusion sets, bedside, bedstands and walls and the origin of VRE was thought to be environmental contamination. It was concluded that adherence to infection control guidelines and continuous education of the health-care personel were prerequisites for effective control of VRE colonization and infection in the health-care setting.

[Subacute sclerosing panencephalitis cases diagnosed by increased CSF/serum measles antibody indices]. / Yüksek BOS/Serum Kizamik Antikor Indeksi ile Tanimlanan Subakut Sklerozan Panensefalit Olgulari

Subacute sclerosing panencephalitis (SSPE) caused by persistent defective measles virus strains, is a progressive neurological disorder of children and adolescents. The aim of this letter was to share the data from SSPE-suspected cases who were definitely diagnosed by the detection of increased antibody index in serum and cerebrospinal fluid (CSF) samples. A total of 11 patients (mean age: 14.3 years) with suspected SSPE between February 2006 to August 2008, were included in the study. Simultaneously obtained serum and CSF samples from patients were analyzed in terms of albumin, total IgG and measles-specific IgG levels (Measles Virus IgG ELISA for CSF Diagnostics, Euroimmun, Germany). The value of CSQrel (relative CSF/serum quotient) ≥ 1.5 was accepted indicative for intrathecal measles antibody synthesis. Seven (63.6%) of the 11 patients' diagnosis were confirmed with the demonstration of elevated CSF/serum indices (CSQrel range: 2.3-36.9; mean: 12.9). Mean age of those seven cases was 12.3 years (age range: 7-21) and four of them were male. The history of patients with high antibody indices indicated that three of four patients who had measles infection had not been vaccinated against measles. These three unvaccinated patients had measles infection at 3rd, 8th and 30th months of age, respectively, and the period of SSPE development were 15, 6 and 4.5 years, respectively. With this letter we would like to emphasize once more that effective measles vaccination is the only way for the prevention of measles and SSPE and the demonstration of increased measles antibody index in simultaneously obtained serum and CSF samples is crucial for the diagnosis of SSPE.

The evaluation of the distribution of yeast like fungi 'Candida Species' at a tertiary care center in western Turkey.

OBJECTIVE: Candida infections have increased due to transplant patients, prolonged ICU stay and invasive procedures. The most common isolated strain is C. albicans. The aim of this study was to evaluate the distribution of Candida isolates at Tepecik Education and Research Hospital. MATERIALS AND METHODS: Yeast like fungi were isolated between 13.01.2010 and 19.08.2011 at Mycology Laboratory. The identification was done by conventional methods and carbohydrate assimilation profile using the ID32C identification system (Biomerieux, France). RESULTS: Yeast like fungi were isolated from 337 clinical specimens. They consisted of urine, blood culture, respiratory specimen and wound. The most isolated yeast strains were C.albicans (38.6%), C.tropicalis (13.9%), C. parapsilosis (28.4%), C.glabrata (7.4%), C.krusei (3.8%). CONCLUSION: Recently there is an increment in Candida infections. In this study the most common strain was C.albicans and the rate C. glabrata and C. krusei isolates were lower than expected. C. parapsilosis was the most isolated strain in blood cultures and this may be due to invasive procedures and the use of indwelling catheters.

Rotavirus and adenovirus prevalence at Tepecik education and research hospital (Turkey).

Diarrhoea affects many people globally. Rotaviruses and enteric adenovirus types 40 and 41 are the most common viruses causing childhood gastroenteritis. The aim of this study was to determine the prevalence of rotavirus and adenovirus from the faecal samples obtained at the Infectious Diseases and Clinical Microbiology Laboratory of Tepecik Education and Research Hospital. The faecal samples were screened for rotavirus, and adenovirus by commercially available immunochromatographic EIA kit (Rotavirus/Adenovirus Combo Rapid Test Device) (San Diego, CA, USA). A total of 1112 stool samples were collected from May 23rd 2008 to May 25th 2010. Of these faecal samples, 201(18.07%) were positive for rotavirus and 14 (1.2 %) for adenovirus antigen. In our study the most common agent detected was rotavirus. Viral antigen analysis in stool specimens is important for diagnosis. Detection of the viral aetiology in gastroenteritis cases will prevent unnecessary antibiotic consumption.

Clinical and microbiological evaluation of eight patients with isolated Achromobacter xylosoxidans.

Achromobacter xylosoxidans causes infections in patients with underlying disorders. The aim of this study was to evaluate Achromobacter xylosoxidans cases. Eight patients were included, 5 infections and 3 colonizations. Three of them survived and 2 died. The predisposing factor was catheter. Infection control measures could prevent infection.

Evaluation of antifungal susceptibility testing with microdilution and Etest methods of Candida blood isolates.

