Propensity Score and Desirability of Outcome Ranking Analysis of Ertapenem for Treatment of Nonsevere Bacteremic Urinary Tract Infections Due to Extended-Spectrum-Beta-Lactamase-Producing Enterobacterales in Kidney Transplant Recipients.

There are scarce data on the efficacy of ertapenem in the treatment of bacteremia due to extended-spectrum-beta-lactamase (ESBL)-producing Enterobacterales (ESBL-E) in kidney transplant (KT) recipients. We evaluated the association between treatment with ertapenem or meropenem and clinical cure in KT recipients with nonsevere bacteremic urinary tract infections (B-UTI) caused by ESBL-E. We performed a registered, retrospective, international (29 centers in 14 countries) cohort study (INCREMENT-SOT, NCT02852902). The association between targeted therapy with ertapenem versus meropenem and clinical cure at day 14 (the principal outcome) was studied by logistic regression. Propensity score matching and desirability of outcome ranking (DOOR) analyses were also performed. A total of 201 patients were included; only 1 patient (treated with meropenem) in the cohort died. Clinical cure at day 14 was reached in 45/100 (45%) and 51/101 (50.5%) of patients treated with ertapenem and meropenem, respectively (adjusted OR 1.29; 95% CI 0.51 to 3.22; P = 0.76); the propensity score-matched cohort included 55 pairs (adjusted OR for clinical cure at day 14, 1.18; 95% CI 0.43 to 3.29; P = 0.74). In this cohort, the proportion of cases treated with ertapenem with better DOOR than with meropenem was 49.7% (95% CI, 40.4 to 59.1%) when hospital stay was considered. It ranged from 59 to 67% in different scenarios of a modified (weights-based) DOOR sensitivity analysis when potential ecological advantage or cost was considered in addition to outcome. In conclusion, targeted therapy with ertapenem appears as effective as meropenem to treat nonsevere B-UTI due to ESBL-E in KT recipients and may have some advantages.

Efficacy of ß-lactam/ß-lactamase inhibitors to treat extended-spectrum beta-lactamase-producing Enterobacterales bacteremia secondary to urinary tract infection in kidney transplant recipients (INCREMENT-SOT Project).

BACKGROUND: Whether active therapy with ß-lactam/ß-lactamase inhibitors (BLBLI) is as affective as carbapenems for extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E) bloodstream infection (BSI) secondary to urinary tract infection (UTI) in kidney transplant recipients (KTRs) remains unclear. METHODS: We retrospectively evaluated 306 KTR admitted to 30 centers from January 2014 to October 2016. Therapeutic failure (lack of cure or clinical improvement and/or death from any cause) at days 7 and 30 from ESBL-E BSI onset was the primary and secondary study outcomes, respectively. RESULTS: Therapeutic failure at days 7 and 30 occurred in 8.2% (25/306) and 13.4% (41/306) of patients. Hospital-acquired BSI (adjusted OR [aOR]: 4.10; 95% confidence interval [CI]: 1.50-11.20) and Pitt score (aOR: 1.47; 95% CI: 1.21-1.77) were independently associated with therapeutic failure at day 7. Age-adjusted Charlson Index (aOR: 1.25; 95% CI: 1.05-1.48), Pitt score (aOR: 1.72; 95% CI: 1.35-2.17), and lymphocyte count ≤500 cells/µL at presentation (aOR: 3.16; 95% CI: 1.42-7.06) predicted therapeutic failure at day 30. Carbapenem monotherapy (68.6%, primarily meropenem) was the most frequent active therapy, followed by BLBLI monotherapy (10.8%, mostly piperacillin-tazobactam). Propensity score (PS)-adjusted models revealed no significant impact of the choice of active therapy (carbapenem-containing vs any other regimen, BLBLI- vs carbapenem-based monotherapy) within the first 72 hours on any of the study outcomes. CONCLUSIONS: Our data suggest that active therapy based on BLBLI may be as effective as carbapenem-containing regimens for ESBL-E BSI secondary to UTI in the specific population of KTR. Potential residual confounding and unpowered sample size cannot be excluded (ClinicalTrials.gov identifier: NCT02852902).

Evaluation of Aspergillus Lateral-Flow Test in Serum Samples of Pediatric Patients.

