Discontinuation of Nucleos(t)ide Analog treatment in HBeAg-Negative Non-Cirrhotic Chronic Hepatitis B Patients: Real-Life Data of 20 Years.

BACKGROUND/AIMS: Discontinuation of nucleos(t)ide analog is controversial in HBeAg-negative chronic hepatitis B patients not achieved HBsAg loss. We aimed to evaluate re-treatment rates and risk factors in non-cirrhotic HbeAg-negative chronic hepatitis B patients for whom nucleosi(t)ides analogs were discontinued. MATERIALS AND METHODS: Demographic, clinical, and laboratory data before and at the end after discontinuation of nucleos(t)ide analogs were collected retrospectively. RESULTS: Seventy-two patients followed up between January 2000 and December 2019 were included; 43 were male, with a mean age of 46.3 (±10.8). Baseline median alanine aminotransferase (ALT) and hepatitis B virus DNA levels were 55.5 IU/L and 465 925 IU/mL, respectively. The median histologic activity index was 5.5 and the fibrosis score was 2. The median duration of treatment and consolidation therapy were 59 and 56 months, respectively. The median follow-up time after discontinuation of treatment was 55 months. Among 56 patients eligible for evaluation according to proposed re-treatment criteria, 29 (51.7%) patients were re-treated. The median time for relapse was 11 months. Re-treatment was significantly common in males (P = .034) and patients treated with tenofovir/entecavir (P = .04). Baseline hepatitis B virus DNA and levels of ALT, aspartate aminotransferase (AST) at the third and sixth months of treatment and at the end of treatment were statistically significantly higher in re-treated patients. A cutoff value of ≥405 000 IU/L for hepatitis B virus DNA discriminated patients for re-treatment. HBsAg was lost permanently in 2 non-re-treated patients. CONCLUSION: In resource-limited areas where follow-up of HBsAg or other markers is not possible, nucleos(t)ide analog discontinuation can be considered in patients in the early stage, with low baseline hepatitis B virus DNA and ALT levels, after a long consolidation therapy.

Can treatment with teicoplanin improve the prognosis of COVID-19 patients?

AIM: In patients with COVID-19, no validated efficient treatment has been reported. Herein, we examine the effect of treatment with teicoplanin in hospitalised patients with COVID-19. METHODS: This retrospective study included 115 hospitalised patients in one medical centre. Fifty-four patients with laboratory-confirmed COVID-19 who received teicoplanin plus standard care were included in the Teicoplanin arm of this study, whereas 61 patients who were treated with standard care (SC) according to the Turkish Health Organization guidelines were included in the control arm. Patients' baseline characteristics, clinical presentation, treatment and outcomes were compared between the two groups. RESULTS: In this non-randomised control study, all baseline characteristics were comparable between the two arms and there were no significant differences in the presenting symptoms, comorbidities and clinical outcomes between the two groups. However, the mortality rate was significantly lower in the teicoplanin group than in the control group (1.9% vs 14.8%; P < .05). In addition, no adverse reactions were found in the teicoplanin arm. CONCLUSIONS: Teicoplanin administration is associated significantly with lower mortality in hospitalised patients with COVID-19 in our study. Further clinical investigations is required to verify the role of teicoplanin in COVID-19 patients.

Prevalence and mortality of cancer among people living with HIV and AIDS patients: a large cohort study in Turkey.

BACKGROUND: Cancer is responsible for elevated human immunodeficiency virus (HIV)-related mortality but there are insufficient data about cancer in HIV-positive patients in Turkey. AIMS: We aimed to investigate the prevalence and mortality of cancer among people living with HIVand AIDS patients in Istanbul, Turkey. METHODS: Between January 1998 and December 2016, people living with HIVand AIDS patients were enrolled in this study by the ACTHIV-IST Study Group, which consists of 5 centres to follow-up HIV-positive patients in Istanbul. The cancer diagnoses included AIDS-defining cancers (ADCs) and non AIDS-defining cancers (NADCs). RESULTS: Among 1872 patients, 37 (1.9%) were diagnosed with concurrent cancer. Eleven patients were diagnosed during follow-up; the prevalence of cancer among people living with HIVand AIDS patients was 2.6%. Among 48 cancer patients, 35 patients had ADCs, and 32 of them were diagnosed at their first hospital admission. There were 1007 late presenters and 39 of them had cancer (29 were ADCs). The most prevalent NADCs were gastrointestinal, genitourinary, and pulmonary cancers. NADCs were mostly diagnosed during follow-up of patients. The mortality of this group was significantly higher than that of patients with ADCs (53.9% vs 22.9%). CONCLUSIONS: These results indicate the importance of cancer screening at diagnosis and during follow-up of HIV infection. A detailed physical examination contributes to diagnosis of the most prevalent ADCs (Kaposi's sarcoma and non-Hodgkin's lymphoma), especially in late presenters. For NADCs, individual risk factors should be considered.

