Evaluation of more than one billion outpatient prescriptions and eight-year trend showing a remarkable reduction in antibiotic prescription in Turkey: A success model of governmental interventions at national level.

PURPOSE: To present the antibiotic prescription trend between 2011-2018 at primary healthcare in Turkey in order to evaluate the effects of interventions at national level for providing rational prescription of antibiotics. METHODS: Electronic prescription data of the family physicians collected from January 1, 2011 to December 31, 2018 in 81 provinces of Turkey were recorded through the Prescription Information System and screened for the antimicrobial drugs. The interventions to promote rational antibiotic use during 2011-2018 in Turkey includes reminding the legislation to stop access of antibiotics without prescription, monitoring of antibiotic prescription behaviors of primary healthcare physicians, and education of healthcare workers and the public on the appropriate use of antibiotics. RESULTS: A total of 1 054 261 396 prescriptions for outpatients of all age groups were recorded during this period. Of the prescriptions written by family physcians, 34.94% were containing at least one antibiotic in 2011, which declined to 24.55% in 2018. Antibiotics constituted 13.99% of all the items in prescriptions in 2011 and 10.47% in 2018. Percentage of total antibiotic expenditure to the total drug expanditure decreased from 14.14% to 4.12% during 2011-2018. The most commonly prescribed antibiotics were amoxicillin and enzyme inhibitor combination, cefdinir, and cefuroxime during 2011-2018, with an increasing trend for prescription of first-line antibiotic, amoxicillin, in recent years. CONCLUSIONS: Governmental interventions at national level have contributed to reducing antibiotic prescription and increasing preference of first-line antibiotics at primary healthcare level in Turkey over a course of 8 years. Turkey's model of governmental interventions may set an example for other countries with high consumption of antibiotics, and contribute to the actions against antimicrobial resistance worldwide.

[The Epidemiology of Carbapenemases in Escherichia coli and Klebsiella pneumoniae Isolated in 2019 in Turkey]. / Türkiye'de 2019 Yili Içinde Izole Edilen Escherichia coli ve Klebsiella pneumoniae Izolatlarinda Karbapenemaz Epidemiyolojisi.

Antibiotic resistance is one of the most important public health problem and one of the most critical steps in preventing resistance is the monitorization of the resistance. Local, regional and global monitoring enables the spread of antibiotic resistance to be understood more clearly. In this study, it was aimed to evaluate the results of the pilot study for the establishment of molecular-based carbapenem surveillance system in Escherichia coli and Klebsiella pneumoniae isolates and to investigate the carbapenemase epidemiology in Turkey. Hospitals (n= 28) from 26 different statistical level II regions from Turkey were included in the study. The hospitals participated in the study submitted ten carbapenem susceptible and ten carbapenem resistant E.coli and K.pneumoniae isolates to our laboratory that were isolated in two different periiods of six-month either between 1 March-31 August or 1 April-30 September 2019. A total of 509 isolates were collected from 26 of the 28 participating hospitals in the study. Isolates were identified by matrix assisted laser desorptionization-time of flight mass spectrophotometry (MALDI TOF MS) (Bruker Daltonics, Germany) method and antibiotic susceptibility tests for imipenem, meropenem and colistin were studied by broth microdilution. Moreover, susceptibilities to amikacin, amoxicillin-clavulanic acid, ampicillin, aztreonam, cefepime, cefotaxime, ceftazidime, ciprofloxacin, ertapenem, gentamicin, piperacillin-tazobactam, tobramycin and trimethoprim-sulfamethoxazole were determined by disc diffusion method. The resistance genes were investigated in isolates which were found to be phenotypically resistant to carbapenem and colistin, in house method was used to investigate carbapenemase genes and a commercial colistin resistant real-time PCR kit (Biospeedy, Turkey) was used for colistin resistance genes. In total, 493 of the 509 isolates collected from hospitals were identified as E.coli (25.7%, n= 127) and K.pneumoniae (74.3%, n= 366) and included in the study. It was determined that 31% of the isolates evaluated were from community-acquired infections and 69% were either from healthcare-associated infections or from colonization sites. Among the tested isolates, 248 (50.3%) were susceptible to carbapenems and 245 (49.7%) were resistant. The types of carbapenemases in carbapenemase-producing were OXA-48 (52.2%), KPC (16.1%), NDM-1 (15%), OXA-48 + NDM-1 (12.6%), KPC + NDM-1 (2.8%) and VIM (0.5%) and OXA-48+VIM (0.5%). Resistance to colistin was detected in 23.3% of the isolates but mcr1-8 genes were not detected. It was found that all colistin resistant isolates are resistant to at least one of the carbapenems. The importance of a molecular-based antimicrobial resistance surveillance system in our country was demonstrated with this pilot study. It is thought that continuous monitoring of these epidemiological features will contribute to the management of infections due to carbapenemase-producing organisms.