BACKGROUND: Diagnosis of invasive aspergillosis (IA) in patients with hematologic malignancies and under the risk of IA may be uncertain or may delay because of nonspecific clinical presentation of the patients and difficult application techniques of conventional methods. Early diagnosis can provide initial antifungal therapy and prevent high mortality. In this study, we investigated the performance of an Aspergillus lateral-flow device (LFD) test (OLM Diagnostics, Newcastle upon Tyne, United Kingdom) for the diagnosis of IA in pediatric febrile neutropenic patients with hematologic malignancies. METHODS: Three hundred and fourty seven serum samples of 26 febrile neutropenic episodes of 21 patients at risk for IA were tested. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the Aspergillus LFD test at episode level and at serum level were calculated. RESULTS: According to the reference diagnostic criteria of IA, one proven and 13 probable IA episodes were defined. Twelve episodes (46.1%) did not meet the criteria for IA. The sensitivity, specificity, PPV, NPV, accuracy of the Aspergillus LFD test at episode level and at serum level were 14.3%, 100%, 100%, 50%, 53.8% and 12.1%, 100%, 100%, 50.8%, 53.9%, respectively. CONCLUSIONS: Aspergillus LFD test is an easy-to-use assay with short hands-on time; however, further study of the clinical utility in children and especially in serum samples are needed. It is a highly specific test for IA on bronchoalveolar lavage (BAL) samples but is not useful as a screening test for serum samples unless combined with galactomannan (GM) antigen test because of its potentially suboptimal sensitivity.

The Evaluation of the Performance of C. Diff Quik Chek Complete and Toxin A + B (Clostridium difficile) DUO Diagnostic Tests Compared with Toxigenic Culture in the Diagnosis of Clostridium difficile Infection.

BACKGROUND: Clostridium difficile is an important cause of nosocomial diarrhea and the best standard laboratory method for the diagnosis of C. difficile infection is controversial. In this study, we aimed to investigate the performance of Toxin A + B (Clostridium difficile) DUO kit which detects C. difficile toxin A and B by the immunochromatographic method and C. Diff Quik Chek Complete (QCC) rapid membrane immunoassay kit which determines the presence of glutamate dehydrogenase (GDH) and C. difficile toxin A and B in stool samples, compared with toxigenic culture in the diagnosis of C. difficile infection. METHODS: One hundred ninety-three stool samples from patients suspected of having C. difficile infection were included in the study. The performances of two commercial tests were compared with toxigenic culture which was accepted as the reference method. RESULTS: The sensitivity and specificity of the GDH component of QCC were 94.4% and 97.7%, the sensitivity and specificity of the toxin component were 92.3% and 100%, respectively. The sensitivity and specificity of Toxin A + B (Clostridium difficile) DUO test were found as 53.8% and 87.8%, respectively. CONCLUSIONS: C. Diff Quik Chek Complete test, which is a rapid test with high sensitivity and specificity, can be used alone for the diagnosis of C. difficile infection while Toxin A + B (Clostridium difficile) DUO test cannot be used for the same purpose due to the low sensitivity and specificity of the test.

Evaluation of Commercially Available Real-Time Polymerase Chain Reaction Assays for the Diagnosis of Invasive Aspergillosis in Patients with Haematological Malignancies.

Early diagnosis of invasive aspergillosis (IA) is a challenge. Non-specific clinical and radiologic findings, as well as difficulties in conventional diagnostic method application, may delay correct diagnosis. Nowadays, nucleic acid-based assays have reduced the need for conventional antigen detection and culture-based methods and provided new opportunities for patient care. Aspergillus PCR is now included in the latest European Cancer Research and Treatment Organization/Mycosis Study Group definition updates. We evaluated the performance of commercial real-time polymerase chain reaction (PCR) MycAssay Aspergillus PCR and Artus Aspergillus RG PCR assays and compared the results with galactomannan enzyme immunoassay. During 41 febrile neutropenic episodes, 168 serum samples were collected from 32 patients with haematological malignancies. IA diagnosis was established according to the revised guidelines of the European Organization for Research and Treatment of Cancer/Mycoses Study Group. Twenty-one probable episodes were identified. There were no proven IA cases in the study. In 20 episodes, patients did not fulfil the established criteria for the IA diagnosis. Artus Aspergillus RG PCR assay had a sensitivity of 47.6% and specificity of 100%, while those of MycAssay Aspergillus PCR were 61.9% and 100%, respectively. Two different PCR assays were used in this study. Although there are many studies that evaluated MycAssay Aspergillus PCR, data regarding Artus Aspergillus RG PCR assay are scarce. We found moderate sensitivity and high specificity in the diagnosis of IA in patients with haematological malignancy in both PCR methods. Our results demonstrated that commercial PCR assays can be applied for the early diagnosis and pre-emptive treatment of IA.

[Evaluation of a Commercial Multiplex Tandem Polymerase Chain Reaction Method for the Identification of the Yeasts Isolated from Blood Cultures]. / Kan Kültürlerinden Izole Edilen Mayalarin Tanimlanmasinda Ticari Bir Multipleks Tandem Polimeraz Zincir Reaksiyonu Yönteminin Degerlendirilmesi.

