The Effects of Antimicrobial Resistance and the Compatibility of Initial Antibiotic Treatment on Clinical Outcomes in Patients With Diabetic Foot Infection.

We aimed to determine pathogen microorganisms, their antimicrobial resistance patterns, and the effect of initial treatment on clinical outcomes in patients with diabetic foot infection (DFI). Patients with DFI from 5 centers were included in this multicenter observational prospective study between June 2018 and June 2019. Multivariate analysis was performed for the predictors of reinfection/death and major amputation. A total of 284 patients were recorded. Of whom, 193 (68%) were male and the median age was 59.9 ± 11.3 years. One hundred nineteen (41.9%) patients had amputations, as the minor (n = 83, 29.2%) or major (n = 36, 12.7%). The mortality rate was 1.7% with 4 deaths. A total of 247 microorganisms were isolated from 200 patients. The most common microorganisms were Staphylococcus aureus (n = 36, 14.6%) and Escherichia coli (n = 32, 13.0%). Methicillin resistance rates were 19.4% and 69.6% in S aureus and coagulase-negative Staphylococcus spp., respectively. Multidrug-resistant Pseudomonas aeruginosa was detected in 4 of 22 (18.2%) isolates. Extended-spectrum beta-lactamase-producing Gram-negative bacteria were detected in 20 (38.5%) isolates of E coli (14 of 32) and Klebsiella spp. (6 of 20). When the initial treatment was inappropriate, Klebsiella spp. related reinfection within 1 to 3 months was observed more frequently. Polymicrobial infection (p = .043) and vancomycin treatment (p = .007) were independent predictors of reinfection/death. Multivariate analysis revealed vascular insufficiency (p = .004), hospital readmission (p = .009), C-reactive protein > 130 mg/dL (p = .007), and receiving carbapenems (p = .005) as independent predictors of major amputation. Our results justify the importance of using appropriate narrow-spectrum empirical antimicrobials because higher rates of reinfection and major amputation were found even in the use of broad-spectrum antimicrobials.

Association of Serum Krebs von den Lungen-6 (KL-6) Levels and Disease Severity in Patients Hospitalized with COVID-19.

Objective: We aimed to evaluate Krebs von den Lungen-6 (KL-6) as a possible biomarker in determining disease severity in patients with moderate and severe COVID-19. Materials and Methods: This cross-sectional study included moderate or severe COVID-19 patients; critically ill patients who were followed up in the intensive care unit were not included. KL-6 level and routine laboratory test measurements were performed on the first day of admission. The patients were also categorized according to their hyperinflammatory state. Results: The study included 92 patients, 56 (61%) women. The National Institutes of Health (NIH) score was 2 in 52.2% of the patients and 3 in 47.8%. KL-6 levels did not significantly differ in disease severity (NIH score 2 vs. 3; p=0.15). Median KL-6 values were 52.7 (29.1) in patients with <2 COVID-19 hyperinflammatory syndrome score (cHIS) and 61.7 (32.2) in patients with cHIS ≥ 2 (p= 0.077). KL-6 values tended to be higher among the patients with lower lymphocyte counts, but the difference was not statistically significant (<1000 mm³/L p=0.006 and higher cHIS scores ≥2 p=0.07). KL-6 values were also higher in the patients with diabetes mellitus compared to the remaining patients (p =0.036). Conclusion: There was no significant association between the serum KL-6 measured at admission and the severity of COVID-19.

Antibiotic Use among Patients Hospitalized with COVID-19 and Treated in Three Different Clinics.

Objective: In this study, we aimed to determine and compare the rates of empirical antibiotic use and duration between the chest diseases clinic (CDC), infectious disease clinic (IDC), and internal medicine clinic (IMC) among patients hospitalized because of COVID-19. Methods: This cross-sectional study was performed in a single university hospital. The study included all patients aged 18 years and older hospitalized with a PCR-confirmed COVID-19 between May 30, 2021, and August 30, 2021. Clinical and laboratory findings were recorded from the electronic medical records database. Results: The study included a total of 581 inpatients, of whom 310 (53.4%) were women. Of the 581 patients, 475 (81.8%) were prescribed antibiotics. The rate of antibiotic prescription was 71.6% for IDC, 88.5% for CDC, and 87.4% for IMC. The most commonly used antibiotic was moxifloxacin in all groups. The mean treatment duration was 8.9±6.16 days. The mean duration of antibiotic treatment was 11.1±5.90 days for CDC, 11.3±6.74 days for IMC, and 5.3 days±3.76 for IDC. Conclusion: Patients with COVID-19 who were treated in IDC had a lower rate and shorter duration of antibiotic use compared to the other clinics. However, the rate of antibiotic prescription in all three groups was very high. Therefore, antimicrobial management programs should be meticulously conducted to reduce unnecessary antibiotic use.

