Registry-Based Retrospective Cohort Study of Mortality among Adults Admitted to Intensive Care Units in Istanbul with Hospital Acquired Pseudomonas aeruginosa Bloodstream-Infection between 2014-2021.

BACKGROUND: Managing Pseudomonas aeruginosa bloodstream infections (BSIs) is challenging due to increasing antimicrobial resistance, limited therapeutic options, and high mortality rates. In this study, we aimed to identify 30-day mortality risk factors and assess infectious diseases consultants' preferences for combination or monotherapy. METHODS: The study was conducted in four hospitals in Istanbul, Turkey, involving 140 adult ICU beds and 336,780 ICU-bed-days between 1 January 2014, and 31 December 2021. A total of 157 patients were included in the study. Cox proportional hazard regression was performed to assess the factors on 30-day mortality. RESULTS: The 30-day mortality rate was 44.6% (70/157). Higher Charlson Comorbidity Index (CCI) score, severe sepsis, primary bloodstream infection, being in COVID-19 pandemic period, and infection caused by MDR strain were associated with higher hazard of 30-day mortality. Combination therapy was more commonly used in patients with BSIs with MDR or DTR (difficult-to-treat) strains but did not significantly improve the hazard of 30-day mortality. CONCLUSIONS: Targeted interventions and vigilant management strategies are crucial for patients with defined risk factors. While infectious disease consultants tended to favor combination therapy, particularly for drug-resistant strains, our analysis revealed no significant impact on 30-day mortality hazard. The increased incidence of P. aeruginosa BSIs during the pandemic emphasizes the need for infection control measures and appropriate antibiotic prescribing practices.

Clinical efficacy and safety of prolonged versus intermittent administration of antipseudomonal beta-lactam antibiotics in adults with severe acute infections: A meta-analysis of randomized controlled trials.

INTRODUCTION: In order to compare the clinical efficacy and safety of prolonged versus intermittent antipseudomonal beta-lactam antibiotic infusion for the treatment of severe acute infections in adult patients, a meta-analysis of randomized controlled trials (RCTs) was performed. METHODS: We systematically searched MEDLINE and Cochrane Library databases until December 2022. The outcomes were all-cause mortality, clinical success, microbiological eradication and adverse events. The pooled risk ratios (RR) were estimated by the fixed or random effect methods according to heterogeneity statistics. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence for each outcome. RESULTS: Twenty eligible RCTs with 2081 participants were included in the meta-analysis. The risk of all-cause mortality was significantly lower in the prolonged infusion group than in the intermittent infusion group (RR 0.77, 95% confidence interval [CI] 0.63-0.95, p = 0.01, I2 = 0%; moderate certainty). Treatment with prolonged infusion showed significant benefit in clinical success (RR 1.09, 95% CI 1.02-1.17, p = 0.008, I2 = 19%; moderate certainty). There were no significant differences in microbiological eradication (RR 1.12, 95% CI 0.99-1.28, p = 0.07, I2 = 49%; low certainty), any adverse events (RR 0.96, 95% CI 0.86-1.08, p = 0.50, I2 = 27%; moderate certainty) and serious adverse events (RR 0.99, 95%CI 0.70-1.39 p = 0.95, I2 = 0%; low certainty). CONCLUSIONS: Prolonged antipseudomonal beta-lactam infusion probably decreases all-cause mortality. Additionally, it probably increases clinical success in adults with severe acute infections. This infusion strategy may result in little to no difference in microbiological eradication and is probably not associated with a rise in any adverse events.The evidence suggests that prolonged infusion may not increase serious adverse events.

Can Ultrasonographic Measurement of Bone Cortical Thickness Predict Osteoporosis?

