Clinical and microbiological efficacy and toxicity of colistin in patients infected with multidrug-resistant gram-negative pathogens.

Polymyxins have recently again become important because of multidrug-resistant (MDR) gram-negative pathogens. The aim of this study was to evaluate the clinical and microbiological efficacy and toxicity of different dosages of colistin in patients infected with MDR microorganisms that were sensitive only to colistin. The study was conducted in the 1,200-bed Ankara Numune Training and Research Hospital. Patients with normal renal function who received colistin for 48 h or more were retrospectively evaluated. Clinical response was defined as resolution of fever and clinical and laboratory findings. Microbiological response was defined as bacteriological eradication from the infection site. Nephrotoxicity was defined as at least two consecutive serum creatinine measurements with an increase of 0.5 mg/dl from baseline at least 24 h apart after 2 or more days of colistin therapy. Twenty-four patients were included in the study: total clinical response was obtained in 17 of 24 (70.8 %) patients and microbiological response in 15 of 24 (62.5 %) patients. Patients were grouped according to colistin dosage of 3 × 1 million units (MU) versus 3 × 2 MU. Clinical response rates were 69.2 % and 72.7 %, respectively (p = 0.65). Microbiological response rate was similar (p = 0.62). Nephrotoxicity was revealed in 1 of 13 patients (7.7 %) for the 3 × 1 MU group and 2 of 11 patients (18.2 %) in the 3 × 2 MU group (p = 0.57). The nephrotoxicity rate was greater with higher dosages of colistin, but the difference was not statistically significant. Renal function of patients receiving higher dosages of colistin should be more closely monitored.

[Evaluation of tularemia cases originated from Central Anatolia, Turkey]. / Orta Anadolu Kaynakli Tularemi Olgularinin Degerlendirilmesi.

Tularemia is an infection caused by Francisella tularensis with a worldwide distribution and diverse clinical manifestations. In recent years, tularemia cases are increasing in Turkey, with a special attention to Marmara, western Blacksea and Central Anatolia regions. The aim of this study was to evaluate tularemia cases admitted to our hospital during an outbreak emerged at Central Anatolia between December 2009 and September 2010, making a point for the disease. A total of 32 patients (17 female, 15 male; age range: 15-80 years, mean age: 41 ± 16 years) with fever, sore throat, cervical mass and failure to respond to beta-lactam antibiotics, were followed up with the preliminary diagnosis of tularemia. The diagnosis was confirmed by specific laboratory tests. Serum samples were obtained from 25 patients and in 17 (68%) of them microagglutination test yielded positive result (≥ 1/160) in their first serum samples. All of the 8 patients who had negative results in their first samples (< 1/160), revealed seroconversion in their second samples. In 10 (91%) of the 11 patients from whom lymph node aspirates were obtained, PCR performed with species specific (tul4) primers yielded positivity and subspecies differentiation done by RD1 primers identified the agent as F.tularensis subspecies holarctica. F.tularensis growth was not detected in the cultures of lymph aspirates and/or throat swabs of the cases (n= 16). All the patients had oropharyngeal tularemia and eight of them also had oculoglandular form. The mean duration of the symptoms were 25.6 ± 17.2 (2-60) days. They had a history of oral intake of contaminated water. Cervical or submandibular lymphadenopathy were detected in all patients. One patient had cervical abscess and the other one had erythema nodosum. Elevated sedimentation rate was found in 26 (81.3%) patients and elevated CRP in 24 (75%) patients. Spontaneous drainage was detected in nine cases during follow-up. Lymph node aspiration was performed in patients when fluctuation was detected. Streptomycin 2 g/day for 10 days was given to 21 patients and doxycycline 2 x 100 mg for 14 days was given to 11 patients. Twelve (37.5%) patients received further antibiotic treatment since they failed to respond to the first therapy. Of the patients, 21 recovered completely and two patients had lymph node excision. No severe complications were observed. The patients who applied to the hospital within 10 days of the initiation of the symptoms were treated successfully, while the others that applied later were not. In conclusion, tularemia which is an endemic disease in Turkey, should be kept in mind in patients with fever, sore throat and lymphadenopathy.

[A rare cause of nosocomial bacteremia: Sphingomonas paucimobilis]. / Sphingomonas paucimobilis: nadir bir hastane kaynakli bakteriyemi etkeni.

Sphingomonas paucimobilis, is a yellow-pigmented, aerobic, non-fermentative, non-spore-forming, gram-negative bacillus. Infections by S. paucimobilis which is widely found in nature and hospital environments are rarely serious or life threatening. In this report we present a case of hospital acquired bloodstream infection due to S. paucimobilis. The patient had a history of hydrocephalus diagnosed at sixth months of his birth and had experienced two ventriculoperitoneal shunt surgery. He was hospitalized and been treated for bronchopneumonia. On the 47th day of hospitalization, blood cultures (BACTEC, Becton Dickinson, USA) were taken because of a body temperature of 38.5 degrees C. One of the blood cultures was positive for gram-negative rods. After 48 h of incubation, the sub-cultures on blood agar medium yielded pure growth of a yellow, non-fermentative, gram-negative, rod-shaped bacterium. The microorganism was positive for oxidase, and esculin hydrolysis, while negative for urea and nitrate reduction and citrate utilisation. Motility was negative as well. The isolate has been identified as S. paucimobilis by using mini API (bioMerieux, France) system. The antibiotic susceptibility test was also performed with the same system and the strain was found susceptible to ceftazidime, ceftriaxone, cefoperazone, cefepime, cefotaxime, ciprofloxacin, imipenem, piperacillin-tazobactam, aztreonam, amikasin and gentamicin. Treatment with intravenous ceftriaxone (2 x 750 mg/day) was initiated. He responded well to the treatment and discharged on the tenth day. This case was reported to emphasize that S. paucimobilis should be kept in mind as a nosocomial infectious agent and the infections should be treated according to the sensitivity test results.

[Case report: subdural hemorrhage in neurobrucellosis]. / Olgu raporu: subdural kanama ile seyreden nörobrusellozis.

In this report, a 49-year-old female patient who were diagnosed as neurobrucellosis by the clinical, bacteriologic and serologic findings, has been presented. The case deserved presentation and discussion since it presented with subdural hemorrhage which is a rare complication of neurobrucellosis.