Influence of multidrug resistant organisms on the outcome of diabetic foot infection.

OBJECTIVES: We described the clinical outcomes of the diabetic patients who had foot infections with multidrug resistant organisms. METHODS: We included the patients with diabetic foot infections (DFI) from 19 centers, between May 2011 and December 2015. Infection was defined according to IDSA DFI guidelines. Patients with severe infection, complicated moderate infection were hospitalized. The patients were followed-up for 6 months after discharge. RESULTS: In total, 791 patients with DFI were included, 531(67%) were male, median age was 62 (19-90). Severe infection was diagnosed in 85 (11%) patients. Osteomyelitis was diagnosed in 291(36.8%) patients. 536 microorganisms were isolated, the most common microorganisms were S. aureus (20%), P. aeruginosa (19%) and E. coli (12%). Methicillin resistance (MR) rate among Staphylococcus aureus isolates was 31%. Multidrug resistant bacteria were detected in 21% of P. aeruginosa isolates. ESBL (+) Gram negative bacteria (GNB) was detected in 38% of E. coli and Klebsiella isolates. Sixty three patients (8%) were re-hospitalized. Of the 791 patiens, 127 (16%) had major amputation, and 24 (3%) patients died. In multivariate analysis, significant predictors for fatality were; dialysis (OR: 8.3, CI: 1.82-38.15, p=0.006), isolation of Klebsiella spp. (OR:7.7, CI: 1.24-47.96, p=0.028), and chronic heart failure (OR: 3, CI: 1.01-9.04, p=0.05). MR Staphylococcus was detected in 21% of the rehospitalized patients, as the most common microorganism (p<0.001). CONCLUSION: Among rehospitalized patients, methicillin resistant Staphylococcus infections was detected as the most common agent, and Klebsiella spp. infections were found to be significantly associated with fatality.

Association between biofilm and multi/extensive drug resistance in diabetic foot infection.

PURPOSE: We aimed to determine significant risk factors for biofilm production and to investigate the association between antimicrobial resistance profile and biofilm formation in the bacterial isolates obtained from patients with diabetic foot infection (DFI). METHODS: Demographic, clinical, laboratory and outcome data of 165 patients, prospectively recorded and followed between January 2008 and December 2015 by a multidisciplinary committee, were analysed. Standard microbiological methods were adopted. Risk factors associated with biofilm were determined by univariate and multivariate analyses. RESULTS: The overall rate of biofilm production among 339 wound isolates was 34%. The biofilm production rate was significantly higher in Gram-negative micro-organisms (39%) in comparison with Gram positives (21%) (P = .01). A. baumannii presented the highest biofilm production (62%), followed by P. aeruginosa (52%) and Klebsiella spp. (40%). On univariate analysis, significant factors associated with biofilm were antibiotic use within last 3 months (OR:2.94, CI: 1.5-5.75, P = .002), recurrent DFI within last 6 months (OR:2.35, CI: 1.23-4.53, P = .01), hospitalisation within last 3 months due to ipsilateral recurrent DFI (OR:2.44, CI: 1.06-5.58, P = .03), presence of amputation history (OR: 2.20, CI: 1.14-4.24, P = .01), multidrug-resistant (MDR) micro-organism (OR: 7.76, CI: 4.53-13.35, P<.001) and extensively drug-resistant (XDR) micro-organism (OR:11.33, CI:4.97-26.55, P<.001). Multivariate regression analysis revealed two variables to be significant factors associated with biofilm: MDR micro-organism (OR: 3.63, CI: 1.58-8.33, P = .002) and XDR micro-organism (OR:4.06, CI: 1.25-13.1, P = .01). CONCLUSIONS: Multi/extensive drug resistance and previous recurrent DFIs were significantly associated with biofilm formation in patients with diabetic foot.

Adherence to Antiretroviral Therapy in Turkey: Results from the ACTHIV-IST Study Group.

