Clinical experience with tigecycline in the treatment of carbapenem-resistant Acinetobacter infections.

Tigecycline is a promising therapeutic option against many current multidrug resistant pathogens. The aim of this retrospective study was to determine the clinical and microbiological outcomes of patients treated with tigecycline for serious infections caused by carbapenem-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex (Acb-complex). A retrospective study was conducted to define the patients who received tigecycline for carbapenem-resistant Acb-complex infections between 1 June, 2008 and 1 may, 2009. A total of 21 patients were eligible for the study. The median age of the patients was 48 years and 6 patients were female. Eighteen patients were treated with tigecycline for carbapenemresistant Acb-complex as the sole microorganism while 3 received it for polymicrobial infections. All Acb-complex isolates were susceptible to tigecycline. The most common indication of tigecycline treatment was surgical-site infections (SSI) followed by ventilator associated pneumonia (VAP). Tigecycline was the sole antibiotic administered in 7 patients while concurrent antibiotics were used in 14 patients. The median duration of tigecycline therapy was 14 days. Two patients died within 14 days of initiating treatment, representing an attributable mortality rate of 9.5% while 4 patients died within 30 days representing a crude mortality rate of 19.1%. Seventeen out of 21 patients had successful clinical outcomes, cure in 11 patients and improvement in 6. Fourteen of 21 patients had microbiological failure. Correlation between microbiological response with clinical outcome was poor. Clinical failure was more common in patients with VAP. Patients with bacteremia were more likely to have microbiological failure while microbiological outcome was better in patients with SSI. In this retrospective study, 81% (17 of 21) of the patients infected with carbapenem-resistant Acb-complex had a positive outcome under tigecycline therapy. However, these preliminary results should be evaluated cautiously in the absence of well-controlled studies.

Ghrelin and obestatin levels in end-stage renal disease.

Malnutrition is fairly common in end-stage renal disease (ESRD) patients, persistent lack of appetite being a major symptom. Ghrelin and obestatin are two hormones that are involved in appetite and energy homeostasis. The present study examined ghrelin and obestatin levels in 24 ESRD patients undergoing haemodialysis and 24 age-matched healthy controls. Serum and saliva ghrelin and obestatin levels in the ESRD patients were significantly higher compared with controls, while saliva ghrelin and obestatin levels in all study participants were significantly higher than serum levels. Saliva ghrelin correlated with serum ghrelin and saliva obestatin correlated with serum obestatin in all study participants, although there was no correlation between ghrelin and obestatin levels. In conclusion, the results suggest that the kidneys may have a role in the metabolism and/or clearance of obestatin, as they do for ghrelin. Further studies are needed to determine if elevated levels of these hormones in ESRD patients contribute to the malnutrition that is common in these patients.

Hypokalemic quadriparesis associated with renal tubular acidosis in a patient with Sjögren's syndrome.

Sjögren's syndrome is an autoimmune exocrinopathy that involves both glandular and extra-glandular systems. We report a 25-year-old woman who had rapidly progressive quadriparesis. Biochemical investigations showed severe hypokalemia with hyperchloremic metabolic acidosis diagnosed as distal renal tubular acidosis. Salivary gland biopsy revealed Sjögren's syndrome as the underlying cause. She recovered following from quadriparesis potassium and alkali replacement.

Nocardiosis in a teaching hospital in the Central Anatolia region of Turkey: treatment and outcome.

Predisposing factors, antimicrobial susceptibility patterns, treatment and outcome were analysed for nine consecutive patients with nocardiosis. Predisposing factors were identified in six (67%) of the nine patients. Clinical syndromes of nocardial infection were pulmonary infection (three patients), cerebral infection (five patients) and disseminated infection (one patient). The predominant (60%) species was Nocardia farcinica rather than the Nocardia asteroides complex. Treatment was started empirically, modified according to the antimicrobial susceptibility pattern, and then continued for 6-12 months. Overall mortality was 33%, with death being caused by the Nocardia infection in two cases.

