Methodology in improving antibiotic implementation policies.

The basic requirements of antibiotic prescribing are components of methodology; knowledge, logical reasoning, and analysis. Antimicrobial drugs are valuable but limited resources, different from other drugs and they are among the most commonly prescribed drugs all over the world. They are the only drugs which do not intentionally affect the patient. They affect the pathogens which invade the host. The emergence and spread of antibiotic-resistant pathogens are accelerated by heavy antibiotic usage. The effective antimicrobial stewardship and infection control program have been shown to limit the emergence of antimicrobial-resistant bacteria. In this respect, education for antibiotic prescribing could be designed by going through the steps of scientific methodology. A defined leadership and a coordinated multidisciplinary approach are necessary for optimizing the indication, selection, dosing, route of administration, and duration of antimicrobial therapy. In scenarios, knowledge is also as important as experience for critical decision making as is designated. In this setting, the prevalence and resistance mechanisms of antimicrobials, and their interactions with other drugs need to be observed. In this respect, infectious disease service should play an important role in improving antimicrobial use by giving advice on the appropriate use of antimicrobial agents, and implementing evidence-based guidelines.

Long-term treatment of persistent disseminated Nocardia cyriacigeorgica infection

In this paper a disseminated persistent Nocardia cyriacigeorgica infection in an immunocompetent patient is described. The patient's long-term treatment, as well as its implications for managing similar cases in the future, is emphasized. Presenting with high fever, multiple nodules, and ulcerative cutaneous lesions of body sites, the patient was treated with various antimicrobials. Under combined therapy, empyema and arthritis, leading to disseminated nocardiosis, were seen. The overall treatment course was 28 months. It can be concluded that the choice of the antibiotics and optimal duration of treatment are uncertain; therefore the treatment of nocardiosis requires expertise.

Long-term treatment of persistent disseminated Nocardia cyriacigeorgica infection.

In this paper a disseminated persistent Nocardia cyriacigeorgica infection in an immunocompetent patient is described. The patient's long-term treatment, as well as its implications for managing similar cases in the future, is emphasized. Presenting with high fever, multiple nodules, and ulcerative cutaneous lesions of body sites, the patient was treated with various antimicrobials. Under combined therapy, empyema and arthritis, leading to disseminated nocardiosis, were seen. The overall treatment course was 28 months. It can be concluded that the choice of the antibiotics and optimal duration of treatment are uncertain; therefore the treatment of nocardiosis requires expertise.

The Nocardia farcinica infection developing after total knee arthroplasty surgery.

Infection is an important complication in total knee prosthesis implementations and possesses a serious morbidity. We present a case of Nocardia farcinica infection which appeared after application of cemented total knee prosthesis. A 78-year-old male patient had referred to the outpatient clinic with the complaints of restricted movement, pain and swelling of the knee which started after a month following total knee arthroplasty surgery due to left gonarthrosis. As no improvement could be achieved after arthroscopic debridement, synovectomy and antibiotherapy, the components of the total knee prosthesis were removed from him. Although improvement could not be achieved in the knee of the patient at the end of 20-month therapy, the case has still being followed-up.

[Septic arthritis of hip due to Salmonella Typhi in a patient with multiple sclerosis]. / Multipl Sklerozlu Bir Olguda Salmonella Typhi'ye Bagli Kalça Eklemi Artriti.

The most common microorganisms isolated from septic arthritis are Staphylococcus aureus and streptoccocci. Septic arthritis due to Salmonella spp. are rare and the most commonly isolated species are S.Choleraesuis and S.Typhimurium. However the number of septic arthritis cases due to S.Typhi is low in literature. In this report, septic arthritis of hip due to S.Typhi in a multiple sclerosis patient who was under steroid therapy, was presented. A 25-year-old female patient was admitted to our clinic with the complaints of fever, left hip pain, standing and walking disability for 10 days. Her anamnesis revealed that she had had a multiple sclerosis attack and underwent triple pulse steroid therapy. Laboratory findings were as follows; WBC count: 16.300/mm3 (70% polymorphonuclear leukocyte), hemoglobin: 10.6 g/dl, erythrocyte sedimentation rate: 140 mm/hour, CRP: 28.7 g/L, AST: 86 U/L and ALT: 77 U/L. In lumbosacral magnetic resonance imaging, trochanteric bursitis and generalized myositis were detected in left hip joint compatible with septic arthritis. S.Typhi was isolated from patient's blood and operational tissue samples. Serum Salmonella TO and TH titers were found as 1/400 and 1/200, respectively. Antibiotic susceptibility test was performed by disk diffusion method, and the isolate was found susceptible to ampicillin, chloramphenicol, ceftriaxone, ciprofloxacin and trimethoprim-sulphametoxazole. The patient was treated by surgery and also by two weeks parenteral (2 x 400 mg) and 6 weeks oral (2 x 500 mg) ciprofloxacin treatment. Six months follow-up of the patient revealed that clinical, radiological and laboratory findings were normal. As far as the national literature was considered, this was the first S.Typhi septic arthritis case involving the hip joint and demonstrating bacterial growth both in blood and operational tissue. The presentation of the infection as arthritis plus diffuse myositis and bursitis, is also noteworthy.

Hospital acquired infections (HAI) in the elderly: comparison with the younger patients.

