Epidemiology and risk factors of 28-day mortality of hospital-acquired bloodstream infection in Turkish intensive care units: a prospective observational cohort study.

OBJECTIVES: To uncover clinical epidemiology, microbiological characteristics and outcome determinants of hospital-acquired bloodstream infections (HA-BSIs) in Turkish ICU patients. METHODS: The EUROBACT II was a prospective observational multicontinental cohort study. We performed a subanalysis of patients from 24 Turkish ICUs included in this study. Risk factors for mortality were identified using multivariable Cox frailty models. RESULTS: Of 547 patients, 58.7% were male with a median [IQR] age of 68 [55-78]. Most frequent sources of HA-BSIs were intravascular catheter [182, (33.3%)] and lower respiratory tract [175, (32.0%)]. Among isolated pathogens (n = 599), 67.1% were Gram-negative, 21.5% Gram-positive and 11.2% due to fungi. Carbapenem resistance was present in 90.4% of Acinetobacter spp., 53.1% of Klebsiella spp. and 48.8% of Pseudomonas spp. In monobacterial Gram-negative HA-BSIs (n = 329), SOFA score (aHR 1.20, 95% CI 1.14-1.27), carbapenem resistance (aHR 2.46, 95% CI 1.58-3.84), previous myocardial infarction (aHR 1.86, 95% CI 1.12-3.08), COVID-19 admission diagnosis (aHR 2.95, 95% CI 1.25-6.95) and not achieving source control (aHR 2.02, 95% CI 1.15-3.54) were associated with mortality. However, availability of clinical pharmacists (aHR 0.23, 95% CI 0.06-0.90) and source control (aHR 0.46, 95% CI 0.28-0.77) were associated with survival. In monobacterial Gram-positive HA-BSIs (n = 93), SOFA score (aHR 1.29, 95% CI 1.17-1.43) and age (aHR 1.05, 95% CI 1.03-1.08) were associated with mortality, whereas source control (aHR 0.41, 95% CI 0.20-0.87) was associated with survival. CONCLUSIONS: Considering high antimicrobial resistance rate, importance of source control and availability of clinical pharmacists, a multifaceted management programme should be adopted in Turkish ICUs.

Impact of COVID-19 pandemic on diagnosis and treatment access of patients with viral hepatitis in Turkey.

INTRODUCTION: We aimed to evaluate access to diagnosis, treatment and follow-up in patients with viral hepatitis during the COVID-19 pandemic. METHODOLOGY: Patients who started treatment for hepatitis B and hepatitis C were included in the study and analyzed in two periods: before-pandemic and during-pandemic. Indication for treatment and frequency of laboratory follow-up was obtained from hospital records. A telephone survey was administered to evaluate treatment access and compliance. RESULTS: Four centers with 258 patients were included in the study. Of these 161 (62.4%) were male, median age was 50 years. The number of patients, admitted to outpatient clinics was 134647 in the before-pandemic period and 106548 in the during-pandemic period. Number of patients who started treatment for hepatitis B were significantly high during-pandemic period compared with before-pandemic (78 (0.07%); 73 (0.05%) respectively; p = 0.04). The number who received treatment for hepatitis C was similar in both periods: 43 (0.04%); 64 (0.05%), respectively (p = 0.25). Prophylactic treatment for hepatitis B, due to immunosuppressive agents was significantly higher in during-pandemic period (p = 0.001). In the laboratory follow-ups at 4th, 12th and 24th weeks of treatment, worse adherence was detected in during-pandemic (for all p < 0.05). Access to treatment and compliance of all patients was over 90% and did not differ in the two periods. CONCLUSIONS: During-pandemic, hepatitis patients' access to diagnosis, treatment initiation and follow-up had worsened in Turkey. The health policy implemented during the pandemic had a positive impact on patients' access to and compliance to treatment.

Rates of underreported needlestick and sharps injuries among healthcare workers in Turkey: in the light of Infection Control Committee data.