Candida species that show an increasing number of clinical and/or microbiological resistance to several antifungals and are the most common agents of invasive fungal infections. The aim of this study was to investigate the in vitro susceptibility of Candida blood isolates to antifungal agents (amphotericin B, fluconazole, itraconazole, and voriconazole) by comparative use of the CLSI reference microdilution method and Etest. Four hundred Candida blood isolates (215 Candida albicans, 185 non-albicans Candida strains) were included in the study. The broth microdilution test was performed according to the CLSI M27 A2 document. Etest was carried out according to the manufacturer's instructions. The MIC results obtained with reference microdilution were compared with those obtained with the Etest by using percent and categorical agreements. According to MIK(90) values, voriconazole was the most active and itraconazole was the least active drug in vitro against all Candida species. Other than voriconazole, statistically significant differences were found when the susceptibility of Candida albicans and non-albicans Candida spp. to amphotericin B, fluconazole, and itraconazole were compared. These antifungal agents were found to be more active to C. albicans. Among the non-albicans Candida species, the lowest MIC values were obtained for Candida parapsilosis isolates. When the standard method was compared with Etest, the total agreement was higher for C. albicans than for non-albicans species, especially for fluconazole and voriconazole. In view of the findings, it was concluded that itraconazole showed the lowest activity against all Candida species. Etest could be an alternative method in assessing the in vitro antifungal susceptibility of Candida spp., but it is more convenient to use the microdilution method for studying in vitro susceptibility of non-albicans species, in particular for those possessing high MIC values against azoles.

[Investigation of anti-HTLV I/II seroprevalence in healthy blood donors in Izmir region, Turkey]. / Izmir bölgesinde saglikli kan vericilerinde anti-HTLV-I/II seroprevalansinin arastirilmasi

Almost 10-20 million people in the world are thought to be infected by human deltaretroviruses, namely human T-cell lymphotropic virus (HTLV) type I and II, recently. HTLV-I is endemic in southwestern Japan, the Caribbean and sub-Saharan Africa, whereas HTLV-II is more prevalent in intravenous drug addicts, and in American indian populations, endemically. HTLV-I is mainly responsible for adult T-cell leukemia (ATL) and HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), however, HTLVII is not clearly associated with a known clinical disease. Both viruses may be transmitted by sexual contact, parenteral route, whole blood transfusion and breast-feeding. In most of the countries [USA, Canada, South America, Caribbean, Japan, Taiwan and some Europe countries (France, UK, Ireland, Sweden, Denmark, The Netherlands, Portugal, Romania, Greece)] routine screening of anti-HTLV-I/II in blood donors is mandatory, however, there is no such practice in Turkey since seroepidemiologic data on HTLVI/II infections is insufficient. In this study, the seroprevalence of HTLV-I/II in healthy blood donors admitted to the blood bank of Ege University Medical Faculty Hospital, Izmir (located at Aegean region), was investigated to support data on the decision making process on routine screening of anti-HTLV-I/II in blood centers. Serum samples from 10.000 healthy blood donors (mean age: 32.6 years; 87.8% were male), who succeeded the donor history questionnaire, were included to the study, and HTLV-I/II antibodies were screened by a commercial enzyme immunoassay (ELISA) (Murex HTLVI-II, Murex Diagnostics, UK) method. Serum samples which were yielded reactive and borderline results were retested by ELISA, and repeated reactive/borderline results were then confirmed by HTLV-I/II confirmation test (INNO-LIA HTLV-I/II, Innogenetics, Belgium). Seven samples yielded reactive/borderline reactive results by both ELISA lots, however, all of them were found negative by confirmatory test. According to our data HTLV-I/II infections are not endemic in Izmir region, and anti-HTLV-I/II screening of blood donors is not required in our blood center currently. Nevertheless, screening HIV which is very rare in prevalence among the donor population, is mandatory for blood donors in our country. Thus, even its prevalence is very low, much more comprehensive and multi-centered studies are necessary for making the decision of integrating HTLV-I/II in routine blood bank screening tests in Turkey.

Evaluation of three different assays for the assessment of Epstein Barr Virus immunological status.

Various attempts have been made to improve Epstein Barr Virus serodiagnosis by developing convenient methods. The present study evaluated the performance of multiplexed bead assays and immunoblot based assays on automated platforms by comparing them with immunofluorescence based assays for the determination of EBV immune status. A total of 45 serum samples were included in the study. Serum samples were tested by multiplexed bead EBV assays (AtheNA Multi-Lyte, Zeus Scientific,USA) and immunoblot based assays (Euroline, Euroimmun AG, Germany) on automated platforms. Assay systems were evaluated by comparing them with immunofluorescence based assays (Zeus Scientific, USA). For EBV anti-VCA IgM, anti-VCA IgG, anti-EA and anti-EBNA, the kappa values reflecting agreements of AtheNA and IFA were 0.20, 0.54, 0.92 and 0.95 for anti-EA, anti-VCA IgG, anti-VCA IgM and anti-EBNA respectively and the agreements of Euroline and IFA were 0.53, 0.67, 0.81 and 1.000 for anti-VCA IgG, anti-EA, anti-VCA IgM and anti-EBNA respectively. The results of the study performed on a limited number of serum samples demonstrated that the multiplexed bead assays and immunoblot assays agree with the standard IFA assay for anti-EBNA IgG and anti-VCA IgM detection while the agreement is less for anti-EA and anti-VCA IgG.