RATIONALE AND OBJECTIVES: In this study, we aimed to describe a more accessible and safe diagnostic tool for osteoporosis or osteopenia diagnosis. We utilized cortical thickness (CoT) measurement of various bones via ultrasonography and evaluated the method's accuracy relative to bone mineral density (BMD) results determined by dual-energy X-ray absorptiometry (DXA). MATERIALS AND METHODS: A total of 200 volunteers (all female) who agreed to participate in the study and had undergone BMD measurement (femoral or vertebral) were included in the study. Patients with normal BMD result (≥-1.0 T-score) were defined as controls. CoT measurements were made from three bones (radius, tibia, and second metatarsal) for each patient via ultrasonography. RESULTS: Radius CoT and tibial CoT measurements of both femoral and vertebral osteoporotic or osteopenic patients were significantly higher compared to controls. Second metatarsal CoT of femoral osteoporotic and osteopenic patients was also found to be significantly higher than the control group. We found tibia CoT and radius CoT to have high sensitivity and positive predictive value in identifying patients with abnormal femoral T-scores (<-1). In multivariable analyzes, radius CoT was found to be independently predictive in distinguishing patients with abnormal T-score (<-1) from controls in both the femur and vertebral BMD groups. CONCLUSION: Radius CoT and tibia CoT values appear to have value in predicting patients with abnormal T-scores measured via DXA. This method may be a very simple technique that can be used for early detection of osteoporosis and osteopenia, but its results need to be supported by more comprehensive studies.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is not detected in the vagina: A prospective study.

OBJECTIVE: To determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is present in the vagina of women diagnosed with coronavirus disease-19 (COVID-19) pneumonia. STUDY DESIGN: The study was conducted prospectively in a university affiliated hospital. Forty-one women of reproductive age whose nasopharyngeal PCR test were positive for SARS-CoV-2 and clinically diagnosed with pneumonia were included in the study. Vaginal swabs were obtained for SARS-CoV-2 PCR tests when the patients were admitted to the inpatient service before pneumonia treatment was initiated. RESULTS: Vaginal swab samples of 38 patients were analysed with SARS-CoV-2 PCR tests. None of the vaginal swabs were positive for SARS-CoV-2. CONCLUSIONS: SARS-CoV-2 does not infect the vagina of women diagnosed with SARS-CoV-2 pneumonia.

Trends and factors associated with modification or discontinuation of the initial antiretroviral regimen during the first year of treatment in the Turkish HIV-TR Cohort, 2011-2017.

BACKGROUND: There is limited evidence on the modification or stopping of antiretroviral therapy (ART) regimens, including novel antiretroviral drugs. The aim of this study was to evaluate the discontinuation of first ART before and after the availability of better tolerated and less complex regimens by comparing the frequency, reasons and associations with patient characteristics. METHODS: A total of 3019 ART-naive patients registered in the HIV-TR cohort who started ART between Jan 2011 and Feb 2017 were studied. Only the first modification within the first year of treatment for each patient was included in the analyses. Reasons were classified as listed in the coded form in the web-based database. Cumulative incidences were analysed using competing risk function and factors associated with discontinuation of the ART regimen were examined using Cox proportional hazards models and Fine-Gray competing risk regression models. RESULTS: The initial ART regimen was discontinued in 351 out of 3019 eligible patients (11.6%) within the first year. The main reason for discontinuation was intolerance/toxicity (45.0%), followed by treatment simplification (9.7%), patient willingness (7.4%), poor compliance (7.1%), prevention of future toxicities (6.0%), virologic failure (5.4%), and provider preference (5.4%). Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based (aHR = 4.4, [95% CI 3.0-6.4]; p < 0.0001) or protease inhibitor (PI)-based regimens (aHR = 4.3, [95% CI 3.1-6.0]; p < 0.0001) relative to integrase strand transfer inhibitor (InSTI)-based regimens were significantly associated with ART discontinuation. ART initiated at a later period (2015-Feb 2017) (aHR = 0.6, [95% CI 0.4-0.9]; p < 0.0001) was less likely to be discontinued. A lower rate of treatment discontinuation for intolerance/toxicity was observed with InSTI-based regimens (2.0%) than with NNRTI- (6.6%) and PI-based regimens (7.5%) (p < 0.001). The percentage of patients who achieved HIV RNA < 200 copies/mL within 12 months of ART initiation was 91% in the ART discontinued group vs. 94% in the continued group (p > 0.05). CONCLUSION: ART discontinuation due to intolerance/toxicity and virologic failure decreased over time. InSTI-based regimens were less likely to be discontinued than PI- and NNRTI-based ART.

