Fecal carriage of extended-spectrum beta-lactamase and ampc beta-lactamase-producing enterobacteriaceae in a turkish community.

BACKGROUND: Community-acquired infection caused by extended-spectrum beta-lactamase (ESBL)-producing microorganisms has an increasing frequency. AIM: The aim of this study was to determine the fecal carriage of ESBL and AmpC beta-lactamase-producing Enterobacteriaceae in community and to investigate cefotaxime-M (CTX-M) genes among ESBL isolates. MATERIALS AND METHODS: A total of 1402 fecal specimens which were collected from outpatients included in the study. ESBL screening, ESBL production, and AmpC beta-lactamase detection were performed. Matrix-assisted laser desorption ionization-time-of-flight (MALDI-TOF) was used for identification of species. Antibiotic susceptibilities of the isolates were detected by disk diffusion method. CTX-M beta-lactamase genes were investigated by polymerase chain reaction. RESULTS: During the study period, a total of 1402 fecal samples were analysed with ESBL screening test and 490 Enterobacteriaceae strains isolated from these samples (Escherichia coli [n = 461, 94.1%], Klebsiella pneumoniae [n = 25, 5.1%], and Enterobacter cloacae [n = 4, 0.8%]). Fecal carriage of ESBL-producing Enterobacteriaceae in the community was 34.3%. AmpC beta-lactamases were detected in 26 (5.3%), and the frequency of CTX-M was found as 96.9%. The resistance rates of the E. coli strains to fluoroquinolones, trimethoprim-sulfamethoxazole, and carbapenems were 31.2%, 33.3%, and 0%, respectively. CONCLUSION: The relative high prevalence of fecal carriage of ESBL-producing bacteria in community warrants further study in this field including developing policies about antimicrobial use and close monitoring of resistance patterns.

An unusual case of urinary tract infection caused by Saprochaete capitata under anidulafungin treatment.

Saprochaete capitata may cause uncommon severe infections, especially in immunocompromised patients. Here, we describe a rare case of urinary tract infection by S. capitata in a chronic kidney disease and diabetes mellitus patient, which occur during anidulafungin therapy. Mycological examinations of urine were positive to S. capitata identified by mass spectrometry and confirmed by ITS sequencing. Minimum inhibitory concentration (MIC) of the isolate for amphotericin B, fluconazole, itraconazole, voriconazole and, anidulafungin were 2, 16, 1, 1, and 8µg/mL, respectively. Presence of S. capitata infection was not known. Clinicians should be aware about these rare opportunistic fungal pathogens, particularly those with intrinsic or variable resistance to antifungals including echinocandins.

Could vital signs predict carbon monoxide intoxication?

OBJECTIVE: This retrospective study examined the correlation between carboxy haemoglobin (COHb) levels and vital signs in patients with carbon monoxide (CO) intoxication. METHODS: Over a 10-year period, patients>16 years of age who presented to the emergency department due to CO intoxication were included. Age, gender, comorbidities, month/year of presentation, presenting symptoms, vital signs, blood pH, COHb level, treatment and outcome were recorded. RESULTS: In total, 476 patients were included. The mean±SD age was 36.22±13.65 years; 96.4% of the patients had a normal Glasgow Coma Scale score, 91.0% had normal blood pressure and 80.0% had a normal heart rate. COHb levels were stratified into three groups: <10% (n=39), 10-20% (n=106) and >20% (n=205); levels could not be obtained in the remaining 126 patients. In patients with COHb levels>20%, 34 (16.6%) had alkalosis and nine (4.4%) had acidosis. Among patients with COHb levels>20%, 140 (68.3%) had normal vital signs. CONCLUSIONS: Vital signs cannot be used as a prognostic marker of CO intoxication and, therefore, patients must be monitored closely.

A multicenter case-control study of diagnostic tests for urinary tract infection in the presence of urolithiasis.

