Predictors for limb loss among patient with diabetic foot infections: an observational retrospective multicentric study in Turkey.

We aimed to investigate the predictors for limb loss among patients with diabetes who have complicated skin/soft-tissue infections. In this observational study, consecutive patients with diabetic foot infection (DFI) from 17 centres in Turkey, between May 2011 and May 2013 were included. The Turkish DFI Working Group performed the study. Predictors of limb loss were investigated by multivariate analysis. In total, 455 patients with DFI were included. Median age was 61 years, 68% were male, 65% of the patients were hospitalized, 52% of the patients had used antibiotics within the last month, and 121 (27%) had osteomyelitis. Of the 208 microorganisms isolated, 92 (44.2%) were Gram-positive cocci and 114 (54.8%) were Gram-negative rods (GNR). The most common GNR was Pseudomonas; the second was Escherichia coli, with extended spectrum ß-lactamase positivity of 33%. Methicillin-resistant Staphylococcus species were found in 14% (29/208). Amputations were performed in 126/455 (28%) patients, 44/126 (34%) of these were major amputations. In multivariate analysis, significant predictors for limb loss were, male gender (OR 1.75, 95% CI 1.04-2.96, p 0.034), duration of diabetes >20 years (OR 1.9, 95% CI 1.18-3.11, p 0.008), infected ulcer versus cellulitis (OR 1.9, 95% CI 1.11-3.18, p 0.019), history of peripheral vascular disease (OR 2, 95% CI 1.26-3.27, p 0.004), retinopathy (OR 2.25, 95% CI 1.19-4.25, p 0.012), erythrocyte sedimentation rate >70 mm/hr (OR 1.6, 95% CI 1.01-2.68, p 0.05), and infection with GNR (OR 1.8, 95% CI 1.08-3.02, p 0.02). Multivariate analysis revealed that, besides the known risk factors such as male gender, duration of diabetes >20 years, infected ulcers, history of peripheral vascular disease and retinopathy, detection of GNR was a significant predictor of limb loss.

The clinical and pharmacoeconomic analysis of invasive aspergillosis in adult patients with haematological diseases.

Invasive pulmonary aspergillosis (IPA) poses major management problems for clinicians caring for patients with haematological diseases. The clinical courses of patients with IPA who had been hospitalised in Hematology Unit, Bone Marrow Transplantation Unit and Infectious Diseases and Clinical Microbiology Unit between 1998 and 2005, the efficacy and adverse effects and costs of antifungal drugs (conventional amphotericin B deoxycholate, liposomal amphotericin B, amphotericin B lipid complex and caspofungin) used in the therapy of these patients were analysed in this study. Ninety-three patients with IPA were reviewed retrospectively. Mean age of the patients was 40.4 +/- 15.1 years (range 14-70 years). Fifty-eight male patients and 35 female patients were included in the study. Manageable hypopotassemia, nausea/vomiting and headache were the most commonly observed side-effects during antifungal (AF) therapy. While it was not found to be statistically significant with regard to the mean time to resolution of fever (P = 0.8), it was found to be statistically significant with regard to radiological regression at 30th day, and mean duration of therapy between patients who were dead or alive (P < 0.05, P < 0.001). Total cost of AF therapy for 93 patients was found to be US$4 461 824 (minimum US$387-maximum US$279 023). Of this amount, US$4 272 845 represents the payment for AF drugs, US$188 979 the payment for other expenditures. Mean cost of therapy for a patient with IPA was found to be US$49 336. Although it seemed to be difficult, investigations should primarily focus on providing standardisation of parameters relating to the duration of AF therapy. Despite the less-than-optimal safety profile of CAB, it often remains to be the preferred first line option for the treatment of fungal infections because of its broad spectrum, activity and low acquisition cost.

Hospital-acquired pneumonia guidelines in Europe: a review of their status and future development.