Foot self-care in diabetes mellitus: Evaluation of patient awareness.

AIMS: To assess diabetic patients' knowledge and practices regarding foot care. METHODS: This study was conducted as a cross-sectional study in 1030 patients between November 2017 and February 2018.The descriptive survey instrument was developed by the investigators. Survey content and format were based on prior surveys and guidelines. The survey sought socio-demographic characteristics of the patients and the level of knowledge about diabetic foot care practice. RESULTS: 29.5% of patients had bad foot care, 49.6% of patients had moderate foot care and 20.8% of patients had good foot care. There were no significant differences between patient groups in regard to age, gender, foot infection history and having undergone amputation surgery. We found that patients who good at foot care had higher education status (p<0.001), were more likely live in a city (p<0.001), had higher income (p<0.001), had been trained about foot care (p<0.001) and were more likely to have type I DM (p=0.015). Disease duration was longer in those who had good foot care compared to the other groups (p=0.010). CONCLUSIONS: The mean knowledge and practice scores of our patients were moderate, indicating that much is to be done for the education of patients on this matter. We also found that knowledge about the importance of this practice, education status and disease duration had significant influence on the practice of foot-care in patients with DM.

Development and validation of a modified quick SOFA scale for risk assessment in sepsis syndrome.

Sepsis is a severe clinical syndrome owing to its high mortality. Quick Sequential Organ Failure Assessment (qSOFA) score has been proposed for the prediction of fatal outcomes in sepsis syndrome in emergency departments. Due to the low predictive performance of the qSOFA score, we propose a modification to the score by adding age. We conducted a multicenter, retrospective cohort study among regional referral centers from various regions of the country. Participants recruited data of patients admitted to emergency departments and obtained a diagnosis of sepsis syndrome. Crude in-hospital mortality was the primary endpoint. A generalized mixed-effects model with random intercepts produced estimates for adverse outcomes. Model-based recursive partitioning demonstrated the effects and thresholds of significant covariates. Scores were internally validated. The H measure compared performances of scores. A total of 580 patients from 22 centers were included for further analysis. Stages of sepsis, age, time to antibiotics, and administration of carbapenem for empirical treatment were entered the final model. Among these, severe sepsis (OR, 4.40; CIs, 2.35-8.21), septic shock (OR, 8.78; CIs, 4.37-17.66), age (OR, 1.03; CIs, 1.02-1.05) and time to antibiotics (OR, 1.05; CIs, 1.01-1.10) were significantly associated with fatal outcomes. A decision tree demonstrated the thresholds for age. We modified the quick Sequential Organ Failure Assessment (mod-qSOFA) score by adding age (> 50 years old = one point) and compared this to the conventional score. H-measures for qSOFA and mod-qSOFA were found to be 0.11 and 0.14, respectively, whereas AUCs of both scores were 0.64. We propose the use of the modified qSOFA score for early risk assessment among sepsis patients for improved triage and management of this fatal syndrome.

Influence of multidrug resistant organisms on the outcome of diabetic foot infection.

OBJECTIVES: We described the clinical outcomes of the diabetic patients who had foot infections with multidrug resistant organisms. METHODS: We included the patients with diabetic foot infections (DFI) from 19 centers, between May 2011 and December 2015. Infection was defined according to IDSA DFI guidelines. Patients with severe infection, complicated moderate infection were hospitalized. The patients were followed-up for 6 months after discharge. RESULTS: In total, 791 patients with DFI were included, 531(67%) were male, median age was 62 (19-90). Severe infection was diagnosed in 85 (11%) patients. Osteomyelitis was diagnosed in 291(36.8%) patients. 536 microorganisms were isolated, the most common microorganisms were S. aureus (20%), P. aeruginosa (19%) and E. coli (12%). Methicillin resistance (MR) rate among Staphylococcus aureus isolates was 31%. Multidrug resistant bacteria were detected in 21% of P. aeruginosa isolates. ESBL (+) Gram negative bacteria (GNB) was detected in 38% of E. coli and Klebsiella isolates. Sixty three patients (8%) were re-hospitalized. Of the 791 patiens, 127 (16%) had major amputation, and 24 (3%) patients died. In multivariate analysis, significant predictors for fatality were; dialysis (OR: 8.3, CI: 1.82-38.15, p=0.006), isolation of Klebsiella spp. (OR:7.7, CI: 1.24-47.96, p=0.028), and chronic heart failure (OR: 3, CI: 1.01-9.04, p=0.05). MR Staphylococcus was detected in 21% of the rehospitalized patients, as the most common microorganism (p<0.001). CONCLUSION: Among rehospitalized patients, methicillin resistant Staphylococcus infections was detected as the most common agent, and Klebsiella spp. infections were found to be significantly associated with fatality.