SARS-CoV-2 Presence in the Saliva, Tears, and Cerumen of COVID-19 Patients.

OBJECTIVES/HYPOTHESIS: The emergence of a new coronavirus strain (SARS-CoV-2) in December 2019 from China led to a global pandemic. The lack of herd immunity against this virus and the possibility of viral spread from asymptomatic individuals is still a major challenge for the prevention of viral transmission. The aim of this study was to evaluate the presence of the virus in different bodily secretions as a potential source of viral spread among patients infected with SARS-CoV-2. STUDY DESIGN: Cross Sectional Study. METHODS: The study included 38 COVID-19 patients with a positive real-time polymerase chain reaction (RT-PCR) test result for SARS-CoV-2, obtained from the combined nasopharyngeal-oropharyngeal swab samples. Saliva, tear, and cerumen samples were taken from the patients within 72 hours of the first RT-PCR test. SARS-CoV-2 N1 and N2 gene regions were studied with single-step RT-PCR in all samples. RESULTS: Among the studied samples, the highest positivity rate was in saliva (76.3%) followed by tears (55.3%) and cerumen (39.5%). Viral load in saliva was also significantly higher compared to tears and cerumen (P < .001), while there was no significant difference between tears and cerumen. Higher viral load in combined nasopharyngeal-oropharyngeal swab samples was associated with higher viral load in tears, but not in saliva or cerumen. Half of the saliva, tear, and cerumen samples obtained from asymptomatic patients contained SARS-CoV-2 genome. CONCLUSIONS: The virus was detected in the saliva, tears, and cerumen samples of both symptomatic and asymptomatic patients. The potential role of these bodily fluids on viral spread needs to be studied. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1677-E1682, 2021.

Effects of immunization program on morbidity and mortality rates ofvaccine-preventable diseases in Turkey

Background/aim: This study aims to serve as a unique consolidated source in Turkey's vaccination history and as an example for other countries by objectively revealing the change in mortality and morbidity rates in Turkey following the beginning of vaccination without asserting any claim on the benefits or risks of vaccines. This unbiased research will also help health professionals identify the challenges more easily when they face with the people who hesitate to vaccinate their children. Materials and methods: Descriptive research design is adopted in this study. The coverages of vaccinations, mortality, and morbidity rates were identified through a retrospective analysis of the data provided from the Ministry of Health of Turkey. The data provided by the Turkish Statistical Institute were used for the identification of the population by the year. Mortality and morbidity rates were calculated based on these data Results: Morbidity rates, mortality rates, and vaccine coverages are all presented in years. Successful interventions have been observed in the eradication of polio, the elimination of maternal neonatal tetanus, and also in combating with other diseases. A decline in pertussis mortality from 0.59 to 0.06 along with a decline in diphtheria morbidity under to 0.0001 were recognized; additionally the last death due to poliomyelitis was observed in 1998. Only 4 deaths occurred in the measles epidemic in 2013. With the initiation of vaccination, both the morbidity of the rubella with the ratio of 3.12/100,000 and the mortality of pumps with the ratio of 25/100,000 fell to zero. Also, no death due to neonatal tetanus has been recorded since 2014. Conclusion: The present study demonstrates that many possible diseases and deaths have been prevented through vaccination studies. In this regard, this study demonstrating the importance of vaccination presents that all individuals in the society have a responsibility in this scope when the communicable diseases and wars are taken into consideration. The main responsibility is to ensure that they and their children are vaccinated against communicable diseases that are risky for society's health.