Hospital-acquired pneumonia (HAP) is the most common healthcare-acquired infection contributing to death. Effective management requires accurate diagnosis, administration of a suitable antibiotic regimen early in infection and implementation of prevention strategies. In recent years, there has been a rapid increase in the number of country-specific HAP guidelines in Europe, which vary in their formulation, coverage of different disease aspects and overall recommendations. Development of comprehensive pan-European HAP guidelines would rationalize the conflicting proposals, provide a useful resource and limit guideline proliferation. However, careful consideration needs to be given to the principles of guideline development to ensure that the output is rigorous, broadly applicable and facilitates update as new data becomes available. The use of an evidence-based approach to HAP guideline development is optimal, but is compromised by limitations in the supporting data. The implementation of a formalized evidence grading system is key to introducing consistency into the guideline development process. Pan-European guidelines should provide recommendations on core aspects of HAP common to all treatment settings and locations, and reflect the differing perspectives of the countries involved. Given the different antibiotic susceptibility profiles across Europe, such guidelines should provide general treatment recommendations suitable for local adaptation. The development of such guidelines represents an ideal time to identify priorities for European research, by addressing controversies and identifying previously unconsidered aspects of HAP. Establishing a pan-European consensus on core processes of care should be viewed as an impetus for change to improve clinical practices and should include a suitable implementation strategy.

Susceptibility of bacterial isolates from Turkey--a report from the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program.

The study monitored the susceptibility of nosocomial pathogens to meropenem and comparator antimicrobial agents isolated as part of the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program from Turkish university hospitals. In terms of minimum inhibitory concentration 90% (MIC(90)) values, meropenem was two- and eight-fold more active than imipenem against Escherichia coli and Klebsiella pneumoniae, respectively. 40.5% of K. pneumoniae, 23.1% of Klebsiella oxytoca and 15.3% of E. coli isolates were extended-spectrum beta-lactamase (ESBL) producers. Piperacillin/tazobactam was the most active agent against isolates of Pseudomonas aeruginosa, followed by meropenem and imipenem. Against Acinetobacter baumannii isolates, meropenem and imipenem were the most active agents. Continued surveillance by the MYSTIC Program appears to be prudent to help focus on effective empiric treatment regimens.

Practical management of avian influenza in humans.

There has been much alarm about avian influenza and its potential for a global pandemic ever since the current epidemic of avian influenza infections in humans began in 2003. While there have been a number of published reports on the clinical features of avian influenza, there are few guidelines on the practical management of patients with avian influenza. A symposium organised by the Society of Infectious Disease (Singapore), Society of Intensive Care Medicine and the Singapore General Hospital was held in Singapore to gather the views of experts from Turkey, Thailand, Vietnam and Indonesia who collectively had first-hand experience of the management of the majority (more than 100 of 192) of cases of avian influenza worldwide. The experts emphasised the importance of adapting international guidelines to the practicalities of situations on the ground. There was stress on wide screening using clinical criteria primarily, molecular diagnostic techniques (with reference laboratory confirmation) for diagnosis, and rational use of antiviral prophylaxis as well as infection control using at least surgical masks, gowns and gloves. A detailed analysis of data from a pooled database from these and other affected countries is critical to building up the evidence base for practical internationally applicable guidelines.

Results of two worldwide surveys into physician awareness and perceptions of extended-spectrum beta-lactamases.

An omnibus survey of microbiologists (n = 400) and a survey of participants (n = 49) in the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) programme were conducted to determine the awareness and prevalence of extended-spectrum beta-lactamases (ESBLs), and the regularity and method of screening. Of the omnibus survey participants, 69% screened regularly for ESBLs, compared with 83% of MYSTIC participants. In both surveys, ESBLs were more common in Klebsiella pneumoniae (73% and 79%, respectively) and Escherichia coli (63% and 81%, respectively) than in other bacteria. The surveys demonstrated that awareness of, and testing for, ESBLs is inconsistent.

Tuberculous meningitis in adults--experience from Turkey.