Urinary stone disease (USD) alone can cause much morbidity, but when present in conjunction with urinary tract infection, complications and morbidity increase even more. This study investigated the clinical and laboratory findings in patients who had USD with and without infection and evaluated the most suitable diagnostic value for urinary tract infection parameters before urine culture results were available. In a prospective fashion, patients who presented to the emergency department with a complaint of colicky flank pain (with or without hematuria) and who were diagnosed as having urolithiasis with ultrasound were evaluated for 1 year. The gold standard for the diagnosis of urinary tract infection was urine culture. The most suitable diagnostic value for urinary tract infection parameters was determined by receiver operating characteristic (ROC) curves. Logistic regression was used to identify independent variables that predicted a positive urine culture. Of the 192 eligible patients, 177 agreed to participate in the study. Of the clinical and laboratory characteristics analyzed, urine WBC, blood WBC, and fever were significantly different between culture positive and negative patients (p < 0.001, p = 0.04 p = 0.012, respectively). Using ROC curve analysis, pyuria (over 10 WBCs per HPF), fever over 37.9°C, and leucocytosis over 11,300 were the best predictors of a positive culture result. The logistic regression model for leukocytosis >11,300 (OR 2.1), pyuria (OR 2.8), and temperature >37.9°C (OR 3.1) showed a significantly increased risk of having a positive urine culture (correct class 87.9%). While a single physical examination or laboratory finding cannot predict urinary tract infection in USD patients with complete reliability, the presence of pyruria, fever, and leukocytosis significantly increases the odds of a positive urine culture.

Henoch-Schönlein nephritis: a nationwide study.

BACKGROUND/AIM: The aim of this retrospective study was to evaluate the presentation, clinical and pathological manifestations and outcome of the Henoch-Schönlein purpura (HSP) nephritis in children. METHODS: Clinical and laboratory data of 443 children with HSP nephritis aged between 3 and 16 years from 16 pediatric nephrology reference centers were analyzed retrospectively. The biopsy findings were graded according to the classification developed by the International Study of Kidney Disease in Children (ISKDC). RESULTS: Renal biopsy was performed in 179 of the patients with HSP nephritis. The most common presenting clinical finding in patients who were biopsied was nephrotic range proteinuria (25%) which was followed by nephritic-nephrotic syndrome (23.5%). The biopsy findings according to the ISKDC were as follows: class I: 8.3%; II: 44.1%; III: 36.3%; IV: 6.7%; V: 3.3%; VI: 1.1%. All of the patients who developed end-stage renal disease had nephritic-nephrotic syndrome at presentation. Of 443 patients, 87.2% had a favorable outcome and 12.8% had an unfavorable outcome. The overall percentage of children who developed end-stage renal disease at follow-up was 1.1%. Logistic regression analysis did not show any association of initial symptoms and histology with outcome. CONCLUSION: In the presented cohort, the presence of crescents in the first biopsy or presenting clinical findings did not seem to predict the outcome of HSP nephritis in children. We conclude that children with HSP nephritis even with isolated microscopic hematuria and/or mild proteinuria should be followed closely.

Worldwide variation of dialysis-associated peritonitis in children.

Peritonitis is the most common cause of dialysis failure in children on chronic peritoneal dialysis. We performed a prospective study of 501 peritonitis episodes in 44 pediatric dialysis centers located in 14 countries that examined peritonitis etiology, efficiency of opinion-based management guidelines, and final outcomes. Culture-negative incidence varied significantly from 11% in North America to 67% in Mexico. Argentina and North America had the highest rate of Gram-negative episodes. Pseudomonas-based peritonitis was eightfold more common in the United States than in Europe, and correlated with the frequency of exit site cleansing and topical mupirocin administration. Significant regional variation in antibiotic susceptibility was noted for the first generation cephalosporins and aminoglycosides. Initial response rates to standardized empiric antibiotic treatment did not differ between regions; however, final outcomes were significantly less favorable in Eastern Europe. The wide regional variation in culture-negative peritonitis, and the distribution and antibiotic susceptibilities of causative bacteria needs to be taken into consideration when the guidelines for empiric therapy of pediatric dialysis-associated peritonitis are revised.

