[In vitro Activity of Rifabutin and Clofazimine to Macrolide-Resistant Mycobacterium abscessus Complex Clinical Isolates]. / Rifabutin ve Klofaziminin Makrolidlere Dirençli Mycobacterium abscessus Kompleks Klinik Izolatlarina In vitro Etkinligi.

Mycobacterium abscessus complex (MABSC) is one of the most resistant bacteria against antimicrobial agents. The number of agents that can be used by oral route, such as macrolides, is limited in antimicrobial therapy. In recent years, rifabutin and clofazimine have gained importance as they can be administered by oral route and have shown synergistic effects with macrolides and aminoglycosides. The aim of this study was to determine the in vitro activity of rifabutin and clofazimine against clinical isolates of MABSC resistant to macrolides. A total of 48 MABSC isolates obtained from respiratory tract and other clinical samples in the Tuberculosis Laboratories of the Faculty of Medicine of Manisa Celal Bayar and Ege Universities were included in the study. Subspecies differentiation and aminoglycoside and macrolide resistance of the isolates were determined by GenoType NTM-DR test. Rifabutin and clofazimine susceptibilities were determined by standard broth microdilution method. Of the MABSC isolates 42 were identified as M.abscessus subsp. abscessus, three as M.abscessus subsp. bolletii and three as M.abscessus subsp. massiliense. None of the isolates exhibited rrs and rrl mutations indicating acquired macrolide resistance and aminoglycoside resistance. However, the erm(41) T28 genotype which is associated with inducible macrolide resistance was detected in 41 (85%) of the strains. All M.abscessus subsp. massiliense isolates were found to be genotypically susceptible to macrolides. The minimum inhibitory concentration (MIC) range values for rifabutin were 0.0625 to 32 µg/mL, while for clofazimine, the range was 0.0625 to 1 µg/mL. Rifabutin MIC values were significantly higher (mean 5.98 µg/mL vs 0.5 µg/mL, p= 0.026) in the isolates with macrolide resistance. There was no correlation between macrolide resistance and clofazimine MIC values (mean 0.25 µg/mL vs. 0.214 µg/mL, p= 0.758). The MIC50 and MIC90 values for rifabutin were 1 and 8 µg/mL, respectively, while for clofazimine they were 0.25 and 0.5 µg/mL. Macrolide resistance was found to be higher in isolates with rifabutin MIC values above the MIC50 value (p= 0.045). In conclusion, the determination of higher rifabutin MIC values in isolates resistant to macrolides suggested that susceptibility testing should be performed before adding rifabutin to the treatment regimen. The low MIC values of clofazimine in all strains indicated that it may be used as a first choice in the combination therapy. However, further studies using a larger number of clinical isolates and applying genotypic and phenotypic susceptibility tests are needed to determine threshold MIC values to assist clinicians in making treatment decisions.

Multicenter evaluation of AYC.2.2 agar for the isolation of mycobacteria from clinical samples.

PURPOSE: The aim of this multicenter study is to evaluate AYC.2.2 agar for the isolation of mycobacteria from clinical samples. METHODS: Totally 5559 media were tested in 7 centers. AYC.2.2 agar media for the study were prepared by C1 and sent to other centers under appropriate conditions. Other media except AYC.2.2 agar were purchased commercially. The media were subjected to routine laboratory operations in the center where they were sent. After the samples received for routine processing (in all centers, samples were processed with the same method (NALC-NaOH)), they were cultivated on routine media and AYC.2.2 agar afterward. RESULTS: C1: Average growth time was determined as 12.74±3.74 days with MGIT 960 system; 24.42±4.75 days with LJ and 24.37±4.96 days with AYC.2.2 agar. C2: Average growth time was determined as 18.25±9.32 days with TK-Medium, 28.73±7.44 days with LJ, and 31.72±6.35 days with AYC.2.2 agar. C3: Average growth time was determined as 20.48±7.24 days with Ogawa medium, 20.74±7.12 days with LJ, and 20.26±7.43 days with AYC.2.2 agar. C4: Average growth time was determined as 15.27±6.37 days with MGIT 960 system, 22.14±9.1 days with LJ, and 22±8.45 days with AYC.2.2 agar. C5: Average growth time was determined as 13±4.24 days with MGIT 960 system, 32.16±6.23 days with LJ, and 33±5.73 days with AYC.2.2 agar. C6: Average growth time was determined as 9±3.11 days with MGIT 960 system, 18.68±5.32 days with LJ, and 18.34±4.63 days AYC.2.2 agar. C7: Average growth time was determined as 14.74±7.65 with MGIT 960 system, 26.01±8.21 days with LJ, and 26.24±7.88 days with AYC.2.2 agar. CONCLUSIONS: In conclusion, similar results were obtained with LJ and Ogawa media and AYC.2.2 agar. Furthermore, more studies should be conducted for isolation of M. tuberculosis and performing antibiotic susceptibility tests using AYC.2.2 agar before it can be used as a routine media in the laboratories.

