Epidemiological and molecular characteristics of meticillin-resistant Staphylococcus aureus in Turkey: A multicentre study.

The aim of this study was to investigate the epidemiological and molecular features of clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates in Turkey. MRSA isolates were collected from six regions of Turkey. The mecA and nuc genes were detected by PCR. Antimicrobial susceptibilities were determined by the disk diffusion method. Staphylococcal cassette chromosome mec (SCCmec) and staphylococcal protein A (spa) typing were performed by the sequencing method for 270 randomly selected MRSA isolates. The US Centers for Disease Control and Prevention (CDC) definition was used for epidemiological diagnosis of community-associated MRSA (CA-MRSA). Resistance rates of MRSA to ciprofloxacin, gentamicin, clindamycin, erythromycin, rifampicin, trimethoprim/sulfamethoxazole and tetracycline were 93.4%, 81.2%, 38.5%, 57.8%, 93.9%, 1.1% and 93.1%, respectively. The most frequent SCCmec type was SCCmec III (91.1%). SCCmec type IV was found in 5.2% of the isolates. The most frequent spa type was t030 (81.1%). Five isolates were CA-MRSA if only the epidemiological definition was used (5/725; 0.7%). Two isolates were defined as CA-MRSA both by epidemiological features and SCCmec typing (2/270; 0.7%). Of 14 SCCmec type IV isolates, 12 were not defined as CA-MRSA by epidemiological features. In conclusion, this is the most comprehensive multicentre study in Turkey investigating MRSA using both epidemiological and genotypic features. The CA-MRSA rate is low in Turkey. Combined use of epidemiological and genotypic methods is the most accurate approach for the diagnosis of CA-MRSA.

Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach, over 8 years, in 11 cities of Turkey.

AIMS: To evaluate the effectiveness of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach in Turkey and analyse predictors of poor hand hygiene compliance. DESIGN: An observational, prospective, interventional, before-and-after study was conducted from August 2003 to August 2011 in 12 intensive care units (ICU) of 12 hospitals in 11 cities. The study was divided into a baseline and a follow-up period and included random 30-minute observations for hand hygiene compliance in ICU. The hand hygiene approach included administrative support, supplies availability, education and training, reminders in the workplace, process surveillance, and performance feedback. RESULTS: We observed 21,145 opportunities for hand hygiene. Overall hand hygiene compliance increased from 28.8% to 91% (95% CI 87.6-93.0, p 0.0001). Multivariate and univariate analyses showed that several variables were significantly associated with poor hand hygiene compliance: males vs. females (39% vs. 48%; 95% CI 0.79-0.84, p 0.0001), ancillary staff vs. physicians (35% vs. 46%, 95% CI 0.73-0.78, p 0.0001), and adult vs. pediatric ICUs (42% vs. 74%, 95% CI 0.54-0.60, p 0.0001). CONCLUSIONS: Adherence to hand hygiene was significantly increased with the INICC Hand Hygiene Approach. Specific programmes should be directed to improve hand hygiene in variables found to be predictors of poor hand hygiene compliance.

International Nosocomial Infection Control Consortium (INICC) national report on device-associated infection rates in 19 cities of Turkey, data summary for 2003-2012.