OBJECTIVE: Doctors and nurses are frequently exposed to needlestick and sharps injuries (NSIs) because of their work. It is estimated that NSIs are more common than the rates reported to Infection Control Committee. The purpose of this study was to determine the incidence and reporting rates of NSIs in our hospital. METHODS: After their consent forms were obtained for the questionnaire, 670 doctors and nurses were interviewed face-to-face by the Infection Control Committee nurse. The questionnaire consisted of 22 questions, and the answers were recorded. The questions were on demographic data and injuries. The data of NSIs, whose active surveillance was made in our hospital since 2005 and in the last 1 year, were also analyzed retrospectively. RESULTS: A total of 119 (17%) people out of 670 people who participated in the study had at least one NSI; 43 (36%) people of the 119 people were doctors and 76 (63.9%) people were nurses. The most common injuries among doctors were found in assistant doctors (60%). No statistically significant differences were detected between the doctors and nurses in terms of injury status (P = 0.398). The most common injuries were found in surgical clinics, and a significant difference was detected here when compared to other clinics. The data that 20 (17%) people of the 118 people who were injured by the NSIs reported the injury were obtained from the Infection Control Committee database. CONCLUSION: It is seen that injuries are high in surgical clinics and assistant doctors who have high work stress and workload. There were more injuries with sharp objects than the expected rates in our hospital although the reports were made very rarely. First of all, we should determine strategies, especially education, to reduce injuries, and then remove the obstacles to unreported injuries. The methods of clinics with a high rates of reporting needlestick and sharps injuries to the infection control committee should be examined and tried to be applied in our own clinics.

Snakebites in Pediatric Patients in Kahramanmaras: Is Pro-brain Natriuretic Peptide a Prognostic Biomarker for Snakebites?

BACKGROUND: Snake envenomations are a serious cause of mortality and morbidity in the world. AIMS: This study was conducted to investigate snake bites in pediatric patients in Kahramanmaras and to determine whether pro-brain natriuretic peptide (proBNP) has a prognostic value in these patients. METHODS: Pediatric patients aged <18 years who presented to the pediatric emergency department with snakebites were reviewed retrospectively. The demographical, clinical, laboratory, treatments, and outcomes data were collected from their medical records. Stage 0 and 1 envenomation was considered as a non-serious complication and stage 2 and 3 envenomation was considered as a serious complication. RESULTS: A total of 32 pediatric patients, six females and 26 males, between 2016 and 2021, were included in the study. The mean age was 12.52±3.28 years. There were seven patients without serious complications and 25 patients with serious complications. The best cutoff point for proBNP to predict serious complications was found to be ≥272.5 ng∙L-1 (sensitivity, 83.3%; specificity, 100%, p=0.011). We also detected complex regional pain syndrome in one of our patients. CONCLUSIONS: In this study, proBNP was shown to be predictive of a poor outcome of snakebites. Moreover, complex regional pain syndrome, which is rarely reported in the literature, should be kept in mind during the long-term follow-up of snakebites.

Real-World Data from Turkey: Is Sofosbuvir/Ledipasvir With or Without Ribavirin Treatment for Chronic Hepatitis C Really Effective?

BACKGROUND: In this study, we aimed to investigate the efficacy and safety of sofosbuvir-based therapies in the treatment of chronic hepatitis C in real-world clinical practice. METHODS: Data from patients with chronic hepatitis C treated with SOF/LDV ± RBV or SOF/RBV in 31 centers across Turkey between April 1, 2017, and August 31, 2018, were recorded in a nationwide database among infectious disease specialists. Demographics, clinical, and virological outcomes were analyzed. RESULTS: A total of 552 patients were included in the study. The mean age of the patients was 51.28 ± 14.2, and 293 (55.8%) were female. The majority had HCV genotype 1b infection (65%), 75.04% of the patients underwent treatment, and non-cirrhosis was present at baseline in 381 patients (72.6%). SOF/LDV ± RBV treatment was given to 477 patients and 48 patients received SOF/RBV according to HCV genotype. The total SVR12 rate was 99% in all patients. Five patients experienced disease relapse during the study and all of them were genotype 2. In patients infected with HCV GT2, SVR12 was 77.3%. SVR was 100% in all patients infected with other HCV genotypes. All treatments were well tolerated by patients without causing severe adverse events. Side effects and side effects-associated treatment discontinuation rates were 28.2% and 0.4%, respectively. Weakness (13.7%) was the common side effect. CONCLUSION: The present real-world data of 525 patients with HCV genotypes 1, 1a, 1b, 3, 4, and 5 who underwent SOF/LDV ± RBV treatment in Turkey demonstrated a high efficacy and safety profile. HCV GT2 patients should be treated with more efficacious treatment.

The Role of Ciprofloxacin Resistance and Extended-spectrum beta-lactamase (ESBL) Positivity in Infective Complications Following Prostate Biopsy.