The reliability of tuberculin skin test in the diagnosis of latent tuberculosis infection in psoriasis patients: A case-control study.

Tuberculin skin test (TST), which is used in the diagnosis of latent tuberculosis infection, may cause Koebner's phenomenon and false-positive results in psoriasis patients. The purpose of this study is to compare TST with QuantiFERON-TB Gold Plus (QFT-plus) test in psoriasis patients and to determine the effects of psoriasis on TST results. Ninety-two psoriasis patients and 30 control subjects were included in the study. QFT-plus test, TST, and prick test to distinguish the increase of induration because of the skin trauma were performed on both groups. The demographics, risk factors for latent tuberculosis infection, BCG vaccination history, Koebner's history, psoriasis severity, and treatment history of the patients were recorded. The effects of these variables on test results were investigated by comparing those with control group. The criteria of National Tuberculosis Diagnosis and Treatment Guidelines were used in the evaluation of test results, and threshold value of positivity for TST was taken as 10 mm in BCG-vaccinated patients who are planned to start biological treatment. Prick test results were negative in the control group. There was no significant relation between the results of prick test and TST induration diameters in the patient group. Although TST positivity was significantly higher in patients (62%) compared with control group (33%), QFT-plus test results were not statistically different between two groups. Agreement between two tests was determined to be low in patient group with 48% (K = 0.1), and it was determined to be moderate with 77% in control group (K = 0.4). QFT-plus test was found to be negative in 46 of 57 TST-positive patients (80.7%) in patient group. It was determined in both groups that vaccination did not have any effect on test results. When threshold value was lowered to 5 mm in patient group without considering BCG reaction, the number of TST-positive patients increased from 57 to 65. Mean TST induration diameter was 10 mm and 14 mm in cases with mild and moderate to severe clinical manifestation, respectively (P = .04). However, no effect of disease period and treatment was determined on both test results. TST positivity was higher in psoriasis patients compared with control group. It was considered due to the increased reaction of the skin to mycobacterial antigens rather than the Koebner's response. Although TST results were not affected by BCG, it was concluded that a 10-mm threshold value of positivity was a suitable approach in order to reduce the number of patients receiving unnecessary preventive treatment in patients who are considered to initiate biologic agents. Furthermore, it was also concluded that QFT-plus test may be preferred in psoriasis patients since it is applied in vitro and its specificity is higher and not affected by disease severity.

A new colorimetric method for rapid detection of ethambutol and streptomycin resistance in Mycobacterium tuberculosis: crystal violet decolorization assay (CVDA).

Streptomycin (STR) and ethambutol (EMB) are important drugs used for the treatment of tuberculosis. There is a need for fast, reliable and inexpensive methods for detecting resistance to these drugs. The aim of this study was to evaluate the performance of the crystal violet decolorization assay (CVDA) for the detection of STR and EMB resistance that is important drugs in tuberculosis treatment. In this study, drug susceptibility testing was performed on 140 Mycobacterium tuberculosis isolates provided from nine centers. Three tubes were used for each isolate. One of the tubes had a concentration of 2 mg/L STR and the other 5 mg/L EMB. The third was drug-free control tube. Sensitivity, specificity, positive predictive value (PPD), negative predictive value (NPD) and agreement for STR were found to be 81.8%, 94.6%, 87.8%, 91.5% and 90.57%, respectively. For EMB, sensitivity, specificity, PPD, NPD, and agreement were found to be 76%, 98.23%, 90.47%, 94.87% and 94.2%, respectively. The results were obtained in 11.3 ± 2.7 days (8-21 days). CVDA is rapid, reliable, inexpensive, and easy to perform for rapid detection of STR and EMB resistance, and it could be adapted for drug susceptibility testing.

Multicenter evaluation of crystal violet decolorization assay (CVDA) for rapid detection of isoniazid and rifampicin resistance in Mycobacterium tuberculosis.

The aim of this multicenter study was to evaluate the performance of the crystal violet decolorization assay (CVDA) for detection of multidrug resistant tuberculosis (MDR-TB). This study was performed in 11 centers in two phases. A total of 156 isolates were tested for INH and RIF resistance. In the phase I, 106 clinical isolates were tested in the Center 1-7. In the phase 2, 156 clinical isolates were tested in the center 1-6, center 8-11. Eighty six of 156 tested isolates were the same in phase I. Agreements were 96.2-96.8% for INH and 98.1-98.7% for RIF in the phase I-II, respectively. Mean time to obtain the results in the phase I was 14.3 ± 5.4 days. In the phase II, mean time to obtain the results was 11.6 ± 3.5 days. Test results were obtained within 14days for 62.3% (66/106) of isolates in the phase I and 81.4% (127/156) of isolates in the phase II. In conclusion, CVDA is rapid, reliable, inexpensive, and easy to perform for rapid detection of MDR-TB isolates. In addition, it could be adapted for drug susceptibility testing with all drugs both in developed and developing countries.