BACKGROUND: The annual incidence of tuberculous meningitis (TM) is unknown. TM is a disease that still often results in residual sequelae, and has a mortality rate ranging between 15 and 51%. Experience of countries such as Turkey where drug-resistant tuberculosis and TM are prevalent is important. METHODS: Clinical and laboratory findings of 42 patients with TM, followed between 1991 and 2002, were evaluated retrospectively. RESULTS: Twenty-eight female and 14 male patients were included in this study. The mean age of the patients was 33.9 +/- 13.2 years (range, 16-60 years). Fourteen had a history of pulmonary tuberculosis; 12 reported close contact with a person with active pulmonary tuberculosis; three were diagnosed with active pulmonary tuberculosis; two, with HIV infection; two, with Pott's disease; and one, with systemic lupus erythematosus. On admission, 17 patients were diagnosed with stage I; 15, with stage II; and 10, with stage III disease. Hemiparesis (35.7%), cranial nerve palsy (30.9%), and altered consciousness (26.9%) were the most common neurological deficits. Prolonged duration of pre-existing symptoms and female gender were found as significant risk factors in those who develop neurological sequelae (p < 0.01 and p < 0.05, respectively). Cranial computerised tomography revealed various pathological findings in all but five patients. Sulcus effacement was the most common radiological finding. Enlargement of ventricles, focal cerebral oedema/shunt, calcification of meninges, tubercle, and infarction were other common abnormal radiological findings. CONCLUSIONS: Prolonged duration of pre-existing symptoms and female gender are predictors of neurological sequelae of TM. Early identification of such patients and prompt initiation of anti-tuberculosis therapy may improve their outcome.

Effects of pneumoperitoneum created through CO2 insufflation and parameters of mechanical ventilation (PEEP application) on systemic dissemination of intraabdominal infections.

BACKGROUND: To examine whether CO2 pneumoperitoneum and positive end expiratory pressure (PEEP) in mechanical ventilation affect the systemic spread of intraabdominal infection. METHODS: Sprague-Dawley male rats weighing 200-300 g were allocated to three groups of 12 animals in each. All rats received mechanical ventilation under general anesthesia. An intraabdominal infection model was established by injecting with 1 ml of Escherichia coli (10(9) CFU/mL) intraperitoneally. Half of the animals in each group were exposed to PEEP (10 cmH2O). CO2 pneumoperitoneum at 13 mmHg was applied to the rats in group 1. Group 2 rats underwent laparotomy. Group 3 served as controls. In addition, TNF-alpha serum levels were measured at baseline and 3 h. A peritoneal specimen for histopathological examination were obtained after the rats were killed at the end of 3 h. For the assessment of data, descriptive statistical methods (mean, standard deviation) as well as Friedman test for repeated measurements in multiple groups, Kruskal-Wallis test for intergroup comparisons, Dunn's multiple comparison test for subgroup comparisons, Mann-Whitney U test for comparisons between paired groups, chi-square and Fisher's exact test for comparison of qualitative data, and McNemar's test for assessment of changes in group variables over time were used. The results were considered statistically significant if probability (p) values were <0.05. RESULTS: Grades of peritonitis in group 1 and 2 were seen to differ nonsignificantly. In group 1, baseline blood cultures were not included in the assessment between the subgroups that received PEEP or not, as there was no growth in any of the subgroups. No significant difference was detected between growth in blood cultures at 1, 2, and 3 h ( p > 0.05). Application of PEEP in subgroups did not alter the blood culture results ( p > 0.05). Significant differences were seen between the initial and final TNF-alpha values of groups (KW: 18.94, p < 0.0001). The values in control group were observed to be significantly lower than those in groups 1 and 2 ( p < 0.01, p < 0.001). Bacteremia and systemic spread of the intraabdominal infection did appear to be different according to the PEEP application. After the assessments of ventilation parameters in our study, significant reductions in pH and HCO3 levels were detected in group 1 as a result of pneumoperitoneum, which was consistent with the literature. There is a significant difference between pH values at baseline and at the end of 1 h because of pneumoperitoneum (Fr: 10.01, p < 0.05). PEEP application in subgroups did not create significant differences in terms of respiratory parameters ( p < 0.01). CONCLUSION: No difference was found between the applications of CO2 pneumoperitoneum and laparotomy with regard to bacteremia and infection-induced peritonitis. It was determined that pneumoperitoneum along with PEEP application had neither a positive nor a negative impact on intraabdominal infection.