Mushroom poisoning.

OBJECTIVE: We aimed to review characteristics of mushrooms and mushroom poisoning and compare clinical picture, laboratory data, treatment modalities and prognostic factors in children with amanita intoxication and non-amanita mushroom poisoning. METHODS: We analyzed 39 pediatric patients through 1994-2004, retrospectively from the patient files and evaluated the patients in two groups as patients with amanita intoxication and patients with non-amanita mushroom poisoning. All of the cases were admitted to the hospital in autumn. Twenty three (59%) of the patients were female and 16 (41%) were male. Mean age of the patients was 8.05 +/- 2.10 years. RESULTS: Amanita phalloides toxin was detected in the serum in 8 patients. Eleven (28%) of the cases were strongly suggestive of amanita poisoning but alpha amanitin level could not be studied. The average time of appearance of symptoms after mushroom consumption, duration of symptoms, hospital stay, serum AST, ALT, PT and creatinine levels were significantly higher in patients with amanita poisoning (p<0.01). Conventional therapy, antidote therapy together with hemoperfusion were carried out in 16 (41%) of the patients. Four of the patients in whose blood amatoxin was detected (50%) and 3 of the patients highly suggestive of amanita poisoning (30%), totally 7 patients died of hepatic coma. The average time of admission to hospital, mean AST, ALT, creatinine and PT values at 3rd day were significantly higher in patients who died of hepatic coma. Prognosis was better in case of early admittance to hospital in patients with amanita poisoning. CONCLUSION: Early diagnosis and treatment in mushroom poisoning can be life saving. Public awareness is very important in prevention of intoxication as well as encouraging early admission to hospitals.

Surgical treatment of pulmonary arteriovenous malformation: report of two cases and review of the literature.

Pulmonary arteriovenous malformations (PAVMs) are rare anomalies. The degree of right-to-left shunting, which can lead to cyanosis and paradoxical embolism causing neurological complications, determines the prognosis. We report two cases of PAVM and review the literature. A 45-year-old woman with clinical signs and symptoms of PAVM was examined using several different scanning techniques, which showed a large PAVM in the lower lobe of her right lung. A lobectomy was performed, which revealed a 5 cm diameter PAVM with one feeding artery and multiple veins. Intravenous angiography of a 7-year-old girl with symptoms of fatigue and acro-cyanosis confirmed the presence of a large PAVM in her right lower lobe. The PAVM had two major arteries arising from the aorta, which were ligated during a lobectomy. Both patients recovered well following surgery. Although PAVMs are rare, their neurological and haemodynamic consequences may be fatal. Interventional treatment techniques, including surgery, are usually curative.

Cyclosporin A plus prednisone treatment of steroid-sensitive frequently relapsing nephrotic syndrome in children.

Recently, there have been numerous reports on the use of cyclosporin A (CyA) in children with nephrotic syndrome (NS). In this prospective study, we wanted to evaluate the efficacy of CyA together with prednisone therapy in children with steroid-sensitive frequently relapsing NS. A total of 11 children (7 boys, 4 girls) with steroid-sensitive NS were included in this study. The patients ranged in age from 3.5 to 15 years (average 8.45 +/- 4.26 years). Renal biopsy showed minimal change disease in five, mesangial proliferation in four, focal glomerulosclerosis in one and membranous glomerulonephritis in one. The NS had lasted from 13 to 113 months (average 50.27 +/- 38.60 months). The number of relapses varied from three to 10 episodes with an average of 5.9 +/- 3.3 episodes. Patients received 5 mg/kg CyA daily in two divided doses for five months and prednisone for a total of eight weeks (30 mg/m2 daily for 4 weeks followed by 30 mg/m2 on alternate days for 4 weeks). After the completion of the treatment protocol, no therapy was given unless a relapse was observed. Mean follow-up period was 14.9 +/- 5.99 months with a range from six to 26 months. Before this combined treatment, there was a mean relapse rate of 0.144 +/- 0.05 relapses month with a range from 0.088 to 0.238. After discontinuation of therapy, the relapse rate dropped to a mean of 0.0179 +/- 0.031 with a range of 0 to 0.083. In conclusion, it would appear that a combination of CyA and prednisone is effective, sustaining the remission in steroid-sensitive NS. Corticosteroids in combination with CyA may be a better approach than conventional steroid treatment in such patients.