Seroprevalence of West Nile virus, Crimean-Congo hemorrhagic fever virus, Francisella tularensis and Borrelia burgdorferi in rural population of Manisa, western Turkey.

BACKGROUND & OBJECTIVES: Zoonotic diseases are well recognised threat to public health globally. The information of regional prevalence and associated risk factors allow the national programmes to determine and frame better strategies for their control, as they also provide the actual status of zoonosis in the region. The aim of this study was to determine the seroprevalence of West Nile virus (WNV), Crimean-Congo hemorrhagic fever virus (CCHFV), Francisella tularensis and Borrelia burgdorferi among the rural residents of Manisa region, Turkey and to identify the associated risk factors. METHODS: Cross sectional study was conducted in rural parts of Manisa, Aegean region of western Turkey in 2012. Blood samples from 324 randomly selected subjects were screened for the presence of IgG antibodies to WNV, CCHFV, F. tularensis and B. burgdorferi with commercially available kits. The demographic structure of the rural residents and risk factors related to lifestyle such as outdoor agriculture activities, animal husbandry, hunting and history of tick bite were questioned and their relationships with positive results were analyzed statistically. RESULTS: It was observed that 49 subjects (15%) had IgG antibodies to at least one of the zoonotic agents studied. The seroprevalence of F. tularensis was highest with a percentage of 7.1% (n = 23). Distribution of the positive results for WNV, CCHFV and B. burgdorferi were 4.3% (n = 14), 3.7% (n = 12) and 0.9% (n = 3), respectively. Older age and uncompleted secondary education were the statistically significant risk factors for seropositivity to at least one zoonotic agent investigated. Logistic regression analyses confirmed that older age (over 50) increased the risk of WNV and CCHFV seropositivity. INTERPRETATION & CONCLUSION: Seropositivity rates were not found to be higher than the expected rates. Further, studies are needed to evaluate the threat of vector borne zoonoses and associated risk factors in the study area.

[Multicenter evaluation of the indirect nitrate reductase assay for the rapid detection of multidrug-resistant tuberculosis]. / Çok ilaca dirençli tüberkülozun hizli tespiti için dolayli nitrat redüktaz testinin çok merkezli degerlendirilmesi.

Multidrug-resistant tuberculosis (MDR-TB) is defined as resistance to at least isoniazid (INH) and rifampicin (RIF), and it complicates the implementation of tuberculosis control programmes. The rapid detection of MDR-TB is crucial to reduce the transmission of disease. The nitrate reductase assay (NRA) is one of the colorimetric susceptibility test methods for rapid detection of MDR-TB and based on the ability of reduction of nitrate to nitrite by Mycobacterium tuberculosis. The aim of this study was to evaluate the performance of the NRA for the rapid detection of MDR-TB. A total of 237 M.tuberculosis complex (MTC) isolates that were identified by the same method (BD MGIT(TM) TBc Identification Test, USA) from nine different medical centers in Turkey were included in the study. The susceptibility results of the isolates against INH and RIF obtained by reference test (Bactec MGIT(TM) 960, BD, USA) were then compared with NRA. In order to ensure consistency between centers, Löwenstein-Jensen (LJ) medium with antibiotics and without antibiotics (growth control) and Griess reagent solution were prepared in a single center (Ondokuz Mayis University School of Medicine, Medical Microbiology Department) and sent to all participant centers with the standardized test procedure. After the inoculation of bacteria into the test tubes, the tubes were incubated at 37°C, and after seven days of incubation, 500 µl Griess reagent was added to the LJ medium without antibiotics. If a color change was observed, an equal volume of Griess reagent was added to test LJ media with antibiotics. When a color change was observed in LJ media with antibiotics, it was considered that the isolate was resistant to tested antibiotics. Among 237 MTC isolates, 16 were resistant only to INH and nine were resistant only to RIF; 93 isolates (39.2%) were resistant (MDR) and 119 isolates (50.2%) were susceptible to both of the drugs determined with the reference susceptibility test. In the study, five INH-resistant isolates determined with reference method were found susceptible with NRT and eight INH-susceptible isolates determined with reference method were found resistant with NRT. In contrast, one RIF-resistant isolate determined with reference method was found susceptible with NRT and three RIF-susceptible determined isolates were found resistant with NRT. Accordingly, the concordance rate between the reference method and NRA were estimated as 94.5% for INH and 98.3% for RIF. The sensitivity, specificity, positive and negative predictive values of NRA were detected as 95.4%, 93.7%, 92.8% and 96% for INH, and 99%, 97.8%, 97.1% and 99.2% for RIF, respectively. The results of the 111 isolates were obtained on the seventh day, while the rest of the results were obtained between 10-14 days. In conclusion, the data of this multicenter study showed that NRA is a reliable, relatively inexpensive and practical method to perform for the rapid detection of MDR-TB.