Candidemia is one of the most important health care-associated infections worldwide. Candida species have species-specific antifungal susceptibility profiles and it has been shown that the identification of the Candida species is necessary for the appropriate treatment of the patients with candidemia. Various methods are used to shorten the identification time for the determination of the causative species. Fungal ID multiplex tandem polymerase chain reaction (MT-PCR) (AusDiagnostics, Australia) is a test developed to identify yeasts and molds isolated from clinical specimens. In this study, we aimed to evaluate the Fungal ID MT-PCR test (AusDiagnostics, Australia) for the identification of the yeasts from positive blood cultures in Akdeniz University Hospital Central Laboratory. Between December 2016 and December 2017, blood culture samples from 92 consecutive patients with yeast cells detected in Gram stained smears were tested by Fungal ID MT-PCR and the reference method. After the subculture of the positive signaling blood culture bottles to Sabouraud dextroz agar (SDA), the identification of the yeasts were performed by morphological identification methods (Germ tube test, Corn Meal Tween® 80 agar media, etc.), BD Phoenix Yeast ID Panel (Becton Dickinson, Sparks, MD) and Bruker Biotyper matrix-assisted laser desorption ionization-time of mass spectrometry (MALDI-TOF MS) (Bruker Daltonics, Germany) systems. Identification with MALDI-TOF MS have been accepted as the reference method. Thirty-five of the isolates were identified as Candida albicans, 17 were Candida glabrata, 13 were Candida parapsilosis, 12 were Candida tropicalis, seven were Candida krusei , two were Candida guilliermondii, two were Candida dubliniensis, two were Candida inconspicua, one was Candida kefyr and one was Saprochaete capitata by the reference method. In our study, no blood culture sample yielded more than one yeast species. 94.6% of the strains were presumptively identified by the morphological identification methods. Discordant results were not detected between the BD Phoenix Yeast ID Panel and the reference method. Thirty-three of the isolates were identified as C.albicans, 15 were C.glabrata, 13 were C.parapsilosis, 11 were C.tropicalis, five were C.krusei , two were C.guilliermondii, one was C.dubliniensis, one was C.kefyr and 10 were Candida spp. by Fungal ID MT-PCR assay. Since C.inconspicua and S.capitata were not included in the test panel, C.inconspicua was identified as Candida spp. in two samples, while S.capitata could not be identified in one sample. Concordance between Fungal ID MT-PCR and the reference method were found to be 88% at the species level and 98.9% at the genus level. The sensitivity of the Fungal ID MT-PCR test in in the detection of C.krusei and C.glabrata was 71.4% and 88.2%, respectively. Fungal ID MT-PCR test has shown a high performance in the identification at the genus level, but the identification at the species level, which is important for the treatment management, was moderate. Fungal ID MT-PCR can be used as an adjunct test to the traditional identification methods for the early identification of the Candida species.

Predictors of mortality in solid organ transplant recipients with bloodstream infections due to carbapenemase-producing Enterobacterales: The impact of cytomegalovirus disease and lymphopenia.

Treatment of carbapenemase-producing Enterobacterales bloodstream infections in solid organ transplant recipients is challenging. The objective of this study was to develop a specific score to predict mortality in solid organ transplant recipients with carbapenemase-producing Enterobacterales bloodstream infections. A multinational, retrospective (2004-2016) cohort study (INCREMENT-SOT, ClinicalTrials.gov NCT02852902) was performed. The main outcome variable was 30-day all-cause mortality. The INCREMENT-SOT-CPE score was developed using logistic regression. The global cohort included 216 patients. The final logistic regression model included the following variables: INCREMENT-CPE mortality score ≥8 (8 points), no source control (3 points), inappropriate empirical therapy (2 points), cytomegalovirus disease (7 points), lymphopenia (4 points), and the interaction between INCREMENT-CPE score ≥8 and CMV disease (minus 7 points). This score showed an area under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI] 0.76-0.88) and classified patients into 3 strata: 0-7 (low mortality), 8-11 (high mortality), and 12-17 (very-high mortality). We performed a stratified analysis of the effect of monotherapy vs combination therapy among 165 patients who received appropriate therapy. Monotherapy was associated with higher mortality only in the very-high (adjusted hazard ratio [HR] 2.82, 95% CI 1.13-7.06, P = .03) and high (HR 9.93, 95% CI 2.08-47.40, P = .004) mortality risk strata. A score-based algorithm is provided for therapy guidance.

Evaluation of a nucleic acid amplification assay for the diagnosis of Clostridioides difficile infection.

Clostridioides difficile is the leading cause of healthcare-associated diarrhea and the laboratory diagnosis of Clostridioides difficile infection (CDI) continues to be challenging. Accurate and rapid identification of C. difficile will reduce unnecessary antibiotic use and ensure contact isolation to control the spread of CDI. In this study, diagnostic performance of BD MAX Cdiff assay (Becton Dickinson, USA) was evaluated for the detection of C. difficile in 2502 fresh stool samples from hospitalized children and adult patients and the results were compared to toxigenic culture. The frequency of CDI in adults and pediatric patients were found as 3.3% and 6.2%, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of BD MAX Cdiff assay were found as; 100%, 99.7%, 93%, and 100% for all patients; 100%, 99.7%, 96.2%, and 100% for pediatric patients; and 100%, 99.6%, 90.2%, and 100% for adult patients, respectively. We concluded that BD MAX Cdiff assay with high sensitivity, specificity, and PPV is useful for the diagnosis of CDI. With a high NPV of 100%, BD MAX Cdiff assay is also suitable for the exclusion of CDI.