Bloodstream infections caused by Staphylococcus aureus in a university hospital in Turkey: clinical and molecular epidemiology of methicillin-resistant Staphylococcus aureus.

In total, 177 patients with bloodstream infections caused by Staphylococcus aureus (BSISA) were investigated prospectively between June 1999 and June 2001. Of these, 19.8% had community-acquired BSISA, while 80.2% had nosocomial BSISA. Surgical intervention, foreign body, mechanical ventilation, total parenteral nutrition, and previous antibiotic treatment were found to be important risk factors for the nosocomial BSISA group. Secondary BSISA formed a greater proportion (62.9%) of community-acquired infections than of nosocomial infections (26.8%; p 0.0001). Catheter-related nosocomial BSISA was observed in 72.1% of patients. The suppurative complication rate was significantly higher among community-acquired infections (22.9%) than among nosocomial infections (6.3%; p 0.008). Of the nosocomial BSISA, 65.5% were methicillin-resistant. Analysis of 80 methicillin-resistant S. aureus isolates by pulsed-field gel electrophoresis identified ten main clones (A-J), but 61 (76.3%) of the 80 isolates belonged to clone A.

Strict fluid volume control and left ventricular hypertrophy in hypertensive patients on chronic haemodialysis: a cross-sectional study.

Left ventricular hypertrophy (LVH) is very common in haemodialysis patients. We measured left ventricular mass in three groups of haemodialysis patients: group A (n = 40) were normotensive and receiving a strict salt-restricted diet; group B (n = 23) were normotensive and receiving anti-hypertensive drugs; and group C (n = 43) were hypertensive despite anti-hypertensive drug treatment. The interdialytic weight gain in group B and group C was significantly higher than in group A; the mean left atrial index and left ventricular end-systolic and end-diastolic diameter indices were all higher in group B than in group A. The interventricular septum and posterior wall were significantly thicker in group B and group C than group A, resulting in a higher left ventricular mass index. Left ventricular systolic and diastolic function parameters were slightly better in group A than in the other groups. These results show that strict fluid volume control decreases blood pressure, reduces dilated cardiac compartments and corrects LVH more effectively than lowering blood pressure without correcting the volume overload.

Tuberculous meningitis in adults in Turkey: epidemiology, diagnosis, clinic and laboratory [corrected].

A retrospective study was performed to assess the epidemiology, diagnosis, clinic, and laboratory of the patients with tuberculous meningitis (TBM) in a multicentral study. The medical records of adult cases with TBM treated at 12 university hospitals throughout Turkey, between 1985 and 1998 were reviewed using a standardized protocol. The diagnosis of TMB was established with the clinical and laboratory findings and/or microbiological confirmation in cerebrospinal fluid (CSF). The non-microbiologically confirmed cases were diagnosed with five diagnostic sub-criteria which CSF findings, radiological findings, extra-neural tuberculosis, epidemiological findings and response to antituberculous therapy. A total of 469 patients were included in this study. Majority of the patients were from Southeast Anatolia (164 patients, 35.0%) and (108 patients, 23.0%) from East Anatolia regions. There was a close contact with a tuberculous patient in 88 of 341 patients (25.8%) and with a tuberculous family member in 53 of 288 patients (18.4%). BCG scar was positive in 161 of 392 patients (41.1%). Tuberculin skin test was done in 233 patients and was found to be negative in 75. Totally 115 patients died (24.5%) of whom 23 died in 24 hour after admittance. The diagnosis was confirmed with clinical findings and CSF culture and/or Ziehl-Nelson staining in 88 patients (18.8%). Besides clinical criteria, there were three or more diagnostic sub-criteria in 252 cases (53.7%), two diagnostic sub-criteria in 99 cases (21.1%), and any diagnostic sub-criteria in 30 patients (6.4%). Since TBM is a very critical disease, early diagnosis and treatment may reduce fatal outcome and morbidity.

Predictors of outcome in patients with tuberculous meningitis.