[Distribution of nontuberculous mycobacteria isolated from clinical specimens and identified with DNA sequence analysis]. / Klinik örneklerden soyutlanan ve DNA dizi analizi ile tanimlanan tüberküloz disi mikobakterilerin dagilimi.

The aims of the study were to perform the identification of nontuberculous mycobacteria (NTM) isolated from different clinical specimens in the Mycobacteriology Laboratory of Celal Bayar University, Manisa (located at Aegean region of Turkey), by DNA sequence analysis, and to discuss the epidemiological aspects of the data obtained. Out of 5122 clinical specimens sent to the laboratory with the initial diagnosis of tuberculosis in the period April 2007 to July 2011, M.tuberculosis complex and NTM were identified in 225 (4.39%) and 126 (2.46%) samples, respectively. DNA sequence analysis by targeting hsp65 and 16S rDNA gene regions was performed on 101 of the NTM strains in Mycobacteriology Laboratory of Ege University, Izmir. DNA sequence analysis data was evaluated using RIDOM and GenBLAST data bases. NTM strains were identified as 40 M.porcinum (39.60%), 36 M.lentiflavum (35.65%), six M.abscessus (5.64%), five M.peregrinum (4.95%), four M.gordonae (3.96%), three M.fortuitum (2.97%), two M.chelonae (1.98%), and one for each M.alvei (0.99%), M.scrofulaceum (0.99%), M.kansasii (0.99%) species. Two strains which were both 95-98% compatible with other mycobacteria in the data bases could not be identified with certainty. Seventy-two (94.73%) strains of M.lentiflavum and M.porcinum, which were the most frequent (75.24%) species in the study, were isolated from bronchoalveolar lavage (BAL) specimens. The remaining 99 strains examined could not be proven as the cause of the disease due to absence of patients' clinical data, whereas two M.abscessus strains isolated from the sputum were considered as the cause of the disease according to the ATS/IDSA criteria. The isolation rate of NTM in 2010 was found significantly higher (5.33%) than previous years. Review of the 2010 data showed that all strains of M.porcinum and M.lentiflavum, which were the most frequently identified strains were isolated from BAL specimens. This situation is in line with the start of using of an automatic bronchoscope washing machine in our hospital in the same year. In conclusion, NTM were isolated in 2.46% of the clinical specimens of the patients with the initial diagnosis of tuberculosis and these strains belonged to 10 different NTM species. The two NTM species most frequently isolated in our study were M.lentiflavum and M.porcinum which are known for their potential to cause human infections and antibiotic resistance. As these strains were mostly isolated in BAL specimens, it is concluded that automatic bronchoscope washing machines and water delivery system in the hospitals should be examined in terms of contamination by NTM. The isolated NTM strains could not be distinguished as the cause of the disease or a contaminant, which is the limiting factor in this study. However, knowing that the environmental mycobacteria can cause hospital infections, the data obtained in this study can contribute to epidemiology of NTM infections in Turkey.

Antituberculosis drug resistance patterns in adults with tuberculous meningitis: results of haydarpasa-iv study.

BACKGROUND: Tuberculous meningitis (TBM) caused by Mycobacterium tuberculosis resistant to antituberculosis drugs is an increasingly common clinical problem. This study aimed to evaluate drug resistance profiles of TBM isolates in adult patients in nine European countries involving 32 centers to provide insight into the empiric treatment of TBM. METHODS: Mycobacterium tuberculosis was cultured from the cerebrospinal fluid (CSF) of 142 patients and was tested for susceptibility to first-line antituberculosis drugs, streptomycin (SM), isoniazid (INH), rifampicin (RIF) and ethambutol (EMB). RESULTS: Twenty of 142 isolates (14.1 %) were resistant to at least one antituberculosis drug, and five (3.5 %) were resistant to at least INH and RIF, [multidrug resistant (MDR)]. The resistance rate was 12, 4.9, 4.2 and 3.5 % for INH, SM, EMB and RIF, respectively. The monoresistance rate was 6.3, 1.4 and 0.7 % for INH, SM and EMB respectively. There was no monoresistance to RIF. The mortality rate was 23.8 % in fully susceptible cases while it was 33.3 % for those exhibiting monoresistance to INH, and 40 % in cases with MDR-TBM. In compared to patients without resistance to any first-line drug, the relative risk of death for INH-monoresistance and MDR-TBM was 1.60 (95 % CI, 0.38-6.82) and 2.14 (95 % CI, 0:34-13:42), respectively. CONCLUSION: INH-resistance and MDR rates seemed not to be worrisome in our study. However, considering their adverse effects on treatment, rapid detection of resistance to at least INH and RIF would be most beneficial for designing anti-TB therapy. Still, empiric TBM treatment should be started immediately without waiting the drug susceptibility testing.