Treatment of ventilator-associated pneumonia (VAP) caused by Acinetobacter: results of prospective and multicenter ID-IRI study.

Ventilator-associated pneumonia (VAP) due to Acinetobacter spp. is one of the most common infections in the intensive care unit. Hence, we performed this prospective-observational multicenter study, and described the course and outcome of the disease. This study was performed in 24 centers between January 06, 2014, and December 02, 2016. The patients were evaluated at time of pneumonia diagnosis, when culture results were available, and at 72 h, at the 7th day, and finally at the 28th day of follow-up. Patients with coexistent infections were excluded and only those with a first VAP episode were enrolled. Logistic regression analysis was performed. A total of 177 patients were included; empiric antimicrobial therapy was appropriate (when the patient received at least one antibiotic that the infecting strain was ultimately shown to be susceptible) in only 69 (39%) patients. During the 28-day period, antibiotics were modified for side effects in 27 (15.2%) patients and renal dose adjustment was made in 38 (21.5%). Ultimately, 89 (50.3%) patients died. Predictors of mortality were creatinine level (OR, 1.84 (95% CI 1.279-2.657); p = 0.001), fever (OR, 0.663 (95% CI 0.454-0.967); p = 0.033), malignancy (OR, 7.095 (95% CI 2.142-23.500); p = 0.001), congestive heart failure (OR, 2.341 (95% CI 1.046-5.239); p = 0.038), appropriate empiric antimicrobial treatment (OR, 0.445 (95% CI 0.216-0.914); p = 0.027), and surgery in the last month (OR, 0.137 (95% CI 0.037-0.499); p = 0.003). Appropriate empiric antimicrobial treatment in VAP due to Acinetobacter spp. was associated with survival while renal injury and comorbid conditions increased mortality. Hence, early diagnosis and appropriate antibiotic therapy remain crucial to improve outcomes.

Active Surveillance of Influenza A and Other Respiratory Viruses in Children with Influenza-like-illness in Two Seasons.

INTRODUCTION: The aim of this study was to asses the surveillance of influenza A/other respiratory viruses and risk factors in hospitalized children with the symptoms of influenza-like illness during two consecutive influenza seasons. METHODOLOGY: All children hospitalized with adiagnosis of influenza-like illness had been investigated for Influenza A and other respiratory antigens in pharengeal/nasopharyngeal secretions. RESULTS: A total of 132 hospitalized children between December 2013-May 2014 and December 2014-May 2015 were enrolled in this study. At least one respiratory virus was found to be positive by RT-PCR in 78 (59%) patients, influenza A (H3N2) was detected in only 8 (6%) patients. In 54 (41%) patients samples no respiratory viral pathogen was detected and in 70 (53%) patients, one non- influenza A virus was detected. The respiratory viral pathogens detected in decreasing rates were:RSV (n = 46, 35%), HCoV (n = 10, 7.5%), adenovirüs (n = 7, 5%), rhinovirüs (n = 6, 4.5%), HMPV (n = 5, 4%), Influenza B (n = 4, 3%) ve human Bocavirus (n = 2, 1.5%). In 10 patients, coinfection was detected, however none was with H3N2. In the H3N2 (+) group, the following risk factors were identified: age older than three years (p < 0.05), asthma history (p < 0.05) and chronic lung diseases (p < 0.05). CONCLUSION: Influenza A virus was detected in 6% of hospitalized patients with influenza-like illness. Viruses other then Influenza, especially RSV, can cause similar symptoms compatible with Influenza-like-illness.

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.

Causative pathogens and antibiotic resistance in diabetic foot infections: A prospective multi-center study.