[Evaluation of the BD Phoenix100 System and Colistin Broth Disk Elution Method for Antimicrobial Susceptibility Testing of Colistin Against Gram-negative Bacteria]. / Kolistinin Gram-negatif Bakterilere In Vitro Etkinliginin Belirlenmesinde BD Phoenix100 Sistemi ve Kolistin Sivi Disk Elüsyon Yöntemlerinin Degerlendirilmesi.

Infections with multidrug resistant gram-negative bacteria is a growing problem especially in health care settings. Colistin is one of the last resort antibiotics for such infections in which treatment options are limited. Increasing resistance to colistin is a global problem. Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) study groups have recommended the ISO-standard broth microdilution method (20776-1) as the reference method for the determination of colistin susceptibility. Since the broth microdilution method is not a practical method, it is rarely used in routine clinical microbiology laboratories, yet simple and accurate phenotypic detection methods for the determination of colistin resistance in routine microbiology laboratories are not precisely defined. The aim of this study was to evaluate BD Phoenix100 (Becton Dickinson, USA) system and colistin broth disk elution method for the detection of in vitro activity of colistin against gram-negative bacteria. A total of 419 gram-negative bacteria, including 199 Klebsiella pneumoniae, 163 Acinetobacter baumannii, 34 Escherichia coli, 20 Enterobacter spp., and three Citrobacter spp. isolates which were isolated from various clinical samples in our hospital between 2016-2018 were tested. The broth microdilution method was used as the reference method applying ISO-standard broth microdilution methods (20776-1) and CLSI/EUCAST recommendations. For colistin broth disk elution method, final concentrations of 0 (growth control), 1, 2 and 4 µg/ml were obtained by adding 10 µg colistin disks to four tubes containing 10 ml cation-adjusted Mueller Hinton broth per isolate. After incubation at room temperature for 30 minutes, 50 µl of standardized inoculum suspensions were added to the tubes. Colistin minimum inhibitor concentration (MIC) values were read visually after 16-20 hours of incubation at 35°C in ambient air. Manufacturer's recommendations were followed for BD Phoenix100 system. The categorical agreement between the reference broth microdilution method and the colistin broth disk elution method was 99.3%, very major error and major error rates were 0.2% and 0.5%, respectively. For BD Phoenix100 system, the categorical agreement was 95%, with a very major error rate of 5%. Our results showed that colistin broth disc elution method worked well compared to the reference broth microdilution method. The BD Phoenix100 system, with a high very major error rate, does not reliably distinguish colistin-resistant and colistin-susceptible strains.

Matrix-Assisted Laser Desorption-Ionization Time-of-Flight Mass Spectrometry (MALDI- TOF MS) for Early Identification of Septic Patients.

BACKGROUND: Matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS) is a powerful technique for the rapid identification of bacteria from growing colonies in routine cultures. In this study, we evaluated the feasibility of a 5-hour incubation on solid medium after sub-cultivation of positive blood culture broth without any preparation steps in order to speed up the identification of bacteria. METHODS: In addition to standard laboratory protocols, a Columbia agar plate with 5% sheep blood was inoculated with 1 drop from the blood culture broth. After a 5-hour incubation period, a colony from the culture plate was submitted to MALDI-TOF MS. RESULTS: A total of 1351 positive blood cultures (1299 monomicrobial and 51 polymicrobial) were analyzed. When compared to routine identification procedure results for positive blood cultures, 79.3% of isolates were correctly identified to the species level. When manufacturer-recommended score values were taken into account, MALDITOF MS correctly identified 98.4% of the isolates to the species level with a score of > 2.0, 89.1% with a score between 1.7 and 2.0, and 75.4% with a score of < 1.7. CONCLUSIONS: ln our evaluation, a large majority of the S. aureus (91.5%) and Enterobacteriaceae (87.6%) were correctly identified at the species level. A 5-hour incubation period was found to be associated with moderate identification results for CoNS, Enterococcus spp., and nonfermentative gram negative bacilli, with failure being mostly observed with Streptococcus spp., Candida spp., and other gram positive bacteria. We believe that the performance of MALDI-TOF MS identification after short-term culture is directly related to the sufficient growth of microorganisms at 5 hours.

[Determination of cytomegalovirus glycoprotein B genotypes in different geographical regions and different patient groups in Turkey]. / Türkiye'de farkli cografi bölgelerde ve farkli hasta gruplarindaki sitomegalovirus izolatlarinin glikoprotein B genotiplerinin belirlenmesi.