COVID-19 outbreak control, example of ministry of health of Turkey

Our first COVID-19 case in Turkey was a 44-year-old male who referred to the hospital on March 9, 2020. The first related death occurred on March 17, 2020. Preparedness for the pandemic has been ongoing before the first case was detected. The National Pandemic Plan was published in 2006. The Pandemic Influenza National Preparedness Plan was available after being updated in light of experiences gained during the 2009 Influenza A pandemic. Accordingly, Pandemic Coordination Boards and Operation Centers have been established on the national and provincial levels. This was an adaptable plan to the Novel Coronavirus Disease (COVID-19). We formed teams to work on a 24/7 basis and established a Scientific Committee at the Public Health Emergency Operation Center within the General Directorate of Public Health. "COVID-19 Risk Assessment", "COVID-19 Guideline" and "Case Report Form", regulations of personal protective equipment along with need-based guidelines, treatment algorithms, brochures and related documents have been released. For the case-based follow-up, Public Health Management System (HSYS) is being used. PCR and rapid diagnostic kits are being used to analyze the samples at the central Microbiology Reference Laboratory and the authorized laboratories in several provinces. Various preventive measures were implemented including flight restrictions to certain countries, gradually expanded to suspending all flights and prohibiting the entry of foreign nationals, 14-day isolation and symptom monitoring for those that came from countries under risk. Persons with chronic diseases have been granted an administrative leave, on campus education at schools and activities of public rest and entertainment areas were temporarily suspended. The measures have been implemented for penitentiary institutions, dormitories, nursing homes, public transport and intercity buses, and also weekend curfews are implemented. In accordance with the pandemic plan, actions have been carried out with a multi-sectoral approach, and preventive measures have been implemented to cover the society as a whole.

[Cladophilaphora bantiana brain abscess treated with voriconazole in an immunocompetent patient]. / Immün kompetan bir hastada vorikonazol ile tedavi edilen Cladophilaphora bantiana beyin apsesi.

Phaeohyphomycosis is a term used to define infections caused by darkly pigmented fungi with septate hyphae which contain melanin in their cell walls. Although fungi rarely cause central nervous system (CNS) infections, the incidence of CNS infections caused by melanin-containing fungi has been increasing in the recent years. Cladophialophora bantiana is the most frequently isolated species from cerebral phaeohyphomycosis. It mostly affects adult men in the second and third decade of life and about half of the cases occurs in immunocompetent patients. In this report, the isolation of C.bantiana from brain tissue of an immunocompetent patient who was operated with the initial diagnosis of a brain abscess, was presented. A 27 year-old male patient presenting without any chronic disease was admitted to the emergency department of our hospital with the complaints of persistent headache and diplopia. Magnetic resonance imaging (MRI) showed a space-occupying lesion in the right parietal lobe and left frontal lobe. Brain abscess was diagnosed in the patient who was referred to the neurosurgery department. Treatment was initiated with ceftriaxone and metronidazole. The abscess material sent for direct microscopic examination in the mycology laboratory was stained with Gram and Giemsa and cultured in the Sabouraud dextrose agar medium (SDA) with and without antibiotics (cycloheximide and chloramphenicol). Then, it was incubated at 37°C and 25°C. Direct examination and staining revealed a septate hyphae. The patient who received liposomal amphotericin B was referred to the infectious diseases department. Surface colors of all media including SDA with cycloheximide were olive-gray to black and contained velvety colonies. Lemon-like very long and integrated chains of conidium with poor branching in cornmeal Tween 80 agar, as well as growth at 42°C in passages, positive urease test result and cycloheximide resistance suggested C.bantiana. The isolate was confirmed as C. bantiana based on its DNA sequence analysis. Minimum inhibitor concentration (MIC) values for amphotericin B, voriconazole, caspofungin, and posaconazole were 2 µg/ml, 0.03 µg/ml, 0.03 µg/ml and 0.03 µg/ml, respectively. Liposomal amphotericin B was replaced with voriconazole due to the antifungal susceptibility profile. The patient who was symptom-free was discharged at 24 days after hospitalization with oral voriconazole treatment. In conclusion, cerebral phaeohyphomycosis should be considered in immunocompetent individuals. Given the fact that early diagnosis saves lives, such specimens should promptly be sent for mycological analysis.