AIM: Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials. METHODS: The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate (NCT02026830). RESULTS: A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group. CONCLUSIONS: Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.

Bed capacities and disinfection practices in hospitals in Istanbul are correlated.

BACKGROUND: Disinfection, antisepsis and sterilization (DAS) practices are of critical importance in hospital practice. This study aims to investigate the daily DAS practices of private hospitals in Istanbul, Turkey. METHODS: The DAS practices of 155 private hospitals in Istanbul province were investigated using a questionnaire including 26 questions. The questionnaire forms were faxed to all private hospitals located in Istanbul. A p value < 0.05 accepted as significant. RESULTS: The 75 [48%] hospitals out of 155 hospitals responded. The quality of DAS practice was correlated with hospital bed capacity. In these hospitals, glutaraldehyde (27%) was the most common chemical used to disinfect endoscopy instruments. The rate of availability of air gun in endoscopy units in these hospitals was significantly associated with hospital bed capacity (p <0.001). Sticky mats placed at doors of risky areas were not reported to be used in the large bed capacity (LBC) hospitals unlike the small bed capacity (SBC) hospitals where 50% of these hospitals reported to use the sticky door mats (p =0.0144). CONCLUSIONS: Private hospitals in Istanbul need in-service training towards sterilization and disinfection issues. It is concluded that private hospitals need policies and educational activities for DAS practices.

Tuberculous and brucellosis meningitis differential diagnosis.

BACKGROUND: The Thwaites and Lancet scoring systems have been used in the rapid diagnosis of tuberculous meningitis (TBM). However, brucellar meningoencephalitis (BME) has similar characteristics with TBM. The ultimate aim of this study is to infer data to see if BME should be included in the differential diagnosis of TBM when these two systems suggest the presence of TBM. METHOD: BME and TBM patients from 35 tertiary hospitals were included in this study. Overall 294 adult patients with BME and 190 patients with TBM were enrolled. All patients involved in the study had microbiological confirmation for either TBM or BME. Finally, the Thwaites and Lancet scoring systems were assessed in both groups. RESULTS: The Thwaites scoring system more frequently predicted BME cases (n = 292, 99.3%) compared to the TBM group (n = 182, 95.8%) (P = 0.017). According to the Lancet scoring system, the mean scores for BME and TBM were 9.43 ± 1.71 and 11.45 ± 3.01, respectively (P < 0.001). In addition, TBM cases were classified into "probable" category more significantly compared to BME cases, and BME cases were categorized into the "possible" category more frequently. CONCLUSIONS: When the Thwaites or Lancet scoring systems indicate TBM, brucellar etiology should also be taken into consideration particularly in endemic countries.

[Fosfomycin susceptibility of urinary Escherichia coli isolates producing extended-spectrum beta-lactamase according to CLSI and EUCAST recommendations]. / CLSI ve EUCAST önerilerine göre genislemis spektrumlu beta-laktamaz üreten Escherichia coli idrar izolatlarinda fosfomisin duyarliligi