Antimicrobial susceptibility and resistance mechanisms of methicillin resistant Staphylococcus aureus isolated from 12 Hospitals in Turkey.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most important nosocomial pathogens and is also emerging in Turkish hospitals. The aim of this study was to determine the antimicrobial susceptibility profiles of MRSA isolated from Turkish hospitals. MATERIALS AND METHODS: A total of 397 MRSA strains isolated from 12 hospitals in Turkey were included to present study. Antimicrobial susceptibilities were tested using agar dilution method. Presence of ermA, ermB, ermC, msrA, tetM, tetK, linA and aac-aph genes were studied by PCR. RESULTS: All strains were susceptible to vancomycin and linezolid. The susceptibility rates for fusidic acid, lincomycin, erythromycin, tetracyclin, gentamycin, kanamycin, and, ciprofloxacin were 91.9%, 41.1%, 27.2%, 11.8%, 8.5%, 8.3% and 6.8%, respectively. Lincomycin inactivation was positive for 3 isolates. Of 225 erythromycin resistant isolates 48 had ermA, 20 had ermC, and 128 had ermA-C. PCR was negative for 15 strains. Of 3 isolates with lincomycin inactivation one had linA and msrA. Of 358 gentamycin resistant isolates 334 had aac-aph and 24 were negatives. Among 350 tetracyclin resistant isolates 314 had tetM. Of 36 tetM negative isolates 10 had tetK. CONCLUSION: MRSA isolates from Turkish hospitals were multiresistant to antimicrobials. Quinolone and gentamycin resistance levels were high and macrolide and lincosamide resistance were relatively low. Susceptibility rates for fusidic asid were high. Linezolide and vancomycin resistance are not emerged. The most common resistance genes were ermA, tetM and aac-aph. Evolution of antimicrobial susceptibilities and resistance genes profiles of MRSA isolates should be surveyed at regional and national level for accurate treatment of patients and to control dissemination of resistance genes.

[Evaluation of the Xpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary tuberculosis in an intermediate-prevalence setting]. / Orta prevalansli bölgede akciger ve akciger disi tüberküloz tanisinda Xpert MTB/RIF testinin degerlendirilmesi.

Early and accurate detection of tuberculosis (TB) is a global priority for TB control. In order to obtain results in a short period of time, nucleic acid amplification tests are increasingly used worldwide for the rapid diagnosis of tuberculosis. The Xpert MTB/RIF® (Cepheid, USA) is a commercially available, real-time PCR-based assay, which can detect both TB and resistance to rifampicin directly in clinical samples. The aim of this study was to evaluate the performance of Xpert MTB/RIF assay for M.tuberculosis detection in pulmonary and extrapulmonary clinical samples in routine laboratory practice in Turkey, an intermediate-prevalence setting. A total of 2639 clinical specimens, 1611 of which were pulmonary and 1028 were extrapulmonary, were included in the study. The results of Xpert MTB/RIF assay were evaluated by comparing the results with those obtained by culture [BACTEC MGIT 960 (Becton Dickinson, USA) and Löwenstein Jensen medium]. Overall sensitivity, specificity, positive and negative predictive values of Xpert MTB/RIF assay were determined as 73.9%, 98.6%, 79.6% and 98.1%, respectively. These values were calculated as 80.8%, 98.8%, 84.9% and 98.4% for pulmonary specimens, and 58.2%, 98.4%, 66.7% and 97.7% for extrapulmonary specimens. The sensitivity and specificity were 100% and 58.1%, respectively, for acid-fast bacilli (AFB) smear-positive specimens, 39.7% and 99.1%, respectively for smear-negative specimens. The sensitivity and specificity were 100% and 76.2% for smear-positive pulmonary specimens; 100% and 20% for smear-positive extrapulmonary specimens; 47.8% and 99.1% for smear-negative pulmonary specimens; and 28.2% and 99.2% for smear-negative extrapulmonary specimens, respectively. The sensitivity and specificity of microscopic examination were found to be 56.7% and 98.7% for all specimens; 63.2% and 98.6% for pulmonary specimens; and 41.8% and 99% for extrapulmonary specimens, respectively. Rifampicin resistance was detected by Xpert MTB/RIF assay in only two specimens, however, rifampicin resistance was failed to be detected by BACTEC MGIT 960 TB method in one of these samples. Xpert MTB/RIF assay appeared to be a reliable method for the diagnosis of TB for AFB smear-positive samples, but less sensitive for smear-negative samples, particularly for extrapulmonary samples which include low numbers of bacilli. However, we concluded that the MTB/RIF is a useful assay for rapid diagnosis of tuberculosis, considering that the results can be given in the same day of sample collection and the assay is superior in sensitivity than microscopic examination.

[t030 is the most common spa type among methicillin-resistant Staphylococcus aureus strains isolated from Turkish hospitals]. / t030, Türkiye'deki Hastanelerden Izole Edilen Metisiline Dirençli Staphylococcus aureus Izolatlari Arasinda En Yaygin spa Tipidir.