BACKGROUND: Device-associated healthcare-acquired infections (DA-HAI) pose a threat to patient safety, particularly in the intensive care unit (ICU). We report the results of the International Infection Control Consortium (INICC) study conducted in Turkey from August 2003 through October 2012. METHODS: A DA-HAI surveillance study in 63 adult, paediatric ICUs and neonatal ICUs (NICUs) from 29 hospitals, in 19 cities using the methods and definitions of the U.S. NHSN and INICC methods. RESULTS: We collected prospective data from 94,498 ICU patients for 647,316 bed days. Pooled DA-HAI rates for adult and paediatric ICUs were 11.1 central line-associated bloodstream infections (CLABSIs) per 1000 central line (CL)-days, 21.4 ventilator-associated pneumonias (VAPs) per 1000 mechanical ventilator (MV)-days and 7.5 catheter-associated urinary tract infections (CAUTIs) per 1000 urinary catheter-days. Pooled DA-HAI rates for NICUs were 30 CLABSIs per 1000 CL-days, and 15.8 VAPs per 1000 MV-days. Extra length of stay (LOS) in adult and paediatric ICUs was 19.4 for CLABSI, 8.7 for VAP and 10.1 for CAUTI. Extra LOS in NICUs was 13.1 for patients with CLABSI and 16.2 for patients with VAP. Extra crude mortality was 12% for CLABSI, 19.4% for VAP and 10.5% for CAUTI in ICUs, and 15.4% for CLABSI and 10.5% for VAP in NICUs. Pooled device use (DU) ratios for adult and paediatric ICUs were 0.54 for MV, 0.65 for CL and 0.88 for UC, and 0.12 for MV, and 0.09 for CL in NICUs. The CLABSI rate was 8.5 per 1,000 CL days in the Medical Surgical ICUs included in this study, which is higher than the INICC report rate of 4.9, and more than eight times higher than the NHSN rate of 0.9. Similarly, the VAP and CAUTI rates were higher compared with U.S. NHSN (22.3 vs. 1.1 for VAP; 7.9 vs. 1.2 for CAUTI) and with the INICC report (22.3 vs. 16.5 in VAP; 7.9 vs. 5.3 in CAUTI). CONCLUSIONS: DA-HAI rates and DU ratios in our ICUs were higher than those reported in the INICC global report and in the US NHSN report.

Impact of a multidimensional infection control approach on central line-associated bloodstream infections rates in adult intensive care units of 8 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC).

BACKGROUND: Central line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey. METHODS: We conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention. RESULTS: During baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 - 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB. CONCLUSIONS: The implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection Control Consortium findings (INICC).

BACKGROUND: We evaluate the effectiveness of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infections (CAUTIs) in 13 intensive care units (ICUs) in 10 hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of Turkey. METHODS: A before-after prospective active surveillance study was used to determine rates of CAUTI. The study was divided into baseline (phase 1) and intervention (phase 2). In phase 1, surveillance was performed applying the definitions of the Centers for Disease Control and Prevention/National Healthcare Safety Network. In phase 2, we implemented a multidimensional approach that included bundle of infection control interventions, education, surveillance and feedback on CAUTI rates, process surveillance, and performance feedback. We used random effects Poisson regression to account for clustering of CAUTI rates across time periods. RESULTS: The study included 4,231 patients, hospitalized in 13 ICUs, in 10 hospitals, in 10 cities, during 49,644 patient-days. We recorded a total of 41,871 urinary catheter (UC)-days: 5,080 in phase 1 and 36,791 in phase 2. During phase 1, the rate of CAUTI was 10.63 per 1,000 UC-days and was significantly decreased by 47% in phase 2 to 5.65 per 1,000 UC-days (relative risk, 0.53; 95% confidence interval: 0.4-0.7; P value = .0001). CONCLUSION: Our multidimensional approach was associated with a significant reduction in the rates of CAUTI in Turkey.

Spread of OXA-48-encoding plasmid in Turkey and beyond.

Eighteen carbapenem-resistant, OXA-48-positive enterobacterial isolates recovered from Turkey, Lebanon, Egypt, France, and Belgium were analyzed. In most isolates, similar 70-kb plasmids carrying the carbapenemase gene bla(OXA-48) were identified. That gene was located within either transposon Tn1999 or transposon Tn1999.2, which was always inserted within the same gene. This work highlights the current plasmid-mediated dissemination of the OXA-48 carbapenemase worldwide.

Association between antibodies against calcifying nanoparticles and mitral annular calcification.

BACKGROUND AND AIM OF THE STUDY: Mechanisms leading to vascular and tissue calcification are not yet fully understood. Previously, an association has been demonstrated between a controversial calcifying nanoparticle (CNP; also known as 'nanobacteria') and vascular calcification and kidney stone formation. The study aim was to evaluate a possible association between mitral annular calcification (MAC) and CNP infection. METHODS: A total of 93 patients with MAC, detected using echocardiography, and 94 asymptomatic subjects without valvular and coronary artery calcification, were enrolled in the study. The serum levels of anti-CNP-antibodies were monitored in all subjects. RESULTS: Patients with MAC were generally older and had a higher prevalence of systemic hypertension, diabetes mellitus, and dyslipidemia. The anti-CNP-antibody titers, which were significantly associated with MAC (p < 0.0001), were increased with older age and MAC thickness, but decreased in line with serum levels of HDL-cholesterol (p < 0.0001). In order to provide a cut-off point for anti-CNP-antibodies when detecting MAC, a receiver operating characteristic curve was created. Serum CNP-antibody levels above 0.19 units/ml showed a sensitivity of 73%, a specificity of 72%, and positive and negative predictive values of 72% and 73%, respectively. Multivariate logistic regression analysis revealed that increasing age, systemic hypertension, diabetes, HDL-cholesterol levels and high anti-CNP titers were risk factors that were independently associated with calcification in the mitral annuli. CONCLUSION: The study results suggested that CNP might play an important role in the pathogenesis of MAC.