The increasing rate of antibiotic resistance in Escherichia coli, the most common pathogen of urinary tract infections (UTIs), leads to difficulties in choosing appropriate antibiotic treatment and achieving treatment success. The aim of this study was to investigate in vitro activity of fosfomycin, presented as a favorable choice for the treatment of UTIs caused especially by extended-spectrum beta-lactamase (ESBL)-producing strains. A total of 244 E.coli strains, of them 118 were ESBL positive and 126 were negative, isolated from urine samples of inpatients and outpatients between May 2011-May 2012, were included in the study. Antibiotic susceptibilities of the isolates were determined by disk diffusion method (DDM) and ESBL production was confirmed by double-disc diffusion method according to the CLSI (Clinical and Laboratory Standards Institute) recommendations. Minimum inhibitor concentration (MIC) values for fosfomycin were detected by E-test method. Fosfomycin zone diameters and MIC values of isolates were interpreted according to the breakpoints of both CLSI and EUCAST (European Committee on Antimicrobial Susceptibility Testing). Susceptibilities of ESBL positive and negative isolates to fosfomycin and other antibiotics, and the results of fosfomycin susceptibility tests obtained by different methods were compared. The correlation between fosfomycin zone diameters and MIC values was calculated. In the study, the resistance rates of ESBL-producing isolates to ciprofloxacin, trimethoprim-sulfamethoxazole, gentamicin and amikacin were detected as 67%, 51%, 51% and 19%, respectively, while those rates were as 9%, 21%, 4% and 11%, respectively in non-ESBL producers. The difference between the two groups were found statistically significant (p< 0.001). Fosfomycin resistance of ESBL-producing and non-producing isolates were 3% and 1%, respectively, indicating no significant difference between the two groups (p= 0.356). According to fosfomycin MIC breakpoints defined by CLSI, 98.3% of ESBL-producing isolates and 100% of non-producing isolates were found susceptible to fosfomycin. According to EUCAST recommendations 98.3% of ESBL-producing isolates and 99.2% of non-producing isolates were found susceptible to fosfomycin. There was no significant difference between ESBL-positive and -negative strains according to CLSI and EUCAST recommendations (p= 0.233 and p= 0.611, respectively). When the methods were compared with each other, there were significant differences between DDM and CLSI-MIC or EUCAST-MIC (p= 0.033 and p= 0.049, respectively) and between CLSI-MIC and EUCAST-MIC (p< 0.001). There was a weak reverse linear correlation between fosfomycin zone diameters and MIC values (r= -0.138, p= 0.032). It was concluded that fosfomycin which had a high activity against ESBL-producing isolates was an appropriate alternative antibiotic in the treatment of UTIs.

Predictors of fatality in pandemic influenza A (H1N1) virus infection among adults.

BACKGROUND: The fatality attributed to pandemic influenza A H1N1 was not clear in the literature. We described the predictors for fatality related to pandemic influenza A H1N1 infection among hospitalized adult patients. METHODS: This is a multicenter study performed during the pandemic influenza A H1N1 [A(H1N1)pdm09] outbreak which occurred in 2009 and 2010. Analysis was performed among laboratory confirmed patients. Multivariate analysis was performed for the predictors of fatality. RESULTS: In the second wave of the pandemic, 848 adult patients were hospitalized because of suspected influenza, 45 out of 848 (5.3%) died, with 75% of fatalities occurring within the first 2 weeks of hospitalization. Among the 241 laboratory confirmed A(H1N1)pdm09 patients, the case fatality rate was 9%. In a multivariate logistic regression model that was performed for the fatalities within 14 days after admission, early use of neuraminidase inhibitors was found to be protective (Odds ratio: 0.17, confidence interval: 0.03-0.77, p=0.022), nosocomial infections (OR: 5.7, CI: 1.84-18, p=0.013), presence of malignant disease (OR: 3.8, CI: 0.66-22.01, p=0.133) significantly increased the likelihood of fatality. CONCLUSIONS: Early detection of the infection, allowing opportunity for the early use of neuraminidase inhibitors, was found to be important for prevention of fatality. Nosocomial bacterial infections and underlying malignant diseases increased the rate of fatality.

Demographic and microbial characteristics and drug resistance of childhood tuberculosis in Istanbul: analysis of 1,541 cases.