Cytomegalovirus (CMV), a common virus found all around the world, usually causes asymptomatic infections in immunocompetent hosts, however it may lead to serious complications in immunodeficient patients and in the fetus. CMV is divided into four genotypes according to the polymorphisms in UL55 gene that encodes for envelope glycoprotein B. Nucleotide polymorphisms of CMV gB gene can affect the cell tropism of the virus and host immune response and believed to have important changes in the pathogenesis of CMV. The aim of this study was to determine the gB genotypes of CMV isolates from different patient groups selected from different regions of Turkey. A total of 136 clinical specimens from patients (66 female, 70 male; age range: 0-65 years, mean age: 24.03 ± 17.17) who were diagnosed to have CMV infection by polymerase chain reaction (PCR) and/or antigenemia tests, between 2001-2014, in the medical school hospitals of Akdeniz, Ege, Istanbul Cerrahpasa and Erciyes Universities (located at Mediterranean, Aegean, northwest and central Anatolia regions, respectively), were included in the study. The patient group consisted of 80 renal transplant (RT) recipients, 35 stem cell transplant (SCT) recipients, 13 newborns, seven heart transplant (HT) recipients and one pregnant woman. CMV gB genotypes were determined by PCR-RFLP (restriction fragment length polymorphism) method, and DNA sequencing and phylogenetic analysis were performed for the randomly selected 15 isolates with different genotypes. Among 136 (135 plasma, 1 amnion fluid) samples, the most frequent genotype was gB1 (n= 44, 32.4%), followed by gB2 (n= 39, 28.6%), gB3 (n= 36, 26.5%) and gB4 (n= 8, 5.9%); however nine (6.6%) samples could not be genotyped. When analysis were interpreted according to the patient groups, it was determined that the genotypes in RT recipients were gB1 32.3%, gB2 28.7%, gB3 26.5% and gB4 5.9%; in SCT recipients gB1 34.3%, gB2 28.6%, gB3 22.9% and gB4 5.7%; in HT recipients gB3 57.1%, gB1 14.3% and gB2 14.3%; in newborns gB1 38.4%, gB3 30.8%, gB2 15.4% and gB4 7.7%, and gB2 genotype in the pregnant woman. As our study was a descriptive study to determine the genotypes of CMV gB, the relationship between the genotypes and the variants such as viral load, symptomatic disease and prognosis were not analyzed. As a result, the isolation of different gB genotypes in various case groups from four distinctive provinces, underlines the diversity of CMV gB genotypes in Turkey.

[Monitoring of cytomegalovirus-specific CD4+ and CD8+ T cell responses by cytokine flow cytometry in renal transplant recipients]. / Böbrek nakil hastalarinda sitomegalovirusa özgül CD4+ ve CD8+ T hücre yanitinin sitokin akim sitometri yöntemiyle izlemi.

In spite of the improvements in the clinical management of solid organ transplant (SOT) recipients provided by immunosuppresion and universal prophylaxis, human cytomegalovirus (CMV) infections continue to be one of the most leading causes of morbidity and mortality. Cell-mediated immunity specific to CMV (CMV-CMI) plays an important role in the control of CMV replication. Therefore, monitoring of CMV-specific T-cell response can be used to predict individuals at increased risk of CMV disease. The aim of this study was to investigate the levels of CMV-specific interferon (IFN)-γ producing CD4(+) and CD8(+) T cells in kidney transplant recipients before and after the transplantation, by cytokine flow cytometry. A total of 21 kidney transplant recipients (14 male, 7 female; age range: 18-66 years, mean age: 34.5 ± 9.9) who were all CMV seropositive have been evaluated in the study. Blood samples from the patients were obtained before and at the 1(st), 3(rd) and 6(th) months after transplantation. CMV seropositive healthy kidney donors (n= 20) constituted the control group. The main stages of our procedure were as follows; isolation of peripheral blood mononuclear cells from whole blood, freezing and storing of the samples, later on thawing the samples, ex vivo stimulation of lymphocytes with pooled CMV peptides and counting CMV-specific IFN- producing CD4(+) and CD8(+) T cells by flow cytometry following surface and intracellular cytokine staining. Monitoring of the viral load (CMV-DNA) was performed in 10 days intervals in the first 3 months followed by 3 week intervals until 6 months using COBAS AmpliPrep/COBAS TaqMan CMV test system (Roche Diagnostics, USA). The frequencies of pretransplant CMV-specific IFN-γ producing CD8(+) T cells in patient (3.53 ± 4.35/µl) and control (4.52 ± 5.17/µl) groups were not statistically different (p= 0.266). The difference between the number of virus-specific CD4(+) T cells in patients (8.84 ± 9.56/µl) and those in the control group (8.23 ± 11.98/µl) was at the borderline of significance (p= 0.057). The age and gender of the patients and type of antiviral prophylaxis protocols [valgancyclovir (n= 4); valacyclovir (n= 17)] did not have any significant effect on CMV-CMI (p> 0.05). Similarly, induction therapy administered to four patients did not show any effect on CMV-CMI (p> 0.05). CMV-specific immune responses of patients who received different immunosuppression protocols [tacrolimus + mycophenolate mofetil (MMF) + steroid (n= 17); cyclosporine + MMF + steroid (n= 2); mTOR inhibitor + MMF + steroid (n= 2)] were not different (p> 0.05). The number of CMV-specific CD4(+) T cells in all patients were significantly decreased in the 3rd month compared to the 1st month after the transplantation (p=0.003), indicating a relationship with the period of immunosuppressive therapy. In one of the patients who did not have CMV-specific CD4+ T-cell response but had cytotoxic T-cells (CD8(+) T= 0.6%) before transplantation, CD4(+) T-cell response have developed during monitorization (1.4%, 1.5% and 0.5% in 1st, 3rd and 6th months, respectively), and no viral reactivation was detected. Out of the two patients who had no CD4(+) and CD8(+) T cell response in the 3rd month, one of them developed low level viremia (150 copies/ml) in the 6th month. In this patient the level of CMV-CMI in the 6th month (CD4(+)T + CD8(+)T= 0.9%), have reached higher values than the values obtained before the transplantation (CD4(+) T + CD8(+) T= 0.5%). The viremia was cleared spontaneously in this patient and no antiviral therapy was required. In conclusion, our results suggested that pretransplant and posttransplant monitoring of CMV-specific T-cell responses might be helpful as well as viral load in the clinical management of CMV infection in SOT patients.