[Molecular characteristics of methicillin-resistant Staphylococcus aureus strains isolated from blood cultures between 2002-2005 in Ankara University Hospital]. / Ankara Universitesi Hastanesinde 2002-2005 yillari arasinda kan kültürlerinden izole edilen metisiline dirençli Staphylococcus aureus suslarinin moleküler ozellikleri.

This study was conducted to investigate the antimicrobial susceptibility, Panton Valentine leucocidine (PVL) and toxin (enterotoxin A-J, staphylococcal toxic shock toxin) genes, agr types, staphylococcal cassette chromosome mec (SCCmec) types and pulsed field gel electrophoresis (PFGE) profiles of a total of 100 non-duplicate methicillin-resistant Staphylococcus aureus (MRSA) bloodstream isolates collected between 2002-2005 at Ankara University Ibn-i Sina Hospital. Antimicrobial susceptibilities were investigated by a semi-automated system (miniAPI, BioMerieux, France); PVL, mecA and toxin (sea, seb, sec, sed, see, seg, seh, sei, sej, tst) genes by polymerase chain reaction (PCR) and SCCmec and agr typing were performed by multiplex PCR. While all isolates were susceptible to vancomycine, aminoglycoside and tetracycline resistance was determined in 91%, ciprofloxacine in 93%, rifampin in 92%, erythromycine in 79% and trimethoprim-sulphametoxazole in 8% of the isolates. mecA gene was detected in all of the isolates, however, PVL positive isolate was not detected. sea was the most frequently (77%) detected enterotoxin gene. SCCmec typing revealed type III in 84 (84%) and agr typing revealed type I in 91 (91%) of the isolates. Multilocus Sequence Typing (MLST) of five representative isolates (two isolates with pattern A, one isolate each from patterns B, C and D) revealed sequence type (ST) 239. This study documented that the dominant MRSA clone in our hospital had SCCmec type III, agr type 1, PVL negative, sea positive and of ST 239. Larger scale intercity and nation wide studies are needed to find out the clonal characteristics of hospital acquired MRSA in Turkey.

Investigation of Panton-Valentine leukocidin genes and SCCmec types in clinical Staphylococcus aureus isolates from Turkey.

Panton-Valentine leukocidin (PVL) is an important virulence determinant of Staphylococcus aureus. The aim of this study was to investigate the prevalence of PVL genes in clinical S. aureus isolates and to determine the staphylococcal chromosomal cassette mec (SCCmec) types of methicillin-resistant S. aureus (MRSA) strains obtained from inpatients and outpatients of two hospitals in Turkey. Of the 304 S. aureus strains (230 hospital acquired [HA] and 74 community-onset [CO]), 261 were MRSA and 43 were methicillin-sensitive S. aureus (MSSA). PVL positivity was determined in 12 (1 HA and 11 community acquired) strains. Eight were MRSA, and four were MSSA. Seven of the PVL-positive strains were isolated from wound specimens, four from urine, and one from synovial fluid. SCCmec type III (93.78%) was more prevalent among HA-MRSA strains, and SCCmec type IIIB (41.18%) was more prevalent among CO-MRSA strains. Pulsed-field gel electrophoresis patterns of the PVL-positive isolates were different. Our results indicate that PVL-positive strains are able to cause infection in nearly every system without the need for additional risk factors. Our PVL-positive CO-MRSA strains carry SCCmec types other than types IV and V. Due to the presence of PVL-positive strains in the hospitals, it is important to establish appropriate infection control measures to prevent their spread in the community and in hospitals.