Does immunologic status predict peritonitis in children treated with CAPD?

The purpose of this study was to evaluate whether immunologic status could predict the development of peritonitis in children on continuous ambulatory peritoneal dialysis (CAPD). Twenty-one patients (12 boys, 9 girls) aged 10.1 +/- 4.32 years (range: 23 months to 14 years) were studied. The mean duration of CAPD treatment was 12.88 +/- 6.69 months (range: 2-22 months). Twelve healthy children (mean age 11.5 years) were selected as a control group. Lymphocyte subpopulations (CD3, CD4, CD8, CD19, NK, and IL-2R) were determined by double-color flow cytometry (Becton-Dickinson). Statistical evaluation was made by Student's t-test. CD4 (38.4 +/- 7.1% vs. 28.0 +/- 5.4%), CD4/CD8 ratio (1.30 +/- 0.4 vs. 0.96 +/- 0.3), and B lymphocyte (19.9 +/- 8.9% vs. 12.0 +/- 3.2%) levels were significantly higher in CAPD patients compared with controls. CAPD patients showed significantly lower natural killer (NK) cell values than controls (12.7 +/- 7.0% vs. 27.3 +/- 8.3%). Apart from CD19 values (21.9 +/- 10.4% vs. 12.0 +/- 3.2%) there were no significant differences between CAPD patients without infection and the control group in the laboratory parameters studied. On the other hand, CD3 (66.3 +/- 7.9% vs. 55.9 +/- 9.7%), CD4 (38.4 +/- 7.1% vs. 28.0 +/- 5.4%), and CD19 (6.3 +/- 3.3% vs. 12.0 +/- 3.2%) levels were significantly higher in CAPD patients with infection compared with the controls. CAPD patients with infection showed significantly lower NK activity (12.7 +/- 7.1% vs. 27.3 +/- 8.3%) than those in the control group. In conclusion, these results can explain the increased vulnerability to peritonitis in CAPD patients compared with healthy subjects. Additionally, immunologic status can predict the development of peritonitis in children treated with CAPD.

Echocardiographic evaluation in children treated with CAPD.

The aim of this study was to evaluate systolic and diastolic cardiac functions in children treated with continuous ambulatory peritoneal dialysis (CAPD). This study included a total of 21 patients (12 boys, 9 girls), aged 23 months to 14 years (average age: 10.1 +/- 4.32 years). The mean duration on CAPD was 12.88 +/- 6.69 months (range: 2-22 months). Twenty age- and sex-matched healthy subjects served as controls. Evaluation was made at the beginning of CAPD treatment in these 21 patients. Tests were repeated in 9 of 21 patients who had completed a 1-year follow-up period. We measured systolic functions [ejection fraction (EF), and fractional shortening (FS)], and diastolic functions [early (E) and late (A) diastolic peak inflow velocities, and E/A ratio, as well as early diastolic flow deceleration velocity (EF slope) and time (dt) functions] using two-dimensional, M-mode, color Doppler echocardiography. Interventricular septum thickness was also recorded. Blood pressure (BP) levels were monitored serially in all patients. Statistical evaluation was made using Student's t-test. Compared with control subjects, systolic and diastolic parameters were significantly inversely affected in patients on CAPD (P < 0.05). The mean BP levels did not differ significantly between CAPD patients and controls. In 9 patients with a second measurement on CAPD, systolic and diastolic cardiac functions tended to have deteriorated. However, these changes were not statistically significant (P > 0.05). In conclusion, CAPD is the preferable option in children with end-stage renal disease to maintain stable cardiac functions. However, systolic and diastolic dysfunctions tend to progress in children on CAPD.