INTRODUCTION: Although tuberculosis (TB) is frequently seen in Turkey, there are limited studies on childhood TB. We aimed to describe clinical and laboratory findings, including drug resistance, of children with TB in Istanbul, Turkey. METHODOLOGY: The study included all children aged 0-14 years who were registered in public dispensaries between 2006 and 2010. RESULTS: The study included 1,541 cases. Forty-four percent (n = 763) of the patients were male with a mean age of 8.86 ± 4.19 years. Fifty-five percent of the patients had pulmonary TB, 39% had extrapulmonary TB, and 6% had both pulmonary and extrapulmonary TB. The most common extrapulmonary involvement sites were the pleura (n = 193), lymph nodes (n = 247), and central nervous system (n = 41). Forty-one percent of the patients were evaluated microbiologically and 35% of them were positive. For the total study group, 14% of them were positive. A drug susceptibility test was performed on 108 patients. Drug resistance to at least one drug was detected in 16% (n = 17), to isoniazid in 15% (n = 16), streptomycin in 12% (n = 12), rifampicin in 9% (n = 10), ethambutol in 7% (n = 8), and multi-drug resistance in 8% (n = 9) of patients. CONCLUSIONS: This is the largest analysis on demographic features and drug resistance of childhood TB in Turkey. In Turkey, the rate of microbiological diagnosis is low, similar to rates worldwide. More microbiological studies and drug resistance tests should be done and annual changes should be followed with multi-center studies.

A registry-based cohort study of pulmonary tuberculosis treatment outcomes in Istanbul, Turkey.

The aim of this study is to evaluate the treatment outcomes and identify factors associated with adverse tuberculosis treatment outcomes for bacteriologically confirmed pulmonary tuberculosis. Treatment outcomes of pulmonary tuberculosis were evaluated retrospectively among 11,186 smear- and/or culture-positive patients treated between 2006 and 2009 in Istanbul, Turkey. Adverse treatment outcomes were identified in 1,010 (9.0%) patients including death (1.8%), treatment default (6.1%), and treatment failure (1.1%). Factors associated with adverse treatment outcomes included being born abroad (odds ratios [OR], 5.38; 95% confidence intervals [CI], 3.67-7.91), history of tuberculosis treatment (OR, 3.77; 95% CI, 3.26-4.36), age > 65 years (OR, 2.79; 95% CI, 2.21-3.53), and male gender (OR, 1.91; 95% CI, 1.59-2.27). Death was most strongly associated with age > 65 years (OR, 45.1; 95% CI, 27.0-75.6), followed by treatment default with history of interrupted treatment (OR, 11.6; 95% CI, 8.94-15.1), and treatment failure with prior history of treatment failure (OR, 17.1; 95% CI, 6.97-41.6). Multidrug resistance was strongly associated with adverse treatment outcomes (OR, 10.8; 95% CI, 8.02-14.6). Age > 65 years, male sex, being born abroad, and history of treatment failure were found to be risk factors for adverse treatment outcomes. Hence, patients with any of these characteristics should be carefully monitored and treated aggressively.

A retrospective case-control study, factors affecting treatment outcomes for pulmonary tuberculosis in istanbul, Turkey.

BACKGROUND: Tuberculosis is a public health problem and its transmission is a threat to the community. AIMS: The aim of this study was to determine the factors influencing the treatment outcomes and the effectiveness of the National Tuberculosis Program (NTP) in relation to the application of the directly observed treatment, short-course (DOTS) program in various sites in Istanbul, Turkey. STUDY DESIGN: Case-Control Study. METHODS: A case-control study was used, where cases and controls were randomly selected from the Turkish Tuberculosis National Database, which includes complete data on treatment outcomes for patients recorded in the database from January 1, 2006 to December 31, 2009 and had one year follow-up. RESULTS: The case group was composed of 464 patients with adverse outcome, while the control group was composed of 441 patients who had been cured of disease. Factors associated with adverse treatment outcome were >65 years of age (OR: 3.39 (1.99-5.76)) ; male gender (OR:2.11 (1.49-2.99)); born outside Turkey (OR: 5.48 (2.13-14.04)); co-morbidity (OR: 1.85 (1.29-2.65)); bilateral radiologic lesions (OR: 2.07 (1.41-3.00); previous treatment history (OR: 3.99 (2.78-5.74)); 3(rd) month positive microscopy (OR: 4.96 (3.04-8.09)) and any H&R +/- others multidrug resistant (MDR) resistance (OR: 22.64 (6.92-74.08)). There was no association between the adverse treatment outcome and the application site of direct observation treatment, short course (DOTS) delivery and the supervisors. CONCLUSION: Our findings indicate similar quality in DOTS application and supervision among patients with or without adverse treatment outcomes. However, patients with certain characteristics should be carefully monitored and aggressively treated.