[Resistance to newer beta-lactams and related ESBL types in gram-negative nosocomial isolates in Turkish hospitals: results of the multicentre HITIT study]. / Türkiye'de hastane izolati gram-negatif bakterilerde yeni beta-laktam antibiyotiklere direnç ve GSBL tipleri: çok merkezli HITIT sürveyansinin sonuçlari.

Increasing resistance due to extended-spectrum beta-lactamases (ESBLs) and multiple resistance mechanisms in gram-negative hospital isolates restrict the role of beta-lactam antibiotics in empirical treatment of serious infections. As the prevalence of ESBL producing strains and resistance rates to antimicrobial agents can vary in each center, local surveillance studies are required to guide therapy. In this study, in vitro rates of resistance to ceftriaxone, ceftazidime, cefepime, imipenem, cefoperazone/sulbactam and piperacillin/tazobactam were evaluated in 1196 gram-negative hospital isolates in a multicenter in vitro study with the participation of six different centers in Turkey between the period of June 2004-January 2005. The isolates included Escherichia coli (n= 457), Klebsiella pneumoniae (n= 390), Pseudomonas aeruginosa (n= 194) and Acinetobacter boumannii (n= 155). In addition, frequency of ESBL production and types of enzymes were determined in blood isolates of E. coli and K. pneumoniae. MICs and ESBL production were investigated by E-test (AB Biodisk, Solna) and the results were evaluated by using CLSI breakpoints. PCR analysis was used for typing of the ESBLs. In E. coli, 26% and in K. pneumoniae 32% of the isolates were ESBL producers. Among the blood isolates of E. coli and K. pneumoniae, 31.7% and 33.3% produced ESBLs, respectively. CTX-M (71.4%) was the most prevalent enzyme, followed by TEM (49.4%) and SHV (46.7%) derived enzymes. CTX-M-15 (69.4%) was the most frequent CTX-M type in blood isolates followed by CTX-M-3 (28.6%) and CTX-M-1 (2%). Resistance to imipenem was not observed in E. coli isolates, however it was 1.3% in K. pneumoniae, 28.9% in P. aeruginosa and 52.2% in A. baumannii strains. Resistance to cefoperazone/sulbactam was found as 6%, 17.7%, 27.9% and 41.3% in E. coli, K. pneumoniae, P. aeruginosa and A. baumannii isolates, respectively, whereas resistance rates to piperacillin/tazobactam were 10.2%, 22.3%, 22.7% and 78.7%, respectively. These results indicate that ESBL production and rates of resistance to beta-lactam antibiotics are high in hospital isolates of gram-negative bacteria in Turkey, however, they show variations in different hospitals and CTX-M enzymes are prevalent in these isolates.

Comparison of the effect of delayed entry into 2 different blood culture systems (BACTEC 9240 and BacT/ALERT 3D) on culture positivity.

The effect of delayed entry (2-48 h) into BacTAlert 3D and BACTEC 9240 and the effect of 2 storage temperatures (22 degrees C vs 35 degrees C) on bacterial growth was evaluated. The delay in transportation of blood culture bottles stored at room temperature had no effect on the recovery rate for the first 12 h. Culture positivity was between 74.4% and 100% for different microorganisms at less than 24 h preincubation time. The positivity rate decreased significantly for Acinetobacter baumannii, Bacteroides fragilis, Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Streptococcus pneumoniae for more than 24 h of delay. Culture positivity was higher at 22 degrees C for all microorganisms especially for Enterococcus faecalis and P. aeruginosa. Effects of instrument, preincubation time, and temperature showed that the risk of culture negativity increased 1.5 times for BACTEC compared with BacTAlert 3D and increased 2.5 times for 35 degrees C compared with 22 degrees C. The negativity increased 5.5 times and 8.5 times at 24 and 48 h of delay respectively, compared with no delay.

Initial Candida dubliniensis isolate in Candida spp. positive haemocultures in Turkey between 2001 and 2004.