The aim of this retrospective study is to determine the frequency, type, microbiological characteristics and outcome of HAIs in the elderly (age ≥ 65) and to compare the data with younger patients in a Turkish Training and Research Hospital. From January 2008 to December 2009, the infection control team analyzed HAIs among 60,585 hospitalized patients (20,109 aged ≥ 65 and 40,747 aged between 18 and 64 years) with a total number of 419,017 patient days. A total of 825 HAIs episodes were detected in 607 patients, of which 395 episodes were in 301 elderly patients. The incidence of HAIs per 1000 patient days was 2.49 in the elderly and 1.64 in the younger patients' group (p<0.001). The most common site of infection in the elderly patients was the urinary tract, whereas in non-elderly group this was the lower respiratory tract. The incidence density of urinary tract infections, respiratory tract infections, surgical site, skin and soft tissue infections, primary bacteremia, and prosthesis infections were significantly higher in the elderly group (p<0.05). Gram-negative species were the most frequently isolated agents in both groups. There were no significant differences between the groups in the frequency of isolated pathogens or antibiotic susceptibility patterns. Overall, the fatality rate was found 16.8%. The elderly patients were more likely to have crude mortality rates (22% vs. 12%; p<0.01). The death was most often related to pneumonia, primary bacteremia or intravascular catheter infections in both groups.

Clinical, diagnostic and therapeutic approaches to complications of brucellosis: an experience of 12 years.

OBJECTIVE: To describe the clinical presentations, laboratory findings, prevalence and pattern of complications and the response to treatment of brucellosis in a 12-year period in a Turkish research hospital. MATERIALS AND METHODS: Between 1996 and 2008, 231 patients were diagnosed with brucellosis and treated in our clinic. Medical records of 189 of the 231 patients with at least one demonstrable complication of the disease were reviewed for anamnesis, diagnosis, complications, treatment and clinical outcomes. RESULTS: The decreasing order of the complications was: hematological, 104 (55%); osteoarticular, 70 (37%); hepatobiliary, 59 (31%), and gastrointestinal, 23 (12%). The most common laboratory findings were anemia, lymphomonocytosis, elevated sedimentation rate and C-reactive protein, and elevated aminotransaminases. CONCLUSION: The hematological, osteoarticular and hepatobiliary manifestations were predominant. Bursitis, synovitis, glomerulonephritis, cutaneous lesion and deep vein thrombosis were the rare complications observed in our study. In clinical practice, brucellosis should be considered in the differential diagnosis in the presence of infrequent complications.

Prevalence and antimicrobial susceptibility of Escherichia coli in outpatient urinary isolates in Izmir, Turkey.

BACKGROUND: Knowledge of antimicrobial resistance pattern in Escherichia coli, the predominant pathogen associated with urinary tract infection (UTI), is important as a guide in selecting empirical antimicrobial therapy. The aim of this study was to determine the antibiotic susceptibility patterns of E. coli strains isolated from adult outpatients with UTI, in Izmir, Turkey. MATERIAL/METHODS: This study was performed with isolates from outpatients with UTI, collected from 5 university and tertiary-care hospitals in Izmir, Turkey. Isolates were analyzed by standard methods and antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion method. RESULTS: A total of 4,534 E. coli strains (3,449 females and 1,085 males) were examined. Antibiotic resistance rates of the isolates for female and male, respectively: Ampicillin (61.8%, 78.7%), amoxicillin-clavulanic acid (36.6%, 59.1%), cefuroxime (22.5%, 41.3%), cefotaxime (18.2%, 35.8%), piperacillin-tazobactam (11.6%, 31.2%), amikacin (8.3%, 13.9%), gentamicin (24.9%, 40%), trimethoprim-sulfamethoxazole (42.1%, 57.3%), and ciprofloxacin/norfloxacin (42.1%, 63.3%). Extended spectrum beta-lactamase rate was found to be 18.3% and 26.1% for females and males, respectively. The isolates were significantly more resistant to all antibiotics in men than in females in this study (p<0.001). CONCLUSIONS: The most important finding of our study is that a considerable proportion of the studied E. coli isolates were resistant to most antibiotics except amikacin. These data provide useful information for clinicians in determining the appropriate empirical antimicrobial regimen, and help authorities to formulate antibiotic prescription policies.

Rate of chronicity and time of disappearance of HBsAg following acute hepatitis B.

BACKGROUND/AIMS: Chronic hepatitis B is associated with significantly increased risk of developing cirrhosis, and hepatocellular carcinoma. It's, therefore, important to understand the incidence and risk factors associated with chronicity following acute hepatitis B. METHODOLOGY: Among 863 acute hepatitis patients admitted consecutively to the hospital, 320 with serum immunoglobulin M antibody to hepatitis B core antigen were classified as acute hepatitis B. Of these patients, serum samples were collected 3 and 6 months after clinical onset. RESULTS: Complete follow-up was achieved in 240 patients and 11 (4.6%) became chronic carriers. Only alcohol addiction other than epidemiological, clinical or biochemical parameters was found to be significantly associated with chronic evaluation. In serum samples collected from 205 of 240 patients 3 months after the onset of infection, hepatitis B surface antigen clearance was observed in 181 (88.3%). Number of patients increased to 194 (94.6%) at the end of 6 month and both of these rates were found to be highly significant. CONCLUSIONS: There is still no certain way of predicting the outcome of acute hepatitis B whether a newly infected patient will resolve the illness or not. Alcohol addiction seems to have an impact on the chronicity but additional research is needed.