OBJECTIVE: To assess predictors of mortality and neurological sequelae in patients with tuberculous meningitis (TBM). METHODS: Patients with TBM treated at 12 university hospitals in Turkey between 1985 and 1997 were evaluated using a standardised protocol applied retrospectively. Variables associated with hospital mortality as well as with the presence of neurological sequelae at 6 months were determined using logistic regression models. RESULTS: Four hundred and thirty-four patients between the ages of 13 and 83 years (mean 33 years) were evaluated. Sixty-eight per cent of these patients presented with Medical Research Council Stage II or III. One hundred and one patients (23.3%) died and 67 (27%) of evaluable survivors had neurological sequelae. In multi-variable analysis, convulsion (OR 3.3, 95%CI 1.2-9.0, P = 0.02), comatose mental status (OR 6.0, 95%CI 3.6-10.2, P = 0.01), and delayed or interrupted treatment (OR 5.1, 95%CI 2.4-11.2, P = 0.01) were shown to be predictors for mortality. The presence of extra-meningeal tuberculosis (OR 2.1, 95%CI 1.1-4.2, P = 0.035), cranial nerve palsy (OR 2.6, 95%CI 1.4-4.2, P = 0.01), hemiparesia/focal weakness (OR 9.3, 95%CI 3.8-22.6, P = 0.01), hemiplegia/multiple neurological deficit (OR 7.1, 95%CI 2.14-23.38, P = 0.01) and drowsiness (OR 4.2, 95%CI 2.04-8.82, P = 0.01) were independent predictors of neurological sequelae at 6 months following hospital discharge. CONCLUSION: The results of this study emphasise the importance of prompt and uninterrupted anti-tuberculosis therapy for tuberculous meningitis. The presence of seizures or coma on admission to hospital are important predictors for mortality, while the presence of focal neurological signs is a predictor for persistent neurological sequelae in survivors.

Polymicrobial ventriculitis and evaluation of an outbreak in a surgical intensive care unit due to inadequate sterilization.

At the end of 1999, a case of polymicrobial ventriculitis in the Department of Neurosurgery followed by an outbreak of Serratia marcescens mediastinitis in the intensive care unit of cardiovascular surgery occurred. These nosocomial surgical infections were considered to be the result of contamination of surgical sites with inadequately sterilized instruments or theatre linen. An epidemiological survey was focused on the central sterilization unit of the hospital. The microbiological results of this survey proved that the cause of the outbreak was the use of inadequately decontaminated theatre linen. This study indicates that strict infection control measures including the control of sterilization procedures and a well-organized infection control team are necessary to prevent nosocomial surgical infections.

Prostatitis and hepatitis due to Brucella melitensis: a case report.

A case is reported of a 43-year-old man who presented prostatitis and hepatitis due to Brucella melitensis. His symptoms were icterus, weakness, anorexia, fever, and urinary discomfort. Physical examination revealed icterus and hepatosplenomegaly. Lymphomonocytosis, elevated erythrocyte sedimentation rate and abnormal liver functions had been detected in laboratory tests. Brucella melitensis was isolated from prostatic fluid and blood cultures.

Adrenal functions in patients with sepsis.