Candida dubliniensis which was first recognized in 1995 can be easily misidentified because of its phenotypic similarities with Candida albicans. In this study blood samples of patients from various departments of Ankara University Medical Faculty between January 2001-June 2004 were investigated for the distribution of Candida spp. and the presence of C. dubliniensis. Culture positive 67 fungi were included to the study. Phenotypic tests such as chlamydospore formation, colony morphology on Staib agar, growth at 45 degrees C, carbohydrate assimilation profiles were investigated for identification and differentiation of C. dubliniensis from C. albicans. To confirm the results polymerase chain reaction were used for suspected C. albicans and C. dubliniensis isolates. Among 38 germ tube and chlamydospore forming isolates, 37 of them were found as C. albicans and one as C. dubliniensis. The incidence of C. dubliniensis in our hospital is still low, this is the first C. dubliniensis isolate as an agent of candidaemia reported from Turkey.

[Evaluation of disk diffusion test for carbapenem sensitivity in Acinetobacter baumannii and Pseudomonas aeruginosa strains]. / Acinetobacter baumannii ve Pseudomonas aeruginosa suslarinda karbapenem duyarliliginda disk difüzyon testinin degerlendirilmesi.

This study was conducted upon the detection of discordant results obtained for Acinetobacter species against meropenem by disk diffusion susceptibility and E-test method. The aim of this study was to investigate the reliability of disk diffusion method for the determination of carbapenem susceptibility in non-fermentative bacilli. Carbapenem (imipenem and meropenem) sensitivites of 157 Acinetobacter baumanii and 157 Pseudomonas aeruginosa strains were performed by disk diffusion test and E-test in our laboratory where quality control of antibiotic susceptibility tests are performed weekly. For meropenem, discordance of the two tests were 10.8% and 4.5% for A. baumannii and P. aeruginosa, respectively. MIC values and disk diffusion zone diameters were significantly different from each other. There was no difference in terms of imipenem in A. baumannii strains but 5.1% of P. aeruginosa isolates showed discordance. Since, for the P. aeruginosa isolates with discordant imipenem susceptibility results, the imipenem disk diffusion zones were close to the lower level and their MIC values were within the intermediate resistance range, it was assumed that this technical discordance had low risk of reproducibility. In routine laboratories, meropenem resistance detected by disk diffusion method, should be verified by another technique. This is not only important for patient results but for epidemiological data as well. Routine quality control studies for antibiotic susceptibility tests and close observation of suspicious results, is mandatory for each laboratory, in order to achieve good quality performance.

Major bacteria of community-acquired respiratory tract infections in Turkey.

To determine the bacterial etiology of lower respiratory tract infections (LRTIs) in Turkey, quantitative cultures of sputum were carried out. The major pathogens for LTRIs were found to be Haemophilus influenzae, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Only 6.1% of the H. inlfuenzae and all strains of M. catarrhalis were beta-lactamase producers. An E-test showed that 31.2% of the S. pneumoniae strains had an intermediate resistance to penicillin, and the remaining strains were susceptible; no fully resistant strains were detected.

[Antibiotic resistance of Acinetobacter baumannii isolates: data from Ibni Sina Hospital for the year 2002]. / Acinetobacter baumannii izolatlarinda antibiyotik direnci: 2002 yili Ibni Sina Hastanesi verileri.

Acinetobacter spp. have a special role in nosocomial infections. They usually colonize intensive care units and cause infections. Multiple antibiotic resistance is observed to be an important problem in Acinetobacter isolates in recent years. The aim of this study was to evaluate the susceptibilities of 277 Acinetobacter baumannii strains (99 blood, 71 abscess, 26 urine, 81 lower respiratory tract isolates) isolated from adult patients hospitalized in Ankara University Ibni Sina Hospital during one year period in 2002. The resistance rates of the strains against studied antibiotics were found as follows; 31.2% for netilmicin, 44.6% for sulbactam-cefoperazone, 53.6% for imipenem, 59.8% for amikacin, 59.9% for tobramycin, 74% for ciprofloxacin, 78% for gentamicin, 78.3% for ticarcillinclavulanate. 79.5% sulbactam-ampicillin, 82.3% for cotrimoxazole, 84.8% for ticarcillin, 87.3% for piperacillin-tazobactam, 88.1% for ceftazidime and 92.1% for piperacillin. When the isolates obtained from the reanimation unit were compared with the isolates obtained from the other hospital units, a significantly high level of resistance was found from the isolates obtained from the reanimation unit except netilmicin and sulbactam/cefoperazone. The high rate of in-vitro antibiotic resistance of the A. baumannii strains indicated the importance of controlled antibiotic usage and appliance of hospital infection control measures.