Cutaneous Alternaria infectoria infection diagnosed by molecular techniques in a renal transplant patient.

Organ transplant recipients under immunosuppressive therapy have a highly increased risk of opportunistic fungal infections. Cutaneous infection caused by Alternaria species are relatively rare in humans and most cases reported in the literature are in immunocompromised individuals. We report here on a 33-year old male renal transplant patient with diabetes mellitus who presented with cutaneous alternariosis caused by Alternaria infectoria, two years after the transplant. The diagnosis was performed by real-time polymerase chain reaction assay and histopathologic examination. The extension of the lesion under itraconazole treatment required treatment consisting of a combination of surgical excision and liposomal amphotericin B.

Evaluation of a chromogenic medium for detection of extended-spectrum-beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae strains.

BACKGROUND: Because of the emergence and spread of extended-spectrum-beta-lactamase (ESBL)-producing strains which are resistant to many antibiotics, reliable detection of ESBL is very important for infection control. Several chromogenic media have been proposed for the detection of ESBL producers in addition to the conventional phenotypic and genotyping methods. The aim of the present study was to evaluate the performance of Brilliance ESBL agar (Oxoid; Thermo Fisher Scientific, UK), a selective chromogenic agar for the detection of ESBL-producing Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) strains. METHODS: A total of 237 strains (143 ESBL producers (76 isolates of E. coli and 67 isolates of K. pneumoniae) and 94 non-ESBL producers (44 isolates of E. coli and 50 isolates of K. pneumoniae)) isolated from various clinical specimens were included in the study. Isolates were identified by conventional methods, Phoenix system (Becton Dickinson, USA), and mass spectrometry. ESBL confirmation was performed by phenotypical tests. A 10 microL aliquot of each isolate's 0.5 McFarland suspension was streaked onto Brilliance ESBL agar. All plates were incubated at 37 degrees C for 24 hours and then were interpreted for growth and colony color according to the manufacturer's recommendations. Identification and ESBL test results were used to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the medium evaluated at 24 hours. RESULTS: The sensitivity, specificity, PPV, and NPV of the medium were 97.9%, 100%, 100%, and 96.9%, respectively, when considering only species specific colored colonies of the isolates. CONCLUSIONS: Brilliance ESBL agar could provide a practical alternative to the traditional methods for the identification of ESBL producers.

Surgical correction of vesico-ureteric reflux for recurrent febrile urinary tract infections after kidney transplantation.

OBJECTIVE: To evaluate the outcome of anti-reflux revision surgery in patients diagnosed with at least a grade 3 reflux at voiding cysto-urethrography in patients with recurrent urinary tract infection (UTI) after renal transplantation. PATIENTS AND METHODS: We identified 60 patients with a diagnosis of recurrent febrile UTI and post-transplantation vesico-ureteric reflux (VUR) who underwent open surgical correction of reflux. Patient characteristics, including the aetiology of end-stage renal disease, age, time to VUR correction, type of VUR correction, serum creatinine levels, and number of UTIs before and after correction were documented. RESULTS: The median (range) age of the patients was 31.5 (9-65) years. A total of 30 patients underwent uretero-ureterostomy or pyelo-ureterostomy and 30 underwent extravesical or intravesical ureteric reimplantation. The median (range) creatinine levels before and after correction were 1.5 (0.8-4.5) mg/dL and 1.3 (0.7-4.5) mg/dL (P<0.05), respectively. The median (range) number of UTI episodes reported before the correction surgery was 4 (3-12), whereas number of UTI episodes after the surgery was 1 (0-12), the difference being significant (P<0.05). CONCLUSIONS: Open surgical correction of post-transplant VUR is an effective and safe method of decreasing UTI episodes and stopping reflux. Surgical correction of reflux may prolong the life of the renal graft.

Distribution and antifungal susceptibility of Candida species causing nosocomial candiduria.