PURPOSE: To evaluate ciprofloxacin resistance (CR) and extended-spectrum beta-lactamase (ESBL) positivity in the rectal flora, antibiotic prophylaxis received, and post-biopsy infectious complications in patients undergoing prostate biopsy. MATERIAL & METHODS: Rectal swab samples collected from 99 patients suspected of prostate cancer two days before prostate biopsy were tested for microbial susceptibility and ESBL production. All patients were given standard ciprofloxacin and ornidazole prophylaxis. Ten days post-biopsy, the patients were contacted by phone and asked about the presence of fever and/or symptoms of urinary tract infection. RESULTS: Escherichia coli (E.coli) was the most common isolate detected in 82 (75%) of the rectal swab samples. Ciprofloxacin resistance was detected in 33% and ESBL positivity in 22% of the isolated E.coli strains. No microorganisms other than E.coli were detected in blood, urine, and rectal swab cultures of patients who developed post-biopsy complications. CR E.coli strains also showed resistance to other antimicrobial agents. The lowest resistance rates were to amikacin (n = 2, 7.4%) and nitrofurantoin (n = 1, 3.7%). Seven patients (7.6%) developed infectious complications. There was no significant difference in probability of hospitalization between patients with CR strains (14.3%) and those with ciprofloxacin-susceptible strains (14.3% vs. 4.7%; p = 0.194). However, strains that were both CR and ESBL-positive were associated with significantly higher probability of hospitalization compared to ciprofloxacin-susceptible strains (28.6% vs. 3.8%; p = 0.009). CONCLUSION: The higher rate of infectious complications with CR and ESBL-positive strains suggests that the agents used for antibiotic prophylaxis should be reevaluated. It is important to consider local resistance data when using extended-spectrum agents to treat patients presenting with post-biopsy infectious complications.

Predicting diabetic foot ulcer infection using the neutrophil-to-lymphocyte ratio: a prospective study.

OBJECTIVE: To investigate whether the neutrophil-to-lymphocyte ratio (NLR) may be used in the early stage risk assessment and follow-up in diabetic foot infection. METHODS: Over a five-year study, NLR values on admission and day 14 of treatment were matched with their laboratory and clinical data in a cohort study. Patients were followed-up or consulted in several clinics or polyclinics (infectious diseases). RESULTS: Admission time NLR was higher, in severe cases as indicated by both Wagner and PEDIS infection scores (severe versus mild Wagner score NLR 6.7 versus 4.2; p=0.04; for PEDIS score NLR 6.3 versus 3.6; p=0.03, respectively). In patients who underwent vascular intervention (12.6 versus 4.6; p=0.02); amputation indicated (9.2 versus 4.1; p=0.005) and healed afterwards (6.9 versus 4.3; p<0,001), when matched with others. NLR was also found to be correlated with duration of both IV antibiotic treatment (r=0.374; p=0.005) and hospitalisation (r=0.337; p=0.02). Day 14 NLR was higher in patients who underwent vascular intervention (5.1 versus 2.9; p=0.007) when matched to others. CONCLUSION: Patients with higher NLR values at admission had more severe diabetic foot infection, higher risk for amputation, need for long-term hospitalisation and aggressive treatment. However, they also have more chance of benefit from treatment.

Evaluation of Post-operative Meningitis: Comparison of Meningitis Caused by Acinetobacter spp. and Other Possible Causes.

AIM: To analyse postoperative meningitis (POM) after craniotomy, and to compare the clinical characteristics, treatment outcomes and mortality rates of POM that were caused by Acinetobacter spp. or other possible causes. MATERIAL AND METHODS: In this study, POM cases in our hospital between 2008 and 2016 were retrospectively reviewed. Cases were divided into three groups; Acinetobacter spp. meningitis (case group), non-Acinetobacter bacterial meningitis (control group 1) and culture negative meningitis (control group 2). Demographic, clinical, laboratory features, treatment modalities and mortality rates were compared between case and control groups. RESULTS: A total of 112 patients with POM were included in the study. Cerebrospinal fluid (CSF) culture results were negative in 50 (44.6%) patients; bacteria were isolated from CSF of 62 (55.3%) patients. Acinetobacter spp. was isolated from 28 (45%) patients, while bacteria other than Acinetobacter spp. were detected in 34 (55%) patients. No significant differences were observed between case and control groups in terms of age, gender, comorbidity and operation type. For the case group, change of treatment according to culture result was significantly different from control groups (p < 0.001). Mortality was 55.6% in the case group, 24.2% in control group 1 (p=0.013), and 24% in control group 2 (p=0.006). In multivariate analysis, isolation of Acinetobacter spp. from CSF culture [OR < sub > adj < /sub > 5.2, 95% confidence interval (CI):1.2-22.0, p=0.026] and inappropriate treatment (OR < sub > adj < /sub > 15.7, 95%CI:3.6-68.9, p < 0.001) were determined to be independent risk factors for mortality. CONCLUSION: Postoperative meningitis, especially caused by Acinetobacter spp., and its inappropriate empirical treatment are associated with high mortality.