Community acquired infections among refugees leading to Intensive Care Unit admissions in Turkey.

OBJECTIVES: Data on the impact of refugees on Intensive Care Units (ICUs) are lacking in the literature, in particular for community-acquired (CA) infectious diseases, for which they are known to be at higher risk. We did a descriptive, multicenter study to analyze CA infections among refugee patients requiring ICU admission. METHODS: Inclusion criteria were adult refugee patients admitted to an ICU due to CA infections. Anonymized data were collected between January 1, 2010 and December 30, 2015 across 10 referral centers. RESULTS: 29.885 patients were admitted to the ICUs in the study period. 37 patients were included the study, the majority were from Syria (n=31, 83.8%). Mean (SD) age of the patients was 45.92±20.16years. The 5-year prevalence rate was 123.8 per 100.000 patients in the ICUs. All patients had at least one comorbid condition. Forty-nine CA infections were diagnosed. The most common CA infection was pneumonia (49%) followed by urinary-tract infections (16.3%). 21 patients (56.7%) hospitalized in the ICU had trauma history. Mortality rate was high at 22 patients (59.5%) with 5 (22.7%) deaths directly attributed to CA infections. CONCLUSIONS: Refugees presented to ICUs with CA infections similar to the host populations (pneumonia and urinary-tract infections) but had high mortality rates (59.5%). It seems that Turkish ICUs were not congested with the refugee patients' influx for CA infections. More research needs to be done to better understand how to deliver preventative and timely health care services to this group of patients.

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.

Mortality indicators in pneumococcal meningitis: therapeutic implications.

BACKGROUND: The aim of this study was to delineate mortality indicators in pneumococcal meningitis with special emphasis on therapeutic implications. METHODS: This retrospective, multicenter cohort study involved a 15-year period (1998-2012). Culture-positive cases (n=306) were included solely from 38 centers. RESULTS: Fifty-eight patients received ceftriaxone plus vancomycin empirically. The rest were given a third-generation cephalosporin alone. Overall, 246 (79.1%) isolates were found to be penicillin-susceptible, 38 (12.2%) strains were penicillin-resistant, and 22 (7.1%) were oxacillin-resistant (without further minimum inhibitory concentration testing for penicillin). Being a critical case (odds ratio (OR) 7.089, 95% confidence interval (CI) 3.230-15.557) and age over 50 years (OR 3.908, 95% CI 1.820-8.390) were independent predictors of mortality, while infection with a penicillin-susceptible isolate (OR 0.441, 95% CI 0.195-0.996) was found to be protective. Empirical vancomycin use did not provide significant benefit (OR 2.159, 95% CI 0.949-4.912). CONCLUSIONS: Ceftriaxone alone is not adequate in the management of pneumococcal meningitis due to penicillin-resistant pneumococci, which is a major concern worldwide. Although vancomycin showed a trend towards improving the prognosis of pneumococcal meningitis, significant correlation in statistical terms could not be established in this study. Thus, further studies are needed for the optimization of pneumococcal meningitis treatment.

Ribavirin is not effective against Crimean-Congo hemorrhagic fever: observations from the Turkish experience.

Crimean-Congo hemorrhagic fever (CCHF) is a viral infection associated with a high mortality rate. Ribavirin is the only drug used in the treatment of this disease. Studies investigating the effectiveness of ribavirin in CCHF have been retrospective and to date have included only a small number of cases. In recent years, due to climate changes, the number of cases of CCHF in Turkey has increased, and experience in the treatment of CCHF has improved. Several studies have evaluated the efficacy of ribavirin in Turkey, including one randomized controlled trial and two studies with a large number of cases. In these studies, ribavirin therapy was not shown to decrease mortality rates; the mortality rate was 2-9% in patients treated with ribavirin and 5.6-11% in those who were not treated with this drug. These findings suggest that patients with CCHF should be followed with supportive care only until randomized controlled trials with larger groups have been conducted.