The aim of the study was to investigate the distribution of Candida species isolated from urine specimens of hospitalized patients in Akdeniz University Hospital, Antalya, Turkey, as well as their susceptibilities to antifungal agents. A total of 100 patients who had nosocomial candiduria between March 2003 and May 2004 at the facility were included in the study. Organisms were identified by conventional methods and the use of API ID 32C strips. Susceptibilities of the isolates to amphotericin B were determined by Etest, whereas the minimum inhibitory concentration (MIC) values of these same strains to fluconazole, voriconazole and caspofungin were assessed using the broth microdilution method. The most common species recovered was C. albicans 44% of all yeasts, followed by C. tropicalis (20%), C. glabrata (18%), C. krusei (6%), C. famata (5%), C. parapsilosis (4%), C. kefyr (2%) and C. guilliermondii (1%). A total of nine (9%) of the isolates, including five C. krusei and four C. glabrata isolates were susceptible dose-dependent (SDD) to fluconazole. In constrast, only two C. glabrata and one C. krusei isolates were resistant to this antifungal. The voriconazole MICs for all Candida isolates were ≤0.5 µg/ml, except for one C. glabrata isolate with a MIC value of 2 µg/ml. Among all isolates, 94% were susceptible to amphotericin B with MIC values of <1 µg/ml and all isolates were susceptible to caspofungin with MIC values of ≤0.5 µg/ml. Future studies are needed to define better treatment regimens for those patients who have fluconazole-resistant Candida urinary tract infections.

Evaluation of in vitro activities of tigecycline and various antibiotics against Brucella spp.

Brucellosis is a zoonosis with a worldwide distribution and remains a significant public health problem mainly in the developing world. In this study we evaluated the in vitro activities and synergistic effects of antibiotic combinations against blood culture isolates of Brucella spp. In vitro susceptibilities of 76 blood culture isolates of Brucella melitensis and one blood culture isolate of Brucella abortus to doxycycline, streptomycin, gentamicin, trimethoprim-sulfamethoxazole, moxifloxacin, rifampin, ciprofloxacin, and tigecycline were examined by Etest method. For 37 patients with Brucella spp. isolates (36 B. melitensis, 1 B. abortus), antibiotic combinations used for treatment were identified with those tested in vitro for synergy using Etest method. Trimethoprim-sulfamethoxazole and tigecycline were the most active of the compounds tested with MIC90 value of 0.094 mg/l. Among antibiotic combinations only streptomycin-rifampin combination was synergistic for one Brucella spp. isolate. The other antibiotic combinations revealed antagonistic or indifferent activity. Complete clinical response was achieved in all patients. Further studies are required to determine the correlation between the antimicrobial susceptibility and synergy test results with the clinical course of patients. Brucellosis can be adequately treated with existing regimens in our region.

[Shall we report the carbapenem resistance in Pseudomonas aeruginosa and Acinetobacter baumannii strains detected by BD Phoenix system?]. / Pseudomonas aeruginosa ve Acinetobacter baumannii suslarinda BD Phoenix sistemi ile saptanan karbapenem direncini raporlayalim mi?

Imipenem and meropenem are broad spectrum antimicrobial agents that are especially useful in the treatment of nosocomially acquired Pseudomonas aeruginosa and Acinetobacter spp. infections. Previous reports have noted that susceptibility tests could show false resistance to imipenem. For this reason, Centers for Disease Control and Prevention has recommended that all carbapenem resistant or intermediate resistant isolates should be tested with an additional method to verify the results. This study was aimed to evaluate the imipenem and meropenem susceptibilities by disk diffusion, E-test and broth microdilution in P. aeruginosa and Acinetobacter baumannii strains found to be resistant or intermediate to imipenem-meropenem by BD Phoenix automated susceptibility testing system. Between January 2006-January 2007, 85 non-duplicate isolates of A. baumannii and 51 non-duplicate isolates of P. aeruginosa which were determined as resistant or intermediate resistant to imipenem and/or meropenem by BD Phoenix automated identification and susceptibility system (Becton Dickinson, Sparks, MD, USA) were collected in Akdeniz University Hospital Central Laboratory. All strains were tested by E-test (AB Biodisk, Sweden), disk diffusion and reference broth microdilution (BMD) method following CLSI recommendations. All 51 isolates of P. aeruginosa determined as imipenem and/or meropenem resistant or intermediate resistant by BD Phoenix, were found to be imipenem and/or meropenem resistant or intermediate resistant by the reference BMD method. Minor error rates were same for all testing systems (1.9%) except for the meropenem results of BD Phoenix system (5.9%). No major errors were produced by any system. For A. baumannii, only one very major error was detected for meropenem by BD Phoenix system. Number of minor errors determined for meropenem by all testing systems compared to the reference test, ranged from 2 (2.4%) to 3 (3.5%). It was concluded that carbapenem susceptibility test results obtained by BD Phoenix system for P. aeruginosa and A. baumannii isolates, could be reported without an additional susceptibility testing method unless indicated on case basis.