Retrospective investigation of 9 years of data on needlestick and sharps injuries: Effect of a hospital infection control committee.

BACKGROUND: The risk of occupational transmission of bloodborne pathogens to health care workers is primarily associated with needlestick and sharps injuries (NSIs). However, most NSIs are not reported, and most health care workers are not aware of postexposure procedures. METHODS: Data for NSIs reported in our hospital between 2008 and 2016 were reviewed retrospectively. RESULTS: A total of 546 staff members reported NSIs. Of these, 376 (68.9%) were women. NSIs were more commonly reported by trainee nurses (243 [44.5%]), followed by nurses (121 [22.2%]), cleaning staff (108 [19.8%]), and doctors (49 [9%]). The rate of postexposure interventions was 13% in 2008 and 92.6% in 2016 (P < .0001; χ2 = 82.866). NSI rates also show that the number of applications with NSIs increased over the years. When occupational blood exposure was examined, the number of bloodborne pathogens was 50 (9.3%) cases of hepatitis B virus, 30 (5.6%) cases of hepatitis C virus, 3 cases of Crimean-Congo hemorrhagic fever, 1 case of HIV, and 2 cases of hepatitis B virus and hepatitis C virus coinfection. DISCUSSION: Over the years, the increase in both the appropriate intervention rate and the number of reports to the hospital infection control committee after NSIs shows that regular training regarding NSIs is effective. CONCLUSIONS: Hospital infection control committees may play a more active role in raising awareness in this regard and thus reducing the rate of unreported NSIs.

Diagnostic value of combined serum biomarkers for the evaluation of liver fibrosis in chronic hepatitis C infection: A multicenter, noninterventional, observational study.

BACKGROUND/AIMS: The hepatitis C virus (HCV) infection is important cause of chronic hepatitis. Liver biopsy is considered the gold standard for assessment of fibrosis but this procedure is an invasive procedure. We aimed to evaluate the diagnostic efficiency of non-invasive serum biomarkers, separately and in combinations, on liver fibrosis in treatment-naive chronic hepatitis C (CHC) patients. MATERIALS AND METHODS: Two hundred and sixteen treatment-naive CHC patients were enrolled from 32 locations across Turkey in this open-labelled, non-interventional prospective observational study. FibroTest®, aspartate aminotransferase-to-platelet ratio index(APRI), aspartate aminotransferase and alanine aminotransferase ratio (AAR), fibrosis index based on four factors (FIB-4), Age-platelet(AP) index and Forns index were measured and compared with Metavir scores got from liver biopsies. RESULTS: Data from 182 patients with baseline liver biopsy were suitable for analysis. One hundred and twenty patients (65.9%) had F0-F1 fibrosis and 62 patients (34.1%) had F2-F4 fibrosis. APRI 0.732 area under the curve(AUC) indicated advanced fibrosis with 69% sensitivity and 77% specificity. FIB-4 0.732 AUC and FibroTest 0.715 AUC indicated advanced fibrosis with 69% and 78.4% sensitivity, and 75% and 71.4% specificity, respectively. The combined use of tests also led to an increase in AUC and specificity. Combinations of FibroTest with APRI and/or FIB-4, and FIB-4 with APRI were optimal for the evaluation of liver fibrosis. CONCLUSION: Fibrotest, FIB-4, APRI, AP index and Forns index exhibit good diagnostic performance for determining liver fibrosis in CHC patients, and the use of at least two tests together will increase their diagnostic value still further.

Reactivation rates in patients using biological agents, with resolved HBV infection or isolated anti-HBc IgG positivity.