Withdrawal of Staphylococcus aureus from intensive care units in Turkey.

BACKGROUND: In the past, Staphylococcus aureus infections have displayed various patterns of epidemiologic curves in hospitals, particularly in intensive care units (ICUs). This study aimed to characterize the current trend in a nationwide survey of ICUs in Turkey. METHODS: A total of 88 ICUs from 36 Turkish tertiary hospitals were included in this retrospective study, which was performed during the first 3 months of both 2008 (period [P] 1) and 2011 (P2). A P value ≤.01 was considered significant. RESULTS: Although overall rates of hospital-acquired infection (HAI) and device-associated infection densities were similar in P1 and P2, the densities of HAIs due to S aureus and methicillin-resistant S aureus (MRSA) were significantly lower in P2 (P < .0001). However, the proportion of HAIs due to Acinetobacter was significantly higher in P2 (P < .0001). CONCLUSIONS: The incidence of S aureus infections is declining rapidly in Turkish ICUs, with potential impacts on empirical treatment strategies in these ICUs.

Influenza B-associated encephalopathy in two adults.

Influenza virus is associated with a variety of neurological complications, of which the most commonly encountered are seizures and encephalopathy. Acute encephalitis and postinfectious encephalopathy have been reported infrequently in association with influenza A and B virus infections. We describe two previously healthy adults who presented with encephalopathy with a virologically documented influenza B infection.

An adult onset Still's disease mimicking pneumonia.

Adult onset Still's disease is a rare systemic inflammatory disease of unknown origin. It is common to involve liver and spleen, and less often lungs. A 24-year-old man presenting with spiking fever, pulmonary infiltrations, and pleural effusion on the right side mimicking pneumonia. All serologic tests of infectious causes, antinuclear antibody, and rheumatoid factor were negative. He was diagnosed as Adult onset Still's disease according to the criteria of Yamaguchi. Adult onset Still's disease is considering in the differential diagnosis pneumonia that is unresponsive to antimicrobial treatment, negative cultures and serologically diagnostic laboratory tests, and high-level serum ferritin.

Comparison of tuberculin skin testing and QuantiFERON-TB Gold-In Tube test in health care workers.

The purpose of this prospective, cross-sectional observational study was to compare the tuberculin skin testing (TST) with QuantiFERON-TB Gold-In Tube (QTF-GIT) for the detection of latent tuberculosis infection in healthcare workers (HCWs). The study included 78 volunteers who are HCWs at the same tertiary care teaching hospital for chest diseases and tuberculosis. Participants with active tuberculosis, immunodefficiency or malnutrition were not included. The TST was administered by the Mantoux method. Peptides representing ESAT-6, CFP-10 and TB7-7 were used as TB-specific antigens in the whole-blood Interferon-gamma (IFN-g) assay (QTF-GIT). There was a statistically significant relation between the number of Bacillus Calmette-Guerin (BCG) scars and the diameter of TST (p< 0.01). QTF results according to previous BCG vaccinations did not significantly differ (p> 0.05). There was an intermediate concordance between two tests (k: 0.346). QTF-GIT has a sensitivity of 56.14% (both TST and QTF-GIT are positive), specificity of 90.48% (both TST and QTF-GIT are negative); positive predictive value of 94.12% and negative predictive value of 43.18% and accuracy is 65.38%. There was a statistically significant relation between TST diameter and QTF result (p< 0.01). Latent tuberculosis infection prevalance of our study population was 43% according to QTF-GIT test, 73% according to TST and BCG vaccination rate was 87%. In conclusion, TST is affected by previous BCG vaccinations, QTF-GIT is not. We can recommend QTF-GIT test for the detection of latent tuberculosis infection as an alternative to TST in populations with routine BCG vaccination programme.

Nosocomial infections and risk factors in the intensive care unit of a teaching and research hospital: a prospective cohort study.