Staphylococcus aureus is one of the most frequent agents causing hospital infections. S.aureus has a great ability to adapt itself to variety of conditions and successful clones can be epidemic and even pandemic by its ability spread from one continent to another. The aims of this study were to detect spa types of 397 methicillin-resistant S.aureus (MRSA) strains isolated from 12 centers in different geographical regions of Turkey from 2006 to 2008, and to investigate their clonality by PFGE and MLST typing. Additionally, 91 MRSA from four of those 12 centers isolated during 2011 were also studied for their spa types. PFGE profiles indicated the presence of a major pulsotype, namely pulsotype A with a rate of 91.4% (363/397), followed by pulsotype B (n= 18, 4.5%) and pulsotype C (n= 11, 2.8%). Among isolates tested 363 (91.4%) were SCCmec type III, 30 (7.6%) were SCCmec type IV. Sequence analysis of representative isolates revealed that ST239 (85.1%) was the most common MLST type followed by two MLST types ST737 (4%), and ST97 (2.8%), both SCCmec type IV. Two isolates were ST80 with SCCmec type IV. Of 397 isolates, 338 (85.1%) were t030, followed by t005 (2.5%) and t632 (2%). Among MRSA isolated during 2011, 64 (70.3%) of 91 were t030, 4 (4.4%) were t005, 2 (2.2%) were t015, and 2 (2.2%) were t1094. Among centers the t030 prevalence of 2006-2008 isolates ranged from 59-100%. The highest t030 prevalence was found in Ankara (100%) and lowest in Trabzon (59%) provinces which are located at central and northestern Anatolia, respectively. In Istanbul province, the prevalence of t030 was 94.5% among 2006-2008 isolates which decreased to 55.5% among 2011 isolates. Also a decrease in t030 rates was observed among samples from Konya and Trabzon but not from Aydin. Our results showed that the most common MRSA clone in Turkey is ST 239-SCCmec type III, t030 which persisted during the six years of the study period. Presence of PVL toxin gene was tested by PCR and 5 (3%) isolates found to be positive, of them two were SCCmec Type IV-ST80 and three were SCCmec Type III-ST239. This study is the largest epidemiological survey ever done in Turkey which showed presence of a hospital Turkish clone TR09 (ST239-SCCmecIII-t030) and a community clone TR10 (ST737-SCCmecIV-t005) largely disseminated in Turkey.

[Investigation of extensive drug resistance in multidrug resistance tuberculosis isolates]. / Çok Ilaca Dirençli Tüberküloz Izolatlarinda Yaygin Ilaç Direncinin Arastirilmasi

Increasing number of drug resistant tuberculosis (TB) cases, observed in recent years, is an important public health problem. Extensively drug resistant TB (XDR-TB) is the development of resistance against any fluoroquinolones and at least one of the injectable second line anti-TB drugs in addition to resistance against isoniazide and rifampicin which are the first line anti-TB drugs [definition of multidrug resistant TB (MDR-TB)]. Anti-TB therapy failed with first-line anti-TB drugs due to MDR-TB cases is being planned according to second-line anti-TB drug susceptibility test results if available and if not, standart treatment protocols are used. Although it is recommended that individual anti-TB therapy should be designed according to the isolate's susceptibility test results, standart therapeutic protocols are always needed since second-line anti-TB drug susceptibility testing generally could not be performed in developing countries like Turkey. For this reason, nationwide and regional surveillance studies to determine the resistance patterns are always needed to make decisions about the standard therapy algorithms. In this study, it was aimed to investigate the presence of extensive drug resistance among 81 MDR-TB isolates obtained from various health care facilities from Istanbul, Izmir and Manisa and to determine the XDR-TB incidence in Marmara and Aegean regions. Furthermore, we aimed to provide epidemiological data to clinicians to support their choice of second-line anti-TB drugs for MDR-TB infections. Susceptibility testing of isolates for the first and the second-line anti-TB drugs were performed by using modified Middlebrook 7H9 broth in fluorometric BACTEC MGIT 960 system (Becton Dickinson, USA). Eighty-one MDR-TB isolates included in this study were isolated from 43 (53.1%) patients residing in Istanbul, 26 (32.1%) in Izmir and 12 (14.8%) in Manisa provinces. We could not find any isolate consistent with XDR-TB definition in this study. Second-line drug resistance rates of MDR-TB isolates to amikacin and kanamycin were 1.2%, ofloxacin and levofloxacin were 2.5%, capreomycin was 14.8%, ethionamide was 37% whereas linezolid resistance was not detected. Statistically significant correlation was detected between resistance rates of these antibiotic pairs; levofloxacin-ofloxacin (p< 0.01), amikacin-kanamycin (p= 0.01) and streptomycin-ethionamide (p= 0.04). In our study, extensive drug resistance was not encountered in any MDR-TB isolates while high resistance rates was observed against ethionamide and capreomycin. It can be concluded that parenteral aminoglycosides amikasin and kanamycin, fluoroquinolones and linezolid seemed to be reliable anti-TB agents in MDR-TB treatment, however, further larger scale studies are needed.

Molecular diversity of drug resistant mycobacterium tuberculosis strains in Western Turkey.