Rhinocerebral mucormycosis treated with 32 gram liposomal amphotericin B and incomplete surgery: a case report.

BACKGROUND: Mucormycosis (or zygomycosis) is the term for infection caused by fungi of the order Mucorales. Mucoraceae may produce severe disease in susceptible individuals, notably patients with diabetes and leukemia. Rhinocerebral mucormycosis most commonly manifests itself in the setting of poorly controlled diabetes, especially with ketoacidosis. CASE PRESENTATION: A 31-year-old diabetic man presented to the outpatient clinic with the following signs and symptoms: headache, periorbital pain, swelling and loss of vision in the right eye. On physical examination his right eye was red and swollen. There was periorbital cellulitis and the conjunctiva was edematous. KOH preparation of purulent discharge showed broad, ribbonlike, aseptate hyphae when examined under a fluorescence microscope. Cranial MRI showed involvement of the right orbit, thrombosis in cavernous sinus and infiltrates at ethmoid and maxillary sinuses. Mucormycosis was diagnosed based on these findings. Amphotericin B (AmBisome(R); 2 mg/kg.d) was initiated after the test doses. Right orbitectomy and right partial maxillectomy were performed; the lesions in ethmoid and maxillary sinuses were removed. The duration of the liposomal amphotericin B therapy was approximately 6 months and the total dose of liposomal amphotericin B used was 32 grams. Liposomal amphotericin B therapy was stopped six months later and oral fluconazole was started. CONCLUSIONS: Although a total surgical debridement of the lesions could not be performed, it is remarkable that regression of the disease could be achieved with medical therapy alone.

Immunization of renal transplant recipients with pneumococcal polysaccharide vaccine.

BACKGROUND: Streptococcus pneumoniae, a common pathogen leading to pneumonia, is a cause of morbidity and mortality in immunosuppressed patients. Vaccination against this agent can be recommended for immunosuppressed patients, including those with chronic renal failure, nephrotic syndrome and renal transplant recipients; however, a diminished immune response and loss of protective antibodies have been observed. PATIENTS AND METHODS: In our prospective study, the efficacy and side effects of polyvalent pneumococcal vaccination were investigated in renal transplant recipients. A total of 21 patients (6 female, 15 male) with well-functioning renal allografts, who had transplant surgery at least 2 months before, were included in the study. The patients were stratified according to the immunosuppressive protocol and 8 received double, while 13 received triple, immunosuppressive agents. After obtaining basal serum samples, all cases were vaccinated with the 0.5 mL intramuscular administration of polyvalent polysaccharide pneumococcal vaccine (Pneumo 23 Pasteur Merieux, lot No: K 1131). RESULTS: Following a mean of 6 wk in all patients and also a mean of 12 wk in 12 patients, serum samples were again obtained to measure pneumococcal antibodies. Antibody titers following 6 and 12 wk of vaccination were significantly higher, as compared with basal values in all patients, except one. These titers did not show any statistically significant difference between double and triple therapies. There was no significant difference between the 12th and 6th wk postvaccination antibody titers. No systemic or local adverse effects were observed. CONCLUSION: Pneumococcal vaccination is safe and effective in patients with well-functioning renal allografts, at least in the short term. This vaccination policy may be useful for preventing invasive pneumococcal disease in immunosuppressed patients.

Stereotactic surgery in the management of brain abscess.