Maintaining optimal adherence to antiretroviral therapy (ART) is essential for optimizing the management of HIV infection. The aim of this study is to explore ART adherence rates in Turkey. Included in this study were a total of 263 HIV-infected patients followed up by the ACTHIV-IST (ACTion against HIV in Istanbul) Study Group affiliated with four tertiary hospitals. The study population included patients 18 years of age or older who were on ART for over 12 months. Adherence was assessed by the medication possession ratio (MPR) calculated for each patient using data (a list of all drugs dispensed within the previous year for that patient) obtained from pharmacy medication records. In addition, patients completed a self-report questionnaire addressing missed doses and the AIDS Clinical Trials Group (ACTG) adherence questionnaire. The study was reviewed and approved by the Ethics Committee of Cerrahpasa Medical Faculty. Patient ages ranged from 19 to 71 years. Two hundred and thirty-one patients were male (88%). Two hundred and twenty-four patients (85%) had optimal adherence (MPR ≥95%). During the course of ART, 236 patients (90%) reported no missed doses in the past 4 days of their treatment, whereas 206 patients (78%) reported no missed doses in the past month. Simply forgetting was the most common reason for nonadherence. MPR was associated with virologic rebound. Major factors affecting adherence were being female, taking antituberculosis drugs, having an opportunistic infection, being able to take all or most of the medication as directed, and being aware of the need to take medication exactly as instructed to prevent the development of drug resistance. Adherence to ART measured by MPR and self-report surveys is relatively high in Turkey when compared with other countries, which probably led to high ART success rates.

Hydrocephalus and vasculitis delay therapeutic responses in tuberculous meninigitis: Results of Haydarpasa-III study.

AIMS: There is no report on the factors affecting the resolution of symptoms related to meningitis during treatment of tuberculous meningitis (TBM). Thus, we examined the factors associated with early therapeutic responses. MATERIALS AND METHODS: This multicenter study included 507 patients with microbiologically confirmed TBM. However, 94 patients eligible for the analysis were included in this study from 24 centers. Six out of 94 patients died and the statistical analysis was performed with 88 survivors. Early and late responder groups were compared in the statistical analysis. P < 0.05 were considered to show a significant difference. RESULTS: In the multivariate analysis, the presence of vasculitis (P = 0.029, OR = 10.491 [95% CI, 1.27-86.83]) was found to be significantly associated with a delayed fever response whereas hydrocephalus was associated with altered mental status for >9 days duration (P = 0.005, OR = 5.740 [95% CI, 1.68-19.57]). According to linear regression analysis, fever was significantly persisting (>7 days) in the presence of vasculitis (17.5 vs. 7, P< 0.001) and hydrocephalus (11 vs. 7, P = 0.029). Hydrocephalus was significantly associated with persisting headache (21 vs. 12, P = 0.025), delayed recovery of consciousness (19.5 vs. 7, P = 0.001), and a delay in complete recovery (21 vs. 14, P = 0.007) in the linear regression analysis. Following institution of treatment, the complaints seemed to disappear in up to 2 weeks among TBM survivors. CONCLUSIONS: In the absence of hydrocephalus or vasculitis, one week of anti-tuberculosis treatment seems to be adequate for the resolution of TBM symptoms. Hydrocephalus and vasculitis delay the resolution of TBM symptoms in response to antimycobacterial treatment.

Cat Scratch Disease in a Renal Transplant Recipient.

Cat scratch disease (CSD) is a disorder characterized by self-limited regional lymphadenopathy and fever. We reported a case of CSD in a kidney transplant recipient who presented with fever and lymphadenopathy. Lymph node biopsy demonstrated bacterial histiocytic lymphadenitis. The patient was diagnosed with CSD. Patient had good clinical improvement after treatment. Therefore, CSD should also be borne in mind for kidney recipients though CSD had been infrequently reported in this group.

Changes in HIV demographic patterns in a low prevalence population: no evidence of a shift towards men who have sex with men.

OBJECTIVES: This study aimed to examine the changes in HIV demographics over time in an exceptionally low prevalence population, with particular emphasis on men who have sex with men (MSM). METHODS: A total of 1292 newly diagnosed HIV-positive patients registered in the ACTHIV-IST Study Group database between 2000 and 2014 were included. The changes occurring over time in the characteristics of patients at the time of initial admission were examined retrospectively. RESULTS: A gradual increase in the total number of newly diagnosed patients was evident during the study period; however, it was not possible to show an increase in the proportion of MSM within the study population (p=0.63). There was a male predominance throughout the study (85% vs. 15%), with further increases in the proportion of males in recent years. The mean age was lower at the end of the study (p<0.05) and there was an increase in the number of unmarried patients (p<0.05). CONCLUSIONS: Sexual preference patterns of HIV patients in extremely low prevalence populations may be different, possibly due to an early phase of the epidemic. Nevertheless, MSM still represent a target subgroup for interventions, since they account for a substantial proportion of cases and a resurgent epidemic may be expected among this group in later phases of the epidemic.

