The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study.

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Lateral flow assay for rapid differentiation of Mycobacterium tuberculosis complex and 97 species of mycobacteria other than tuberculosis grown in Löwenstein-Jensen and TK-SLC medium.

BACKGROUND: Mycobacterial antigen MPB64 is a secretory protein specific for Mycobacterium tuberculosis complex. A lateral flow immunochromatographic assay (ICA) is a method used for the rapid differentiation of M. tuberculosis complex. AIM: We aimed to evaluate the performance of ICA in rapid differentiation of M. tuberculosis complex from 97 Mycobacterium species other than tuberculosis (MOTT), which are grown in Lφwenstein-Jensen and TK-selective (SLC) medium. MATERIALS AND METHODS: The study was performed in our laboratory between January 2009 and January 2010. A total of 394 isolates consisting of reference strains of 34 M. tuberculosis from World Health Organization (WHO) collection, 97 different MOTT bacilli, 7 Mycobacterium bovis BCG substrains and total 256 clinical Mycobacterium isolates were tested by ICA, which is based on anti-MPB64 monoclonal antibodies. All the strains were inoculated onto a TK-SLC (selective) medium and Lowenstein-Jensen medium. TK-SLC is a new rapid mycobacterial culture medium that indicates mycobacterial growth by colour change. RESULTS: The growth of mycobacterial strains was observed in 10-12 days on TK-SLC medium. ICA test was performed in 15 minutes. All strains belonging to M. tuberculosis complex group were found positive and all MOTT species were found negative on ICA slides. The results were confirmed with nucleic acid amplification by polymerase chain reaction (PCR) using primers specific for M. tuberculosis complex. CONCLUSION: With the additive effect of growth on TK-SLC medium in 10-12 days, the mycobacterial antigen MPB64 is a very useful and specific tool in rapid differentiation of M. tuberculosis and MOTT grown in culture.

Bacillus circulans paracardiac infection in non-hodgkin lymphoma--a case report.

A case report is presented concerning Bacillus circulans paracardiac infection in a 27 year old woman with non-hodgkin lymphoma.

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.

Outbreak of nosocomial fungemia caused by Candida glabrata.

An outbreak of Candida glabrata fungemia that was thought to be associated with bottles used for milk feeds occurred at our children's infectious diseases clinic. This cluster of cases was investigated using a case-control study. Isolates were identified by conventional methods and karyotyped using pulsed-field gel electrophoresis (PFGE) of genomic DNA. Potential risk factors for nine hospitalized children with candidemia and 14 controls were long-term hospitalization and treatments with more than two antibiotics. Electrophoretic karyotyping showed a single chromosomal pattern for these outbreak isolates and, in addition, they all had the same antifungal susceptibility results. These findings suggest that clonal dissemination of a single strain was responsible for this outbreak. Karyotyping by PFGE appears to be a useful molecular typing method for strains of C. glabrata.

In vitro activities of new quinolones against Brucella melitensis isolated in a tertiary-care hospital in Turkey.

We have evaluated the in vitro activities of seven fluoroquinolones against 69 strains of Brucella melitensis. According to their minimum inhibitory concentration for 90% growth (MIC(90)) values, the most active agent was found to be sparfloxacin (MIC(90) 0.12 mg/L) followed by levofloxacin, ciprofloxacin, ofloxacin (MIC(90) 0.50 mg/L) and grepafloxacin (MIC(90) 1 mg/L), gemifloxacin (MIC(90) 2 mg/L) and gatifloxacin (MIC(90) 4 mg/L).

Epidemiology of penicillin resistance in Streptococcus pneumoniae isolates in Kayseri, Turkey.