BACKGROUND: Bacterial brain abscesses can be diagnosed and treated with stereotactic aspiration. METHODS: From 1991 to 1997 we have used computed tomography-guided stereotactic aspiration to diagnose and treat 21 patients with a total of 58 bacterial brain abscesses. The ages of the patients ranged from 4 to 72 years (median 25 years); 11 of these 21 patients had multiple abscesses. The number of abscesses per patient with multiple abscesses ranged from 2 to 9, all located deep in subcortical white matter. RESULTS: All patients underwent stereotactic surgical drainage and an 8-week intravenous antibiotic medical treatment. Of the 58 abscesses, 23 were aspirated. Of these 23 abscesses, 19 were radiologically stage III or IV and four were stage I or II. Pathological examination confirmed radiological staging in 19 patients (83%). Except for the three patients who have mild residual hemiparesis and one patient recovering from ataxia, all patients had complete neurological recovery. CONCLUSIONS: Computed tomography-guided stereotaxy achieved all the objectives of management; namely, ascertaining the diagnosis, draining the content of the mass, and obtaining pus for accurate bacteriological diagnosis without morbidity. Stereotactic aspiration combined with an 8-week intravenous antibiotic regimen has yielded an effective therapeutic result in all of our abscesses, small or large, solitary or multiple, superficial or deep-seated. A high radiological-pathological correlation was also deduced from this study.

Immune response to Haemophilus influenzae type B vaccination in renal transplant recipients with well-functioning allografts.

BACKGROUND: Haemophilus influenzae infection is a mild and self-limited disease in the healthy population. However, it may show an aggressive course in the immunocompromised state which underlines the importance of vaccination against this agent. On the other hand, posttranplant immunosuppression may impair immune responses and thus the efficacy of the vaccination. METHODS: Forty-three renal transplant recipients with well-functioning allografts were immunized with H. influenzae type b vaccine in order to investigate the immune response. The patients received a double or a triple immunosuppressive protocol. Seven healthy members of the dialysis unit served as controls. After obtaining basal serum samples, the patients and the control subjects were immunized with H. influenzae type b conjugate vaccine. After 6 and 12 weeks, serum samples obtained again to determine H. influenzae type b antibody titers. RESULTS: The antibody titers 6 and 12 weeks after vaccination were significantly higher as compared with the basal values, similar to those of the control subjects. These titers did not show statistically significant differences between the double and triple immunosuppressive therapy groups. After 12 weeks of vaccination, the antibody titers did not show a statistically significant difference as compared with those obtained after 6 weeks. CONCLUSION: H. influenzae type b vaccination is safe and effective in patients with well-functioning renal allografts and should be recommended to renal transplant recipients who may have the risk of invasive disease on the basis of the immunosuppressive state.

Spontaneous ascitic infection in different cirrhotic groups: prevalence, risk factors and the efficacy of cefotaxime therapy.

OBJECTIVE: To investigate the prevalence of spontaneous ascitic infection (SAI) in different cirrhotic groups, the risk factors for development of SAI, and the efficacy of cefotaxime therapy. DESIGN: A prospective study. SETTING: In-patient clinic of a university hospital. PATIENTS: Eighty cirrhotic patients with ascites were assigned to four groups: hepatitis B or D virus-related 34, alcoholic 18, hepatitis C virus-related 14, miscellaneous 14. INTERVENTIONS: Paracentesis was performed on 80 patients during 92 consecutive hospitalizations. Ascitic fluid was cultured by the method of bedside inoculation of blood culture bottles with ascites. The patients with SAI were treated with cefotaxime (2 g, three times daily, intravenously) for 5 days. MAIN OUTCOME MEASURES: Frequency of SAI in cirrhotic groups; clinical, bacteriological and biochemical findings of SAI; rate of recovery-from infection. RESULTS: Twenty SAI episodes (22%) were found in 16 patients; 8 episodes were spontaneous bacterial peritonitis, 2 bacterascites, and 10 culture-negative neutrocytic ascites. SAI occurred more frequently in patients with hepatitis B or D virus-related liver cirrhosis (32%) than in the alcoholic (6%, P < 0.05), hepatitis C virus-related (14%) or miscellaneous (14%) cirrhotic groups in multivariate analysis, independent predictive factors associated with the development of SAI are chronic hepatitis B virus infection, ascitic fluid total protein and serum bilirubin. Escherichia coli was obtained in 5 of 10 positive ascitic fluid cultures. Cure of the infection was achieved in 95% of episodes. Hospitalization mortality rate in infected patients was 20%. CONCLUSION: Spontaneous ascitic infection occurs in approximately 20% of cirrhotic patients hospitalized with ascites. The patients with low ascitic protein concentration, high serum bilirubin level or hepatitis B virus cirrhosis are more predisposed to SAI. Cefotaxime may be an effective first-choice antibiotic for ascitic fluid infection.