The Syrian conflict and infectious diseases.

The conflict in Syria is a big humanitarian emergency. More than 200,000 Syrians have been killed, with more than half of the population either having been displaced or having immigrated. Healthcare has been interrupted due to the destruction of facilities, a lack of medical staff, and a critical shortage of life-saving medications. It produced suitable conditions leading to the re-emergence of tuberculosis, cutaneous leishmaniasis, polio, and measles. Lebanon and Jordan reported increased rates of tuberculosis among Syrian refugees. Cutaneous leishmaniasis outbreaks were noted not only in Syria but also in Turkey, Jordan, and Lebanon. After a polio-free 15 years, Syria reported a polio outbreak. Ongoing measles outbreaks in the region was accelerated by the conflict. Iraq declared a cholera outbreak among the Syrian refugees. The healthcare facilities of the countries hosting immigrants, mainly Turkey, Lebanon, Jordan, Iraq, and Egypt, are overburdened. The majority of the immigrants live in crowded and unsanitary conditions. Infectious diseases are big challenges for Syria and for the countries hosting immigrants. More structured support from international organizations is needed for the prevention, control, diagnosis, and treatment of infectious diseases.

Bilateral idiopathic granulomatous mastitis.

OBJECTIVES: Idiopathic granulomatous mastitis (IGM) is a benign rare inflammatory pseudotumor. Bilateral involvement of IGM has been reported in a few cases. To our knowledge, this study is the largest series of bilateral cases to date. The goals of this study were to present clinical features of bilateral IGM and to evaluate the results of treatments. MATERIALS AND METHODS: We performed a retrospective review of the idiopathic granulomatous mastitis database from 2010 to 2013. Ten female patients who met required histologic and clinical criteria of IGM in both breasts were included in study. Demographic data, clinical findings, medication history, and radiologic findings are presented. RESULTS: The mean age at onset of the disease was 38.4 ± 8.3 years (range: 29-52 years). Nine patients had no recurrence during a mean follow-up period of 21 months (range: 11-26 months). Additionally, the median time to second breast involvement was 15.6 months. CONCLUSION: Bilateral IGMs have a higher rate of more relapse and greater resistance to medical therapies than do unilateral IGMs. Surgical management should be avoided unless all medical treatment options have been exhausted. Nevertheless, expectant management seems a rational option for the treatment of bilateral IGM.

Early Changes of Mannose-Binding Lectin, H-Ficolin, and Procalcitonin in Patients with Febrile Neutropenia: A Prospective Observational Study.

OBJECTIVE: The significance of mannose-binding lectin (MBL) and H-ficolin deficiency in febrile neutropenic (FN) patients and the correlation of these markers along with consecutive C-reactive protein (CRP) and procalcitonin (PCT) levels during the infectious process are investigated. MATERIALS AND METHODS: Patients with any hematological malignancies who were defined to have "microbiologically confirmed infection", "clinically documented infection", or "fever of unknown origin" were included in this single-center prospective observational study. Serum levels of CRP, PCT, MBL, and H-ficolin were determined on 3 separate occasions: at baseline (between hospital admission and chemotherapy), at the onset of fever, and at the 72nd hour of fever. RESULTS: Forty-six patients (54% male, mean age 41.7 years) with 61 separate episodes of FN were evaluated. Eleven patients (23.9%) had "microbiologically confirmed infection", 17 (37%) had "clinically documented infection", and 18 (39.1%) had "fever of unknown origin". Fourteen (30.4%) patients had low (<500 ng/mL) initial MBL levels and 7 (15.21%) had low (<12,000 ng/mL) H-ficolin levels. Baseline MBL and H-ficolin levels did not significantly change on the first and third days of fever (p=0.076). Gram-negative bacteremia more frequently occurred in those with low initial MBL levels (p=0.006). PCT levels were significantly higher in those with microbiologically documented infections. Mean and median PCT levels were significantly higher in cases with bacteremia. There was no significant difference between hemoculture-positive and-negative patients in terms of CRP levels. CONCLUSION: Monitoring serum H-ficolin levels was shown to be of no benefit in terms of predicting severe infection. Low baseline MBL levels were correlated with high risk of gram-negative bacteremia; however, no significant correlation was shown in the follow-up. Close monitoring of PCT levels is warranted to provide more accurate and specific data while monitoring cases of bacteremia.