BACKGROUND: To evaluate the incidence, risk factors and etiology of nosocomial infections (NIs) in the intensive care unit (ICU) of our hospital in order to improve our infection control policies. MATERIAL/METHODS: A 1-year prospective cohort study of nosocomial infection (NI) surveillance was conducted in our ICU in 2008. RESULTS: Out of 1134 patients hospitalized in the ICU for a period of 6257 days, 115 patients acquired a total of 135 NIs distributed as follows: 36.3% bacteremia, 30.4% ventilator-associated pneumonia (VAP), 18.5% catheter-associated urinary tract infection, 7.4% central-line infection, 5.9% cutaneous infection, and 1.3% meningitis. The incidence rate of NI was 21.6 in 1000 patient-days, and the rate of NI was 25.6%. Length of ICU stay, central venous catheterisation, mechanical ventilation and tracheostomy were statistically significant risk factors for NI. Of all NI, 112 (83%) were microbiologically-confirmed and 68.8% of the isolates were Gram-negative, 27.6% were Gram-positive, and 3.6% were fungi. 23 (17%) were clinically-defined infections. The most frequently isolated organism was P. aeruginosa (25%), followed by S. aureus (21.4%), E. coli (18.7%) and A. baumannii (16.9%). CONCLUSIONS: The bloodstream was the most common site and Gram-negatives were the most commonly reported causes of ICU infections.

A case of gynecomastia due to entecavir.

Hepatitis B is an important health problem all over the world as well as in our country. Entecavir is a nucleoside analog used in the treatment of chronic hepatitis B. We present a case of a 55-year-old male patient who developed unilateral gynecomastia while under treatment with entecavir. Physical examination was unremarkable except for minimal hepatomegaly. Laboratory examination revealed: HbsAg: positive, HBeAg: negative, anti-HBe: positive, HBV DNA: 800,000 copies/ml, total anti-HDV: negative, and alanine aminotransferase: 105 U/L (normal range: 0-41). The treatment was started with pegylated interferon. During the follow-up, transaminases did not regress and HBV DNA was found to still be highly positive at the sixth month evaluation. Pegylated interferon treatment was stopped and entecavir was started at a dose of 0.5 mg/day. Six months after the initiation of entecavir treatment, the patient presented with a painful swelling in the right breast. On physical examination, there was painful gynecomastia on the right side, which was confirmed with mammography and ultrasound of the breast tissue. The patient was not taking any drug that may have caused gynecomastia. Hormonal status of the patient was normal. Laboratory values were normal. We considered that this unilateral gynecomastia might be an adverse effect of entecavir. Since the patient had a rapid viral and biochemical response to entecavir, the drug was continued under close follow-up and there was no further progression of the gynecomastia.

The evaluation of the Quantiferon-TB Gold test in pulmonary and extrapulmonary tuberculosis.

In our study we evaluated the Quantiferon-TB Gold (QFT-G) test and compared it with tuberculin skin test (TST) positivity in 44 pulmonary and 21 extrapulmonary tuberculosis cases in whom active tuberculosis infection was suspected on clinical, microbiologic and radiologic grounds. QFT-G positivity was 75% in pulmonary tuberculosis and 76.2% in extrapulmonary tuberculosis. TST positivity was 68.2 and 62%, respectively. Although QFT-G positivity was higher than TST positivity, the difference was statistically insignificant (P=0.77). Similar to TST, QFT-G is one of the supplementary diagnostic tests for active tuberculosis disease and latent tuberculosis infection. Its advantage over TST is that it gives a result on the same day and it is unaffected by prior BCG and previous exposure to atypical mycobacteria. In conclusion, we think that, as with TST, a positive QFT-G result can be an adjunct to diagnosis in patients having clinical and radiological data compatible with tuberculosis.

Angio-oedema as an unusual tolerable side effect of voriconazole therapy.

Voriconazole (VRC) has not previously been reported to cause angio-oedema. Here, we report a case of angio-oedema associated with VRC therapy. A 37-year-old woman with relapsing invasive vertebral aspergillosis received intravenous VRC and developed angio-oedema 10 days after starting therapy. This condition rapidly diminished after administration of intravenous antihistaminics and did not necessitate cessation of VRC treatment. The treatment was continued for 6 months without recurrence of the symptoms. After 18 months, the patient was in good health. To our knowledge, this is the first report of an angio-oedema associated with VRC.

Ecthyma gangrenosum without bacteremia in a previously healthy man: a case report.

INTRODUCTION: Ecthyma gangrenosum is known as a characteristic lesion of Pseudomonas aeruginosa sepsis and is usually seen in immunocompromised patients. CASE PRESENTATION: A previously healthy 63-year-old man was admitted with sloughy necrotic ulcerations of the skin over his sternum. He was afebrile and in good condition. A skin biopsy revealed ecthyma gangrenosum. Blood cultures remained sterile, but a culture of biopsy material grew Pseudomonas aeruginosa. CONCLUSION: Ecthyma gangrenosum may develop even in the absence of bacteremia and even in immunocompetent patients. It should be considered as a possible diagnosis even when a previously healthy patient has negative blood cultures.