The basal cortisol level and cortisol response to ACTH stimulation test were assessed in patients with sepsis, the results being compared to a control group of 30 healthy persons. The study group included 49 patients with sepsis and 30 healthy subjects as a control group. The mean age in the study group was 42.6 +/- 18.7 years and 41.4 +/- 12.1 years in the control group. Fifteen of the 49 (30.6%) patients had hospital-acquired and 34 (69.4%) patients community-acquired sepsis. Etiological agent was isolated in 35 (71.4%) patients (57.1% gram negative bacteria and 34.3% gram positive bacteria, plus 8.6% polymicrobial). Fourteen of 49 (28.6%) patients died. Mean basal cortisol level was 597.1 +/- 304.6 nmol/l (range 217.8-1667.9) in the study group and 460.2 +/- 180.8 nmol/l (range 253.6-988.9) in the control group. Mean basal cortisol level in the study group was significantly higher than that of the control group (p < 0.05). Mean basal cortisol level was found to be 725.5 +/- 448.9 nmol/l in the patients who died and 545.8 +/- 210.9 nmol/l in the patients who recovered. The difference between the two groups was found to be significant (p < 0.05). ACTH stimulation test was performed in 43 of the patients and 30 healthy subjects. Cortisol response was significantly lower (mean 277.7 +/- 216.9 nmol/l) in the patients than that detected in the control group (mean 519.6 +/- 279.2) (p < 0.001). Mean cortisol response in the patients who died was 227.2 +/- 224.5 nmol/l and 302.1 +/- 212.7 nmol/l in the patients who recovered (p > 0.05). Adrenocortical insufficiency was detected in 16.3% of the patients and 42.9% of these patients died. In conclusion, sepsis is characterized by high basal cortisol level which may show a poor prognosis and a blunted cortisol response to ACTH stimulation. A small percentage of patients with sepsis may develop adrenocortical insufficiency.

Treatment of tuberculous meningitis in Turkey.

A prospective study was performed on 72 cases of tuberculous meningitis studying various treatments. 37 patients were treated with a combination of isoniazid, rifampicin, pyrazinamide and streptomycin for 2 months, followed by a combination of isoniazid and rifampicin for 6 months. 35 patients were treated with various combinations of antituberculous drugs for 12-16 months. Disappearance of symptoms took (mean) 17 days. Mean duration of therapy for the hospitalized patients was 36 +/- 4 days. Seven (9.7%) patients died, 5 in the short-course therapy group and 2 in the long-course therapy group. Sequelae persisted in 18 (31%) cases, 8 of which cases were in the short-course therapy group and 10 in the long-course therapy group. No relapse was observed in either of the groups.

Temporal artery inflammation as a complication of anthrax.

A 41-year-old male patient was treated with penicillin for cutaneous anthrax affecting the region of the right eye. He was also given dexamethasone for 3 days to combat extensive oedema which was causing respiratory difficulty because of tracheal compression. After the oedema had resolved and the typical necrotic black eschar of anthrax had evolved, he developed acute inflammation of the right temporal artery. We believe this is the first report of this type of complication of anthrax.

[Comparison of HBsAg, anti-HCV and anti-HDV positivity in diverse groups]. / Degisik gruplarda HBsAg, anti-HCV ve anti-HDV pozitifliginin karsilastirilmasi.

Three hundred eighty three serum samples obtained from various patient groups and health care personnel were tested for HBsAg, Anti-HCV and Anti-HDV by ELISA technique. Anti-HCV antibodies were found 32.4% of chronic haemodialysis patients, 23% of the patients with chronic viral hepatitis and cirrhosis, 8.3% of health care personnel and less frequently detected in other groups. Anti-HDV antibodies were found 23% of the patients with chronic viral hepatitis and cirrhosis, 2.7% of blood donors, 8.1% of chronic haemodialysis patients and 1.3% of the patients who have malignancy. Anti-HDV antibodies were not detected in other groups.

Serology and anthrax in humans, livestock and Etosha National Park wildlife.

Results are presented from a number of epidemiological studies using enzyme immunoassays (EIA) based on the purified anthrax toxin antigens, protective antigen, lethal factor and oedema factor. Studies on sera from a group of 62 human anthrax patients in Turkey and from cattle in Britain following two unrelated outbreaks of anthrax show that EIA using protective antigen can be a useful diagnostic aid and will detect subclinical infections in appropriate circumstances. A serological survey on wildlife in the Etosha National Park, Namibia, where anthrax is endemic, showed that naturally acquired anthrax-specific antibodies are rare in herbivores but common in carnivores; in carnivores, titres appear to reflect the prevalence of anthrax in their ranges. Problems, as yet unresolved, were encountered in studies on sera from pigs following an outbreak of anthrax on a farm in Wales. Clinical details, including treatment, of the human and one of the bovine outbreaks are summarized and discussed in relation to the serological findings.