Posttransplant malaria.

The frequency and clinical characteristics of plasmodium infection were reported in 420 renal transplant recipients who were followed in the Transplantation Unit and Out-Patient Clinic of the Medical School of Istanbul. Plasmodium infection was diagnosed in eleven (9 male, 2 female) of the 420 patients (2.6%). Ten of the patients were transplanted in India, and one in our institution. The mean duration between the transplantation and the diagnosis of malaria was 21.7 + 44.4 days in patients who were transplanted in India. All of the patients were taking triple immunosuppressive drugs (CsA, AZA, PRED). Plasmodium falciparum was diagnosed in 6 patients, P vivax in 1 patient and P malariae in 1 patient. Also mixed infection with P falciparum and P malariae was diagnosed in 3 patients. After definite diagnosis, the patients were hospitalized. Chloroquine phosphate plus primaquine phosphate was administered for P vivax infection, whereas chloroquine phosphate alone was given for P falciparum and P malariae infection as a first line antimalarial therapy. As a result of therapy, infection improved clinically and the plasmodia disappeared rapidly from the thick blood film in 10 of the patients. Severe hemolysis and acute renal failure developed in one patient, who improved after hemodialysis therapy and exchange transfusions. It was concluded that malaria is quite a frequent infection of transplant recipients who get their allografts from donors living in high-risk areas, and all transplant recipients having this kind of transplantations should be suspected and examined for malaria. This may help to diagnose and treat the complication in the early period, thus resulting in an improved prognosis for this potentially life-threatening complication of the posttransplant period.

Living unrelated (paid) kidney transplantation in Third-World countries: high risk of complications besides the ethical problem.

Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to third-world countries for living unrelated (paid) kidney transplantation. Thirty-four patients who have had transplantations in two centres in India before coming to our centre for post-transplant care and follow-up are reported in this study. In the post-transplant phase at our centre, the mean follow-up period of the patients was 209.7 +/- 137.3 (range 6-450) days. Fourteen of them, having an uneventful course, were followed on an outpatient clinic basis. The rest of the patients were hospitalized because of the following surgical and/or medical complications, during admission: urinary fistula in two patients; lymphocele in three patients; urinary tract obstruction in two patients; decubitus ulcer in one patient; severe wound infection in one patient; subacute myocardial infarction in one patient; acute irreversible vascular rejection in two patients; urinary tract infection in two patients; pneumonia in two patients; congestive heart failure and severe electrolyte disturbance in two patients; post-transplant diabetes mellitus and ketoacidosis in one patient; cyclosporin nephrotoxicity in two patients; cyclosporin nephro-, hepato-, and neurotoxicity in one patient. Plasmodium falciparum malaria in three patients, generalized mucormycosis infection in one patient, and genitourinary aspergillosis in one patient were seen during the first month. Hepatitis B virus infection followed by chronic active hepatitis was diagnosed in two patients, 2 and 4 months after the operation; and Kaposi's sarcoma was noted in another two patients, 1 and 5 months after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)