OBJECTIVE: To determine the penicillin resistance and serotype distribution of Streptococcus pneumoniae strains and to identify clonal relationships of isolates resistant to penicillin by means of pulsed-field gel electrophoresis (PFGE). METHODS: In total, 193 S. pneumoniae strains were isolated from clinical specimens between November 1997 and January 2000. Susceptibility testing was carried out by E test, and serotyping by the Quellung reaction. Clonal relationship was analyzed by using PFGE with smaI endonuclease. RESULTS: Of the S. pneumoniae isolates, 23% were intermediately resistant to penicillin. There were no high-level resistant pneumococci. The majority of isolates intermediately resistant to penicillin were of serogroups/serotypes 19, 23, 14 and 1, in descending order of frequency. There were eight major clones in strains intermediately resistant to penicillin. It was seen that serogroups in the 23-valent polysaccharide vaccine, 7-valent, 9-valent, and 11-valent vaccine formulations caused 92%, 75%, 78% and 87% of pneumococcal diseases in our region, respectively. CONCLUSION: Penicillin resistance in S. pneumoniae is relatively uncommon in Kayseri. All vaccine formulations can prevent the majority of pneumococcal diseases, and there is genetic heterogeneity in intermediately penicillin-resistant pneumococci in this region.

Nosocomial bloodstream infections in a Turkish university hospital: study of Gram-negative bacilli and their sensitivity patterns.

Treatment of nosocomial bacteraemia is usually governed by the surveillance results of the particular unit. Such results are especially important when antimicrobial resistance rates are high. Multiresistant isolates including Gram-negatives producing extended-spectrum beta-lactamases have been frequently reported in tertiary care units in Turkey. In this study, antimicrobial susceptibilities of Gram-negative blood isolates (n=348) were determined by microbroth dilution tests. The results showed carbapenems (meropenem and imipenem) to be uniformly more potent in vitro than any other drug against the Enterobacteriaceae. Quinolone antibiotics were more active in vitro than aminoglycosides against a range of bacteria. Gram-negative bloodstream isolates were highly resistant to many antimicrobial agents in the hospital. In order to prevent hospital infection and antimicrobial resistance, surveillance of aetiological agents must be performed regularly.

Controlled release of vancomycin from biodegradable microcapsules.

Poly D,L-lactic acid (PLA) and its copolymers with glycolide PLGA 90:10 and 70:30 were polymerized under various conditions to yield polymers in the molecular weight range 12000-40000 daltons, as determined by gel permeation chromatography. Vancomycin hydrochloride was the hydrophilic drug of choice for the treatment of methicillin resistant Staphyloccoccal infections. It was microencapsulated in the synthesized polymers using water-oil-water (w/o/w) double emulsion and solvent evaporation. The influence of microcapsule preparation medium on product properties was investigated. An increase in polymer-to-drug ratio from 1:1 to 3:1 caused an increase in the encapsulation efficiency (i.e. from 44-97% with PLGA). An increase in the emulsifier (PVA) molecular weight from 14-72 kD caused an increase in encapsulation efficiency and microcapsule size. The in vitro release of vancomycin from microcapsules in phosphate buffer saline (pH 7.4) was found to be dependent on molecular weight and copolymer type. The kinetic behaviour was controlled by both diffusion and degradation. Sterilization with 60Co (2.5 Mrad) also affected the degradation rate and release profiles. Degradation of microcapsules could be seen by scanning electron microscopy, by the increase in the release rate from PLA and by the decrease in the Tg values of microcapsules. In vitro bactericidal effects of the microcapsule formulations on S. aureus were determined with a special diffusion cell after the preparations had been sterilized, and were found to have bactericidal effects lasting for 4 days.

Susceptibility testing of voriconazole, fluconazole, itraconazole and amphotericin B against yeast isolates in a Turkish University Hospital and effect of time of reading.