OBJECTIVE: The aim of this study was to investigate the molecular diversity and clonal relationship of drug resistant Mycobacterium tuberculosis strains isolated in Western Turkey. MATERIALS AND METHODS: A total of 87 strains isolated between 2006 and 2009, eight of which were rifampicin monoresistant and 79 were multidrug resistant, were analyzed with IS6110 RFLP and spoligotyping methods. RESULTS: The results of spoligotyping showed that 7% of the strains were orphans, and 8% were undefined for family in the SpolDB4 database. Major families of the strains were LAM (38%), T (35%), Haarlem (7%), Beijing (2%), S (2%) and U (1%) families. The clustering rate by spoligotyping was calculated as 75%. The most predominant SIT cluster was SIT41 (29%). According to the results of IS6110 RFLP, 71 different patterns of IS6110 were observed. Low copy number was found in 26% of the strains. When the results of two methods were combined, the final clustering rate was calculated as 26%. CONCLUSIONS: The genotypical distribution of drug resistant tuberculosis isolates in our region indicates genetic diversity and the clustering rate was found low in our region. However, more comprehensive and long-term molecular epidemiological studies are needed to control the drug resistant strains.

[Comparison of proportion method in Löwenstein-Jensen medium with the BACTEC 460 TB system for antimycobacterial susceptibility testing of Mycobacterium tuberculosis isolates]. / Mycobacterium tuberculosis Izolatlarinin Antitüberküloz Ilaçlara Duyarliliginin Saptanmasinda Antibiyotikli Löwenstein-Jensen Besiyerinde Proporsiyon Yönteminin BACTEC 460 TB Sistemi ile Karsilastirilmasi

This study was conducted to compare BACTEC 460 TB system and the proportion method in commercially available and ready to use antibiotic added Löweinstein-Jensen (LJ) medium for susceptibility testing of first line drugs in Mycobacterium tuberculosis complex isolates. A total 238 M.tuberculosis strains isolated from clinical samples in our laboratory between 2006-2010 period were included in the study. Susceptibility testing for streptomycin, isoniazid, rifampicin and ethambutol in commercially provided LJ medium (Salubris Inc., Istanbul) was performed by the proportion method as recommended by the manufacturer, and the results were compared with the results of BACTEC 460 TB (Becton Dickinson, USA) system. Resistance rates of M.tuberculosis strains against streptomycin, isoniasid, rifampicin and ethambutol obtained by BACTEC 460 TB system were 19.7%, 42%, 40.8% and 18%, respectively. Those rates were 22.7%, 38.7%, 37% and 15.5%, respectively, by antibiotic added LJ proportion method. There was no statistically significant difference between the two methods in terms of resistance rates (p> 0.05). The rates of consistency between proportion method in LJ medium and BACTEC 460 TB system for streptomycin, isoniasid, rifampicin and ethambutol susceptibility were found as 85.3%, 92.4%, 95.4% and 92.4%, respectively. When comparing the reporting time (interval between beginning of the process to reporting of the results) of the methods, minimal, maximal and average reporting spans for BACTEC 460 TB system were 5, 12 and 8.08 ± 2.65 days, and 15, 42 and 23.89 ± 6.02 days for the proportion method in LJ medium, respectively, being statistically significant (p= 0.001). It was determined that the sensitivity test results of major antimycobacterial drugs in commercial LJ medium were compatible with the BACTEC 460 TB system. Nonetheless, the rate of incompatible results was higher for STR than the other drugs. Although there has been some disadvantages such as longer reporting time, need for experience in manual processing and visual evaluation, standardized LJ media approved for quality can be used for susceptibility testing of M.tuberculosis in the laboratories which do not have eligible conditions for the establishment of automated systems.

Pott's disease with scrofuloderma and psoas abscess misdiagnosed and treated as hidradenitis suppurativa.

A 29-year-old man with painless ulcers on the lumbar and inguinal regions associated with purulent discharge of 1.5 years' duration presented to our outpatient clinic. Dermatological examination revealed palpable nodules, discharging sinuses and scars on the left lumbar, gluteal and inguinal regions. According to the clinical, histopathological, scintigraphy, and magnetic resonance imaging findings as well as mycobacteriological examinations, the patient was diagnosed with Pott's disease with scrofuloderma and psoas abscess. Herein, we present an interesting case of Pott's disease with scrofuloderma and psoas abscess mistreated as hidradenitis suppurativa for a long time.

[Pyrazinamide monoresistant Mycobacterium tuberculosis in Manisa region, Turkey]. / Manisa bölgesinde pirazinamid-monorezistan Mycobacterium tuberculosis.