BACKGROUND/AIMS: Tumor necrosis factor-α (TNF-α) inhibitors and ustekunimab are widely used in autoimmune diseases. It is known that these biological agents cause the reactivation of hepatitis B virus (HBV). There is no standardized strategy to prevent the reactivation in patients with evidence of a previous HBV infection. In our study, anti-HBc IgG-positive patients who received a biological agent were evaluated in terms of HBV reactivation. MATERIALS AND METHODS: Patients who were followed up for the use of biological agents in our clinic were evaluated retrospectively. Patients with isolated anti-HBc IgG positivity were included in the study. The HBV reactivation data were recorded from the patients' files retrospectively. RESULTS: Two hundred and seventy-eight patients who received biological treatment were evaluated. Twenty-nine patients with isolated anti-HBc IgG positivity or resolved HBV infection were included in the study. The HBV reactivation was seen in 5 patients (17.2%). Of these patients, 3 were using adalimumab, 1 infliximab, and 1 ustekunimab. It was controlled by antiviral therapy that was started in the early period. CONCLUSION: Drugs that block TNF-α and ustekunimab cause an increase in viral replication. In literature, the HBV reactivation rate was approximately 1% in HBsAg-negative, anti-HBC IgG-positive cases, whereas it was found to be as high as 17.2% in our study. Patients receiving the immunomodulator therapy should be evaluated for HBV serology before treatment and carefully monitored for HBV reactivation during and after treatment.

Adherence to Nucleoside/Nucleotide Analogue Treatment in Patients with Chronic Hepatitis B.

BACKGROUND: Adherence to medication is an important aspect of preventing drug resistance and treatment failure in patients receiving nucleos(t)ide analogues for chronic hepatitis B. AIMS: To assess adherence to nucleoside/nucleotide analogues in chronic hepatitis B treatment and to determine factors associated with non-adherence. STUDY DESIGN: Cross-sectional study. METHODS: The study enrolled 85 chronic hepatitis B patients who had been receiving nucleoside/nucleotide analogues for ≥3 months. A questionnaire was completed by patients themselves, and adherence was evaluated based on patients' self-reporting. The use of at least 95% of the drugs in the previous month was considered as adequate adherence. RESULTS: Adherence was adequate in 82.4% of patients. Female gender (p=0.003), unemployment (p=0.041) and lower monthly family income (p=0.001) were related to lower adherence. Better adherence was significantly linked to adequate basic knowledge regarding chronic hepatitis B (p=0.049), longer treatment duration than 12 months (p<0.001), previous use of other medications for chronic hepatitis B (p=0.014) and regular follow-up by the same physician (p<0.001). CONCLUSION: Counselling patients about their disease state and the consequences of non-adherence is an important intervention for enhancing adherence. Naïve patients should be followed up more frequently to reinforce adherence.

Evaluation of Dual Therapy in Real Life Setting in Treatment-Naïve Turkish Patients with HCV Infection: A Multicenter, Retrospective Study.

BACKGROUND: Before the introduction of direct-acting antivirals in the treatment of chronic hepatitis C patients, the combination of peginterferon alpha and ribavirin was the standard therapy. Observational studies that investigated sustained virological response (SVR) rates by these drugs yielded different outcomes. AIMS: The goal of the study was to demonstrate real life data concerning SVR rate achieved by peginterferon alpha plus ribavirin in patients who were treatment-naïve. STUDY DESIGN: A multicenter, retrospective observational study. METHODS: The study was conducted retrospectively on 1214 treatment naïve-patients, being treated with peginterferon alpha-2a or 2b plus ribavirin in respect of the current guidelines between 2005 and 2013. The patients' data were collected from 22 centers via a standard form, which has been prepared for this study. The data included demographic and clinical characteristics (gender, age, body weight, initial Hepatitis C virus RNA (HCV RNA) level, disease staging) as well as course of treatment (duration of treatment, outcomes, discontinuations and adverse events). Renal insufficiency, decompensated liver disease, history of transplantation, immunosuppressive therapy or autoimmune liver disease were exclusion criteria for the study. Treatment efficacy was assessed according to the patient's demographic characteristics, baseline viral load, genotype, and fibrosis scores. RESULTS: The mean age of the patients was 50.74 (±0.64) years. Most of them were infected with genotype 1 (91.8%). SVR was achieved in 761 (62.7%) patients. SVR rate was 59.1% in genotype 1, 89.4% in genotype 2, 93.8% in genotype 3, and 33.3% in genotype 4 patients. Patients with lower viral load yielded higher SVR (65.8% vs. 58.4%, p=0.09). SVR rates according to histologic severity were found to be 69.3%, 66.3%, 59.9%, 47.3%, and 45.5% in patients with fibrosis stage 0, 1, 2, 3 and 4, respectively. The predictors of SVR were male gender, genotype 2/3, age less than 45 years, low fibrosis stage, low baseline viral load and presence of early virological response. SVR rates to each peginterferon were found to be similar in genotype 1/4 although SVR rates were found to be higher for peginterferon alpha-2b in patients with genotype 2/3. The number of patients who failed to complete treatment due to adverse effects was 33 (2.7%). The number of patients failed to complete treatment due to adverse effects was 33 (2.7%). CONCLUSION: Our findings showed that the rate of SVR to dual therapy was higher in treatment-naïve Turkish patients than that reported in randomized controlled trials. Also peginterferon alpha-2a and alpha-2b were found to be similar in terms of SVR in genotype 1 patients.