The Changing Epidemiology of Bloodstream Infections and Resistance in Hematopoietic Stem Cell Transplantation Recipients.

OBJECTIVE: Patients receiving hematopoietic stem cell transplantation (HSCT) are exposed to highly immunosuppressive conditions and bloodstream infections (BSIs) are one of the most common major complications within this period. Our aim, in this study, was to evaluate the epidemiology of BSIs in these patients retrospectively. MATERIALS AND METHODS: The epidemiological properties of 312 patients with HSCT were retrospectively evaluated. RESULTS: A total of 312 patients, followed between 2000 and 2011, who underwent autologous (62%) and allogeneic (38%) HSCT were included in the study. The most common underlying malignancies were multiple myeloma (28%) and Hodgkin lymphoma (21.5%). A total of 142 (45%) patients developed at least 1 episode of BSI and 193 separate pathogens were isolated from the blood cultures. There was a trend of increase in the numbers of BSIs in 2005-2008 and a relative increase in the proportion of gram-positive infections in recent years (2009-2011), and central venous catheter-related BSI was found to be most common source. Coagulase-negative staphylococci (49.2%) and Acinetobacter baumannii (8.8%) were the most common pathogens. Extended-spectrum beta-lactamase-producing strains were 23% and 22% among Escherichia coli and Klebsiella spp. isolates, respectively. Quinolone resistance was detected in 10% of Enterobacteriaceae. Resistance to carbapenems was not detected in Enterobacteriaceae, while it was seen at 11.1% and 23.5% in Pseudomonas and Acinetobacter strains, respectively. CONCLUSION: A shift was detected from gram-negative bacteria to gram-positive in the etiology over the years and central lines were the most common sources of BSIs.

Antituberculosis drug resistance patterns in adults with tuberculous meningitis: results of haydarpasa-iv study.

BACKGROUND: Tuberculous meningitis (TBM) caused by Mycobacterium tuberculosis resistant to antituberculosis drugs is an increasingly common clinical problem. This study aimed to evaluate drug resistance profiles of TBM isolates in adult patients in nine European countries involving 32 centers to provide insight into the empiric treatment of TBM. METHODS: Mycobacterium tuberculosis was cultured from the cerebrospinal fluid (CSF) of 142 patients and was tested for susceptibility to first-line antituberculosis drugs, streptomycin (SM), isoniazid (INH), rifampicin (RIF) and ethambutol (EMB). RESULTS: Twenty of 142 isolates (14.1 %) were resistant to at least one antituberculosis drug, and five (3.5 %) were resistant to at least INH and RIF, [multidrug resistant (MDR)]. The resistance rate was 12, 4.9, 4.2 and 3.5 % for INH, SM, EMB and RIF, respectively. The monoresistance rate was 6.3, 1.4 and 0.7 % for INH, SM and EMB respectively. There was no monoresistance to RIF. The mortality rate was 23.8 % in fully susceptible cases while it was 33.3 % for those exhibiting monoresistance to INH, and 40 % in cases with MDR-TBM. In compared to patients without resistance to any first-line drug, the relative risk of death for INH-monoresistance and MDR-TBM was 1.60 (95 % CI, 0.38-6.82) and 2.14 (95 % CI, 0:34-13:42), respectively. CONCLUSION: INH-resistance and MDR rates seemed not to be worrisome in our study. However, considering their adverse effects on treatment, rapid detection of resistance to at least INH and RIF would be most beneficial for designing anti-TB therapy. Still, empiric TBM treatment should be started immediately without waiting the drug susceptibility testing.

More on hepatic granulomas.

We have read the case report of Nihon-Yanagi et al. The patient they described developed hepatic granuloma two times and the granulomatous lesion was surrounding metal staples/clips suggesting that the granuloma was due to surgical staples/clips. Hepatic granulomas (HGs) are reported in around 5% of patient who undergo a liver biopsy and caused by several diseases including sarcoidosis, tuberculosis, hydatid cyst, brucellosis, typhoid fever, chronic hepatitis B and C and primary biliary cirrhosis (PBC). Chronic hepatitis B and C infections are the most common and serious causes of liver damage in patient with renal failure. Their prevalence is a higher than people without renal failure. We have previously reported that the prevalences of HGs in patients with chronic hepatitis B and C are 1.5 and 1.3% respectively. The described patient was on hemodialysis for 12 years. The other causes of HG seem excluded; however hepatitis B and C infections and PBC should have been tested and excluded before ascribing the HGs to surgical staples/clipping material.