Pyrazinamide (PZA) is a primary antituberculous drug. BACTEC 460TB is the recommended reference method for the detection of PZA resistance in Mycobacterium tuberculosis. This method is more expensive than the conventional susceptibility methods and therefore, it is recommended that each laboratory should establish their own protocol for the inclusion of PZA in the panel of primary drugs tested. One of the most important factors that help this decision is the prevalence of PZA resistance, particularly PZA monoresistance in the related community. The aim of the present study was to determine the extent of PZA monoresistance in M. tuberculosis complex (MTBC) isolates in our region. In this study, PZA susceptibility testing of 109 MTBC strains (susceptible to isoniazid, rifampicin, ethambutol and streptomycin) isolated from Manisa province in the Aegean region of Turkey was performed by using the BACTEC 460TB radiometric system (Becton Dickinson, MD). Two (1.8%) of the 109 isolates which were susceptible to all primary drugs revealed monoresistance against PZA. One of the PZA-monoresistant isolates has been identified as M. bovis and the other as M. tuberculosis by molecular method (Genotype MTBC, Hain Lifescience, Germany). The results of our study indicated that since the rate of PZA monoresistance was low, susceptibility testing of a panel of primary drugs without PZA may be an economical alternative in our region.

[Comparison of interferon-gamma whole blood assay with tuberculin skin test for the diagnosis of tuberculosis infection in tuberculosis contacts]. / Temaslilarda tüberküloz enfeksiyonunun tanisi için interferon-gama tam kan testi ile tüberkülin deri testinin karsilastirilmasi.

Tuberculin skin test which is used for the detection of latent tuberculosis (TB), has many disadvantages such as false positivities due to cross reactions between environmental mycobacteria and BCG strain, false negativities due to immunosuppression and malpractice, and also difficulties in application and evaluation. Recently a new diagnostic test which measures the production of interferon (IFN)-gamma in whole blood upon stimulation with specific ESAT-6 and CFP-10 antigens of Mycobacterium tuberculosis has been introduced. Since most of the mycobacteria other than tuberculosis and BCG strain do not contain these antigens, the detection of IFN-gamma levels indicates the specific T-cell response against M. tuberculosis. The aim of the study was to compare the tuberculin skin test and whole blood IFN-gamma assay (QuantiFERON-TB Gold, Cellestis Ltd, Carnegie, Victoria, Australia) for the identification of latent TB infection in the contacts with active TB patients. The tests results were evaluated by using Kappa (K) analysis, and K coefficients of < 0.4, 0.4-0.75 and > 0.75 were accepted as poor, moderate and excellent agreements, respectively. A total of 233 subjects from three risk groups were included to the study. Group 1 included the household members (n = 133) who had contact with smear positive index cases, Group 2 included the subjects from community (n = 46) who had contact with smear positive index cases, and Group 3 included health care workers (n = 74) who had contact with TB patients or their specimens. The positivity rates of tuberculin skin test and IFN-gamma assay in the cases were found as 37% and 42%, respectively. There were no significant differences among the three patient groups with regard to the results of the tuberculin skin test (p > 0.05). However, the positive result of the IFN-gamma assay in Group 1 was found statistically higher than the other groups (51.3%, p = 0.013). A poor agreement between the two tests was detected in the results taken from 233 subjects (65.7%, K = 0.28), while agreement was moderate in unvaccinated group (72.7%, K = 0.44). Evaluation of agreement rates of the tests according to the risk groups yielded 64.6% (K = 0.3) for Group 1, 71.7% (K = 0.32) for Group 2, and 63.5% (K = 0.21) for Group 3, which all coefficients showed poor agreement. Although IFN-gamma blood assay has many advantages such as objective and quantitative results, no interference with vaccination due to the use of specific antigens and being practical, the high cost and the need for well-equipped laboratory are its disadvantages. As a result it was concluded that, IFN-gamma blood assay has limited value for the detection of latent TB infection in our country, since the prevalence of TB infection and BCG vaccination rates are high in Turkey.

Characterization of rpoB mutations by line probe assay in rifampicin-resistant mycobacterium tuberculosis clinical isolates from the aegean region in Turkey.

The nature and frequency of mutations in the rpoB gene of rifampicin (RIF)-resistant Mycobacterium tuberculosis clinical isolates vary considerably according to the geographical location, and very little information is available regarding specific mutational patterns in our country. The main objective of this study was to determine the frequency of mutations in the hypervariable region of the rpoB gene in RIF-resistant M.tuberculosis isolates recovered from tuberculosis patients in our region by using the INNO-LiPA Rif. TB kit and to evaluate the performance of the kit for the detection of RIF-resistance. Mutations associated with RIF resistance were studied by line probe assay (LiPA) in 65 RIF-resistant and 56 RIF-susceptible M. tuberculosis strains isolated from different patients in the Aegean region of Turkey. The LiPA identified all susceptible strains (100%) as RIF-sensitive and 63 of 65 (96.9%) phenotypically documented RIF-resistant M. tuberculosis isolates as RIF-resistant, with specific detection of mutation in 44 (67.7%) isolates, whilst 2 strains were identified as RIF-susceptible. The R5-pattern (Ser-531-Leu mutation) was the most frequently observed (35 of 65, 53.8%), followed by the deltaS2-pattern (7.7%) and deltaS4-pattern (7.7%).