Evaluation of Prognostic Values of Tissue Plasminogen Activator and Plasminogen Activator Inhibitor-1 in Crimean-Congo Hemorrhagic Fever Patients.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a widespread disease in Turkey, and was responsible for many deaths in endemic regions during the last decade. The pathogenesis of the disease is not fully understood yet. OBJECTIVES: In this study we aimed to determine the levels of tissue plasminogen activator (tPA) and Plasminogen activator inhibitor-1 (PAI-1) as predictors of prognosis in CCHF. PATIENTS AND METHODS: Patients who were diagnosed by the polymerase chain reaction (PCR) and IgM positivity in the reference laboratory were included in this study. Tissue Plasminogen activator and PAI-1 levels were measured by the enzyme linked immunosorbent assay (ELISA) using a commercial kit (human t-PA ELISA and human PAL-1 ELISA; BioVendor research and diagnostic products, BioVendor-Laboratorni medicina a.s., Brno, Czech Republic). RESULTS: A total of 46 patients participated in this study. The significant differences between recovering patients and the patients who died, regarding Aspartate aminotransferase (AST), Creatine Phosphokinase (CPK), Lactate Dehydrogenase (LDH), Prothrombin Time (PT), activated Partial Thromboplastin time (aPTT), and thrombocyte and fibrinogen levels, were consistent with many clinical studies in the literature. The fatal cases were found to have higher tPA and PAI-1 levels in contrast to the patients who completely recovered. CONCLUSIONS: We think that these findings may help the progress of understanding of CCHF pathogenesis.

Surgical site infection rates in 16 cities in Turkey: findings of the International Nosocomial Infection Control Consortium (INICC).

BACKGROUND: Surgical site infections (SSIs) are a threat to patient safety; however, there were no available data on SSI rates stratified by surgical procedure (SP) in Turkey. METHODS: Between January 2005 and December 2011, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in 20 hospitals in 16 Turkish cities. Data from hospitalized patients were registered using the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) methods and definitions for SSIs. Surgical procedures (SPs) were classified into 22 types according to International Classification of Diseases, Ninth Revision criteria. RESULTS: We recorded 1879 SSIs, associated with 41,563 SPs (4.3%; 95% confidence interval, 4.3-4.7). Among the results, the SSI rate per type of SP compared with rates reported by the INICC and CDC NHSN were 11.9% for ventricular shunt (vs 12.9% vs 5.6%); 5.3% for craniotomy (vs 4.4% vs 2.6%); 4.9% for coronary bypass with chest and donor incision (vs 4.5 vs 2.9); 3.5% for hip prosthesis (vs 2.6% vs 1.3%), and 3.0% for cesarean section (vs 0.7% vs 1.8%). CONCLUSIONS: In most of the 22 types of SP analyzed, our SSI rates were higher than the CDC NHSN rates and similar to the INICC rates. This study advances the knowledge of SSI epidemiology in Turkey, allowing the implementation of targeted interventions.

Acute mercury poisoning presenting as fever of unknown origin in an adult woman: a case report.

INTRODUCTION: Mercury intoxication may present in a wide range of clinical forms from a simple disease to fatal poisoning. This article presents a case of acute mercury poisoning, a rare condition that presents challenges for diagnosis with fever of unknown origin. CASE PRESENTATION: A 52-year-old Caucasian woman was admitted to the hospital with high fever, sore throat, a rash over her entire body, itching, nausea, and extensive muscle pain. She had cervical, bilateral axillary and mediastinal lymphadenopathies. We learned that her son and husband had similar symptoms. After excluding infectious pathologies, autoimmune diseases and malignancy were investigated. Multiple organs of our patient were involved and her fever persisted at the fourth week of admission. A repeat medical history elicited that her son had brought mercury home from school and put it on the hot stove, and the family had been exposed to the fumes for a long period of time. Our patient's serum and urine mercury levels were high. She was diagnosed with mercury poisoning and treated accordingly. CONCLUSIONS: Mercury vapor is a colourless and odorless substance. Therefore, patients with various unexplained symptoms and clinical conditions should be questioned about possible exposure to mercury.