[Evaluation of antibiotic susceptibilities and VISA-VRSA rates among MRSA strains isolated from hospitalized patients in intensive care units of hospitals in seven provinces of Turkey]. / Türkiye'de Yedi Ildeki Hastanelerin Yogun Bakim Ünitelerinden Izole Edilen MRSA Suslarinda VISA-VRSA Arastirilmasi ve Antibiyotik Duyarlilik Durumlarinin Saptanmasi

The aim of this study was to determine whether vancomycin resistant Staphylococcus aureus (VRSA) and vancomycin intermediate susceptible S.aureus (VISA) strains were present among methicillin-resistant S.aureus (MRSA) strains isolated from patients hospitalised at intensive care units (ICU) of hospitals located at different regions of Turkey and to determine the minimum inhibitory concentration (MIC) values of teicoplanin, linezolid, tigecycline, quinupristin-dalfopristin and daptomycin, which are alternative drugs for the treatment of MRSA infections. A total of 260 MRSA clinical strains (isolated from 113 lower respiratory tract, 90 blood, 24 wound, 17 catheter, 13 nasal swabs, two urine and one CSF sample) were collected from nine health-care centers in eight provinces [Ankara (n= 52), Konya (n= 49), Antalya (n= 40), Istanbul (n= 7), Izmir (37), Diyarbakir (n= 15), Van (n= 12), Trabzon (n= 48)] selected as representatives of the seven different geographical regions of Turkey. Methicillin resistance was determined by cefoxitin disk diffusion in the hospitals where the strains were isolated and confirmed by oxacillin salt agar screening at the Refik Saydam National Public Health Agency. Screening for VISA and VRSA was conducted using the agar screening test and E-test. Susceptibility of the MRSA strains to other antibiotics was also determined by E-test method. None of the 260 MRSA strains were determined to be VRSA or VISA. All were susceptible to teicoplanin and linezolid, and susceptibility rates to daptomycin, tigecycline and quinupristin-dalfopristin were 99.6%, 96.9%, and 95%, respectively. Absence of VISA and VRSA among the MRSA strains surveyed currently seemed hopeful, however, continuous surveillance is necessary. In order to prevent the development of VISA and VRSA strains the use of linezolid, tigecycline, quinupristin-dalfopristin and daptomycin should be encouraged as alternative agents of treatment of MRSA infections.

Management of Brucella endocarditis: results of the Gulhane study.

Brucella endocarditis (BE) is a rare but life-threatening complication of human brucellosis. The aim of this study was to investigate the course of BE along with the therapeutic interrelations. A total of 53 patients with BE hospitalised in 19 health institutions between 2006 and 2011 were included in the Gulhane study. Diagnosis of brucellosis was established by either isolation of Brucella sp. or the presence of antibodies, and the definition of endocarditis was made according to Duke's criteria. There were four treatment groups: ceftriaxone combined with oral antibiotics (Group 1); aminoglycosides combined with oral antibiotics (Group 2); oral antibiotic combinations (Group 3); and aminoglycoside plus ceftriaxone combined with an oral antibiotic (Group 4). Involvement rates of the aortic, mitral and tricuspid valves were 49.1%, 43.4% and 5.7%, respectively. Thirty-two patients (60.4%) had an underlying cardiac valvular problem, including previous prosthetic valve replacement (n=18). Medical treatment was provided to 32 patients (60.4%), whilst concordant medical and surgical approaches were provided to 21 patients (39.6%). Mortality in Group 1 was 15% (3/20), whilst in Group 2 it was 5.3% (1/19). In Group 3, 25.0% (3/12) of the cases died, whereas none of the cases in Group 4 died. In conclusion, mortality increased 47-fold with pericardial effusion and 25-fold due to congestive heart failure that developed after BE. Although mortality was lower in the aminoglycoside-containing arm (Groups 2 and 4), statistical analysis could not be performed owing to the small number of patients.