[Investigation of Panton-Valentine leukocidin gene, SCCmec gene cassette types and genotypes of methicillin-resistant Staphylococcus aureus strains isolated from outpatients]. / Ayaktan saglik hizmeti alan hastalardan izole edilen metisiline dirençli Staphylococcus aureus izolatlarinda Panton-Valentin lökosidin geni ve SCCmec gen kaseti tiplerinin arastirilmasi ve izolatlarin genotiplendirilmesi.

The identification of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is becoming a hard task since colonization with MRSA is lasting for years and the number of the health care facilities other than hospitals is continuously increasing. In this study we aimed to investigate the genetic properties and health-care association of MRSA strains isolated from skin and soft tissue infections of outpatients admitted to Akdeniz University Hospital. Thirty strains were phenotypically identified as MRSA and after assessing the risk factors, 28 (93.3%) of them were classified as health-care associated (HCA) and 2 (6.7%) of them as community-acquired (CA). All of the isolates were positive for nuc and mecA genes by polymerase chain reaction. Antimicrobial resistance rates of HCA-MRSA and CA-MRSA isolates were found as follows, respectively; 89.3% and 0% for rifampin, 89.3% and 50% for ciprofloxacin, 89.3% and 0% for gentamicin, 50% and 50% for erythromycin, 28.6% and 0% for clindamycin, whereas all of the isolates were susceptible to vancomycin, linezolid and trimethoprim-sulfamethoxazole. SCCmec type III was detected in 24 (85.7%) of HCA-MRSA strains. SCCmec type IV was detected in 1 (3.6%) of HCA-MRSA and in 2 (100%) of CA-MRSA strains. Panton-Valentin leucocidin (PVL) gene positivity was detected in only CA-MRSA isolates (2/2; 100%). MRSA isolates were grouped into 17 different genotypes (from A to R) of which pulsotype A was predominant among HCA isolates and CA-MRSA isolates were found to be clonally related with each other. This is the first study which investigated the genetic properties of MRSA strains in Antalya (a province located at Mediterranean Region, Turkey). In this study HCA risk factors were investigated and CA-MRSA rate was only 6.7% among all MRSA strains isolated from outpatients. As a result of detailed investigation of HCA risk factors, it was possible to detect the exact rate of CA-MRSA among outpatients. Thus it is of clinical and epidemiological importance to know the origin of MRSA isolates since this will affect the empirical treatment choice. Genetic studies supplied by appropriate demographic data will help to clarify the evolution and epidemiology of MRSA in the community and in the hospital setting.

[Investigation of cytomegalovirus seroepidemiology in Antalya with a population-based cross-sectional study and review of related data in Turkey]. / Antalya'da sitomegalovirus seroepidemiyolojisinin toplum kaynakli kesitsel bir çalisma ile arastirilmasi ve Türkiye verilerinin derlenmesi.

Since there are numerous studies on CMV seroprevalence in various groups in Turkey, the number of population based, age-stratified cross-sectional studies which include epidemiological characteristics of the virus are limited. The aim of the study was to investigate the age-stratified seroprevalence and epidemiological characteristics of CMV infection in Antalya (a province located in Mediterranean region of Turkey). Study group was selected by cluster sampling method. The sample size was calculated as 360 subjects (151 male, 209 female; age range: 1-49 years, mean age: 22.5 +/- 14.4 years), with an expected prevalence rate of 80%, at a confidence level of 95% and a sample error less than 5%. With the thought of the presence of maternal antibodies, 0-1 year age group was not included to the study. Serum samples have been screened for CMV-IgG, and those given negative results were also searched for CMV-IgM by a commercial microELISA (Radim, Italy) test. The overall seroprevalence of CMV-IgG was found as 93.6% (337/360) in Antalya municipality and IgM positivity was not detected in CMV-IgG negative sera. An increase in the seroprevalence rates was observed with age (p < 0.001), and the rate was found quite high (93.3%) for the first year of life. The seropositivities in the age groups of 1-6, 7-14 and 14-49 years were detected as 82.1%, 92% and 97.8%, respectively. The seroprevalence rate of 82.1% before the age of seven has rised to 96.8% after that age, and being > or =7 years old was found statistically significant in terms of CMV infection (p < 0.001, OR: 6.635). Ages one and seven were found to be the critical ages for CMV infection in our region. CMV seropositivity was 97.4% in woman at childbearing age (15-49 years). Gender, marital status, education, living area, residence, income, history of sexually transmitted diseases, surgery, blood transfusion and day care attendance did not contribute independently to the seroepidemiology of CMV (p > 0.01). In addition, the data of this study were evaluated and discussed together with the results obtained from the other Turkish studies, as far as accessible. In conclusion, since CMV seroepidemiology in Turkey differs as the socioeconomic changes occur, the changes in CMV serostatus and dire consequences of high seroprevalence rates on public health should be evaluated with prospective, population based studies in further years.