Mean platelet volume in the diagnosis and prognosis of Crimean-Congo hemorrhagic fever.

INTRODUCTION: Crimean-Congo hemorrhagic fever (CCHF) is a viral tick-borne zoonosis, which is a severe illness, causing hemorrhages in humans. Mean platelet volume (MPV) is used as a surrogate marker of platelet function and has been shown to be a sign of inflammation. The objective of the present study is to examine the association between MPV and CCHF. We also aimed to investigate the association between MPV and coagulopathy markers in the mortality rates and prognosis of patients with CCHF. PATIENTS AND METHODS: Ninety-three patients with CCHF were enrolled retrospectively into the study and 15 of them were excluded according to the exclusion criteria. Twenty-five healthy individuals were included as a control group which was age and gender matched with CCHF patients. We compared the levels of MPV between the patient and the control groups. We also compared the coagulopathy markers of fatal CCHF patients (n = 9) with nonfatal cases (n = 69). RESULTS: Platelet counts were significantly lower in the CCHF group. Levels of international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT) were significantly higher in CCHF group (P < .001, <.001, <.001, respectively). A statistically significant increase in MPV was observed in patients with CCHF compared with healthy controls (8.63 ± 1.23 fL vs 7.65 ± 0.42 fL, P < .001). Receiver-operating characteristic curve analysis suggested that the optimum MPV level cutoff points for patients with CCHF was 8.15 fL, with a sensitivity and specificity of 65% and 88%, respectively. The MPV levels were not significantly different between group 2 (nonsurvivor) and group 1 (survivor). However, platelet count, D-dimer, INR, PT, and aPTT were also positively correlated with the mortality rates (P = .008, <.001, <.001, <.001, and <.001, respectively). Multivariable logistic regression model showed an independent correlation between MPV and mortality rate (P < .001). CONCLUSION: In conclusion, MPV may be a beneficial marker in the diagnosis of CCHF, especially in cases with thrombocytopenia, the MPV levels are high. We also conclude that MPV may independently predict the prognosis of patients with CCHF.

Evaluation of factors predictive of the prognosis in Crimean-Congo hemorrhagic fever: new suggestions.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is one of the viral hemorrhagic fevers caused by tick bites. Common symptoms of the infection are fatigue, high fever, headache, and myalgia. In some patients hemorrhage may accompany these symptoms and is a sign of a poor prognosis. Typical laboratory changes are thrombocytopenia, leukopenia, elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatine phosphokinase (CPK), and lactate dehydrogenase (LDH), and prolongation of prothrombin time (PT) and activated partial thromboplastin time (aPTT). Mortality rates vary between 3% and 30%. The aim of this study was to determine the factors affecting the prognosis of CCHF. METHODS: A total of 70 patients with a diagnosis of CCHF who were followed at our clinic between 2005 and 2008 were included in this study. As well as patient clinical history, biochemical parameters tested during the first 5 days and the prognosis were evaluated. Findings were compared between patients who died and those who recovered. Non-parametric statistical tests were used for the statistical analysis. RESULTS: When the laboratory parameters of patients who died and recovered were compared, PT, aPTT, international normalized ratio (INR), AST, LDH, fibrinogen, C-reactive protein (CRP), high-sensitivity CRP (hs-CRP), D-dimer, IgM, IgG, C3 and C4 levels, and platelet count were found to be positively related with fatality. On the other hand, there was no significant difference between groups regarding ALT, CPK, prealbumin, ceruloplasmin, protein C, protein S, and antithrombin III levels, and white blood cell counts. CONCLUSIONS: It is essential to determine the possibility of a fatal prognosis in CCHF patients using clinical history and biochemical parameters so that the necessary precautions can be taken.