The importance of transmission time in HIV infections and an epidemiological prospective follow-up study for 1 year in the Marmara Region of Turkey.

It is important to detect recent and new HIV/1 infections and to take preventative measures in order to prevent rapid disease progression in AIDS and to decrease the incidence of infection. We aimed to detect long standing or recent HIV infections by determining transmission times for the cases in which first-time HIV/1 seropositivity were detected. The serum samples of 323 cases which were found to be seropositive by ELISA and Western-blotting were included in this study. The discrimination between long-term and recent HIV/1 infection was made by determining transmission-time with the Aware BED-EIA, HIV-1 incidence test (IgG capture HIV-EIA) tests. Ninety-six healthy blood donors who did not have a positive anti-HIV test and a chronic infectious disease for at least 1 year were included in this study as a negative healthy control group. In the discrimination of long-term and recent HIV/1 infections, only in vitro ODn values were used. The cases with normalized optical density (OD) (OD(specimen)/OD(calibrator))<0.8 by commercial kit were accepted as recent HIV infection (155 days history or seroconversion less than 6 months). The cases with ODn >1.2 were accepted as long-term HIV/1 infections (more than 155 days history or more than 6 months). The cases with ODn between 0.8 and 1.2 were accepted as "additional tests needed" cases. We detected recent HIV/1 infections (<6 months) in 60 (18.5%) out of 323 cases and long-term HIV/1 infections (>6 months) in 263 (81.5%) out of 323 cases. The most frequently encountered transmission route in long-term and recent HIV/1 infections was heterosexual sexual intercourse as 54 (50%) and 257 (97%), respectively. 63.3% of newly infected patients were married females and 65.3% of recently infected patients were males. In conclusion, the detection of the high ratio of long-term HIV/1 infection cases (81.5%) compared to recent infections (18.5%) suggested to us, that the long standing cases may have some activities related with transmission of HIV/1 in the past. The detection of higher HIV/1-infections in individuals which had heterosexual sex and also in married males suggested that this situation poses a very great threat for the health of society.

Diagnosis of vulvovaginitis: comparison of clinical and microbiological diagnosis.

OBJECTIVE: The purpose of the present study was to compare the current diagnostic clinical and laboratory approaches to women with vulvovaginal discharge complaint. The secondary outcomes were to determine the prevalence of infections in our setting and to look for the relation between vulvovaginal infections and predisposing factors if present. METHOD: Premenopausal women applying to our gynecology outpatient clinic with vaginal discharge complaint were enrolled prospectively into the study. Each patient evaluated clinically with direct observation of vaginal secretions, wet mount examination, whiff test, vaginal pH testing and chlamydia rapid antigen test. Each patient also evaluated microbiologically with vaginal discharge culture and gram staining. Clinical diagnosis was compared with the microbiological diagnosis (the gold standard). Diagnostic accuracy was measured with sensitivity, specificity, positive (ppv) and negative predictive values (npv). RESULTS: 460 patients were included in the study. 89.8% of patients received a clinical diagnosis whereas only 36% of them had microbiological diagnosis. The sensitivity, specificity, ppv, npv of clinical diagnosis over microbiological culture results were 95, 13, 38, 82%, respectively. The most commonly encountered microorganisms by culture were Candida species (17.4%) and Gardnerella vaginalis (10.2%). Clinically, the most commonly made diagnoses were mixed infection (34.1%), bacterial vaginosis (32.4%) and fungal infection (14.1%). Symptoms did not predict laboratory results. Predisposing factors (DM, vaginal douching practice, presence of IUD and usage of oral contraceptive pills) were not found to be statistically important influencing factors for vaginal infections. CONCLUSION: Clinical diagnosis based on combining symptoms with office-based testing improves diagnostic accuracy but is insufficient. The most effective approach also incorporates laboratory testing as an adjunct when a diagnosis is in question or treatment is failing.