Voriconazole is a promising azole effective against a variety of fungi, including yeasts. In this study, we tested in vitro activities of voriconazole, fluconazole, itraconazole and amphotericin B against some ATCC and reference strains and 250 clinical yeast isolates. We also evaluated the effect of time of reading on MIC results. Voriconazole was the most active agent against Candida and Trichosporon isolates, including the putatively fluconazole-resistant C. krusei (MIC(90) 0.25 microg/ml) and C. glabrata (MIC(90) 0.5 microg/ml). Amphotericin B MICs were scattered in a considerably narrow range in both RPMI 1640 and Antibiotic Medium 3. MICs at 24 hours and 48 hours were similar in general for all antifungals tested. The highest percentage of strains that showed 24-hour and 48-hour MICs within +/-1-log(2) dilution was observed for amphotericin B tested in RPMI (99%), and the lowest for amphotericin B tested in Antibiotic Medium 3 (80%). In conclusion, voriconazole is very effective against a wide spectrum of Candida species and 24-hour readings could substitute 48-hour MIC evaluation.

Antimicrobial resistance of gram-negative isolates from intensive care units in Turkey: comparison to previous three years.

Resistance rates to selected antibiotics of gram-negative bacteria isolated from intensive care units (ICU) of 16 Turkish hospitals during 1998 were evaluated and compared to data from the previous 3 years. Antibiotic susceptibilities to imipenem, ceftazidime, ceftazidime-clavulanate, cefoperazone-sulbactam, ceftriaxone, cefepime, cefodizime, cefuroxime, piperacillin-tazobactam, ticarcillin-clavulanate, gentamicin, amikacin and ciprofloxacin were determined by Etest. A total of 1,404 isolates from 1,060 patients were collected, mainly from urinary and respiratory tracts. As in the previous 3 years, Pseudomonas spp. was the most frequently isolated gram-negative species (29.7%), followed by Escherichia coli, Acinetobacter and Klebsiella spp. Imipenem was the most active in vitro agent (73.4% susceptible), followed by ciprofloxacin (60.6%), cefoperazone-sulbactam (58.7%), cefepime (56.7%), piperacillin-tazobactam (55.0%) and amikacin (54.7%). In 1996, a decline in susceptibility rates of all antibiotics was evident. With the exception of imipenem, resistance to which remained stable, rates somewhat increased in 1997. In 1998, susceptibility to imipenem and cefepime remained stable, amikacin resistance tended to increase and susceptibility rates to other antibacterials showed a favorable increase. These results may in part be due to the implementation of a surveillance program and increased understanding of the magnitude of the resistance problem.

Surveillance of antimicrobial resistance among gram-negative isolates from intensive care units in eight hospitals in Turkey.

With the participation of eight major reference hospitals in Turkey, 749 aerobic Gram-negative isolates obtained from 473 intensive care patients in 1997 were tested for their susceptibility to 13 commonly employed antibacterial agents. The frequency with which species were isolated and resistance rates were compared with data from the previous 2 years. Imipenem was the most active agent against the majority of isolates (75%), followed by ciprofloxacin, cefepime and amikacin. The per cent susceptibility to all antibiotics declined from 1995 to 1996. With the exception of imipenem, for which there was no change in resistance, the per cent susceptibility somewhat increased in 1997. However, it was still lower than in 1995.

Analysis of a mini-outbreak of methicillin-resistant Staphylococcus aureus in a surgical ward by using arbitrarily primed-polymerase chain reaction.

In November 1995, an increase was noticed in the number of methicillin-resistant Staphylococcus aureus (MRSA) isolates from a surgical ward at Hacettepe University Hospital. All MRSA isolates obtained from clinical specimens in this ward (14 MRSA isolates from wound cultures of 10 patients) were collected prospectively for 10 weeks. Surveillance cultures were taken from ward personnel (nose cultures from 4 physicians, 7 nurses, 1 secretary, 1 waiter), 2 surgical dressing containers and 1 nebulizer. MRSA was isolated from one of the surgical dressing containers, the nebulizer and nose cultures of 3 physicians, 3 nurses and the ward secretary. Arbitrarily primed polymerase chain reaction (AP-PCR) analysis showed that most MRSA isolates belonged to 2 major clones (pattern A, pattern B). Pattern A was the most frequent one and was present in 4 clinical isolates, surgical dressing container-1. Pattern B was identified in 3 clinical isolates and nose culture of physician-3. AP-PCR analysis revealed that this mini-MRSA outbreak was caused by contamination of surgical dressing container with MRSA and nasal MRSA carriage in ward staff. AP-PCR seems to be a valuable typing method for analysis of nosocomial MRSA outbreaks because of its simplicity and rapidity.