[A water-borne tularemia outbreak caused by Francisella tularensis subspecies holarctica in Central Anatolia region]. / Iç Anadolu Bölgesinde Francisella tularensis alt tür halorctica'ya Bagli Su Kaynakli Bir Tularemi Salgini

In this study, we investigated a waterborne tularemia outbreak occured in Kadiozu, a village of Cerkes county of Cankiri province (located in North-west part of central Anatolia, Turkey) between 18 November 2009-24 December 2009. Active surveillance was conducted to determine clinical characteristics and risk factors of cases after two patients from the same village had been diagnosed as oropharyngeal tularemia. All villagers were examined, and clinical specimens from cases and water samples which may be the source of outbreak in the field investigations were taken. Cases were in the form of oropharyngeal, glandular and pneumonic. Polymerase chain reaction (PCR) and cultures were conducted from lymph node aspirates, throat swabs taken from cases and samples from water sources of epidemic zone. All serum samples taken from the villagers were screened for F.tularensis antibodies with microagglutination test (MAT). Oropharyngeal tularemia was diagnosed in 11 patients, glandular form in 3 patients and pneumonic form in one patient according to clinical and laboratory results. Age of the patients ranged between 6-75 years old (mean age: 52.5 years) and thirty one of them (54.7%) were female. MAT titers ranged between 1/160 and 1/5120 in cases of tularemia. Causative agent was grown in the cultures of two patients (including a throat swab and a lymph node aspirate). F.tularensis DNA was shown by PCR in a throat swab and four lymph node aspirates. F.tularensis was also detected by PCR in the water sample obtained from one of the spring water commonly used by villagers. Only one of the lymph node samples obtained from two different patients, was positive by direct fluorescent antibody method. Causative agent was defined as F.tularensis subsp. holarctica by conventional and also molecular methods. Patients were treated with aminoglycoside (streptomycin, gentamicin, amikacin) or quinolone (ciprofloxacin, levofloxacin) antibiotics. Treatment failure was observed in five patients, due to the delay in initiating treatment. Comparison of characteristics and risk factors for tularemia cases versus controls yielded age and contact with rodent excreta at home as potential risk factors (p= 0.001 and 0.002, respectively). The epidemic was controlled after cleaning the tank collecting spring water and chlorination of the water. Tularemia which is an emerging disease in Turkey is spreading to non-endemic regions and represent a significant threat for public health.

[Investigation of reduced vancomycin susceptibility in methicillin-resistant staphylococci]. / Metisiline Dirençli Stafilokoklarda Azalmis Vankomisin Duyarliliginin Arastirilmasi

The first Staphylococcus aureus strain with reduced susceptibility to vancomycin was reported from Japan in 1996, and since then an increasing numbers of cases had been reported from various countries. Along with the unfeasibility in the identification of these strains with routine laboratory methods, the use of glycopeptid antibiotics in infections due to these strains may result in therapeutic failure. The aim of this study was to investigate the prevalence of vancomycin intermediate staphylococcus (VIS) and heterogenous VIS (hVIS) strains with the use of agar screening, macro E-test, and population analysis profile (PAP-UC; population analysis profile-area under the curve) methods. A total of 148 methicillin-resistant staphylococcus strains isolated from different clinical samples (48 tracheal aspirate, 48 blood, 39 wound swabs, eight urine, two cerebrospinal fluid, two pleural fluid, one catheter tip sample) between November 2007 and May 2009, were included in the study. Of the isolates 107 were identified as S.aureus and 41 were coagulase-negative staphylococci (CNS; 23 Staphylococcus epidermidis, six Staphylococcus haemolyticus, five Staphylococcus chromogenes, three Staphylococcus hominis and four others) by API Staph kit (bioMerieux, USA). Methicillin resistance has been determined by standard disk diffusion method with oxacillin (1 µg) and cefoxitin (30 µg) disks, according to "Clinical and Laboratory Standarts Institute (CLSI)" guidelines. For the identification of VIS and hVIS strains, brain-heart infusion agar plates containing 6 µg/ml vancomycin (BHI-V6) were used for screening. The suspected VISA/hVISA strains which grew in this agar were further tested by macro E-test and PAP-AUC methods. Total VIS and hVIS rates among the tested isolates, were found as 3.4% (5/148) and 1.4% (2/148), respectively. These rates for CNS strains were 9.8% (4/41) and 2.4% (1/41), and for S.aureus strains were 0.9% (1/107) ve 0.9% (1/107), respectively. In the evaluation of the seven patients who were infected with VISA/hVISA strains, it was detected that all had history of use of glycopeptid antibiotics except one whose history was not reached, and all were hospitalized in intensive care units, except one who had an infected knee prosthesis. Since macro E-test and PAP-AUC methods could not be performed for all of the isolates, there was a probability that our resistance rates did not reflect the real results, nevertheless VIS and hVIS prevalence that we found in our study, seemed to be higher than those data reported previously from our country. In conclusion, since the number of VISA/hVISA strains may increase in time, surveillance for vancomycin resistance in methicillin-resistant staphylococci should be carried out in hospitals periodically.