A surveillance study of antimicrobial resistance of gram-negative bacteria isolated from intensive care units in eight hospitals in Turkey.

This study was carried out with the participation of eight hospitals in Turkey to determine the frequency of gram-negative bacteria isolated in intensive care units (ICU) and to compare their resistance rates to selected antibiotics. Aerobic gram-negative bacteria isolated from ICUs during 1996 were studied. Antibiotic susceptibilities to imipenem, ceftazidime, ceftazidime-clavulanate, ceftriaxone, cefotaxime, cefepime, cefodizime, cefuroxime, piperacillin/tazobactam, amoxycillin-clavulanate, gentamicin, amikacin and ciprofloxacin were determined by Etest. A total of 748 isolates were obtained from 547 patients. The majority of organisms were isolated from the respiratory (38.8%) and urinary tracts (30.9%). Pseudomonas spp. were the most frequently isolated gram-negative species (26.8%), followed by Klebsiella spp. (26.2%). Escherichia coli, Acinetobacter spp. and Enterobacter spp. were the other commonly isolated organisms. High resistance rates were observed for all antibiotics studied. Imipenem appeared to be the most active agent against the majority of isolates. Although resistance rates exceeded 50%, ciprofloxacin, cefepime and amikacin were found to be relatively effective. Extended-spectrum beta-lactamase (ESBL) production appeared to be a major mechanism of resistance to beta-lactam antibiotics. In contrast to ceftazidime-clavulanate, piperacillin/tazobactam showed poor activity against organisms thought to produce ESBL, suggesting the presence of an enzyme resistant to tazobactam action. This study has yielded high rates of resistance in aerobic gram-negative isolates from ICUs in Turkey. High resistance rates to all the other antibacterials studied leave imipenem as the only reliable agent for the empirical treatment of ICU infections in Turkey.

Comparison of cytochemical staining, immunofluorescence and PCR for diagnosis of pneumocystis carinii on sputum samples.

Detection of P. carinii has increased with the use of polymerase chain reaction (PCR), particularly in sputum samples. In this study, sputum samples obtained from 30 immunosuppressed patients with respiratory symptoms (12 HIV-infected) were tested by standard cytochemical staining (Giemsa and methenamine silver), immunofluorescence (IF) staining and PCR for detection of P. carinii and the results were compared. Pneumocystis carinii was detected in 4, 8 and 13 sputum samples by cytological staining, IF test and PCR, respectively. Specific amplification bands were obtained in all sputum samples that were positive by both other tests. All tests gave negative results in sputum samples obtained from 5 HIV-infected asymptomatic patients and 22 non-immunosuppressed tuberculosis patients. Our observations suggest that PCR results were well correlated with P. carinii pneumonia (PCP), especially in non-HIV-infected patients. However, PCR positivity obtained in HIV-infected patients could be misleading in the diagnosis of PCP without careful clinical evaluation. Positive results obtained by Giemsa staining or IF test confirm diagnosis of PCP authoritatively. As a result, we suggest testing sputum samples by both PCR and IF techniques for detection of P. carinii.

In vitro activity of a new echinocandin, LY303366, compared with those of amphotericin B and fluconazole against clinical yeast isolates.

The in vitro activity of LY303366, a new echinocandin derivative, was evaluated with 191 yeast isolates by a broth microdilution method. The MICs at which 50% of the isolates were inhibited were 0.125 microg/ml for Candida albicans and C. tropicalis, 0.25 microg/ml for C. krusei, C. kefyr, and C. glabrata, and 2.0 microg/ml for C. parapsilosis.