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

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

HIV-1 subtypes and primary antiretroviral resistance mutations in antiretroviral therapy naive HIV-1 infected individuals in Turkey.

In this study, we determined the subtype distribution and the primary drug-resistant mutations in HIV-1 strains isolated from antiretroviral therapy (ART)-naive patients in Turkey. The study included 117 newly diagnosed HIV-1 positive Turkish patients. HIV-1 subtypes and circulating recombinant forms (CRFs) were identified by phylogenetic analysis (neighbor-joining method), and drug-resistant mutations were analyzed according to the 2009 World Health Organization list of surveillance drug-resistant mutations. Subtype CRFs (CRF 02_AG, CRF 01_AE, CRF 12_BF and CRF 03_AB; 47%, 55/117) and B (33.3%, 39/117) were identified as the most common occurring HIV-1 subtypes in Turkey. The patients had primary antiretroviral resistance mutations to nucleos(t)ide reverse transcriptase (RT) inhibitors (NRTIs) (M41L, T215C, T215D, and K219Q), non-nucleoside RT inhibitors (NNRTIs; K103N), and protease inhibitors (PIs; I47V, G73S). The prevalence of overall primary antiretroviral resistance was 7.6% (9/117) in HIV-1 patients from Turkey and drug-resistant rate for NRTIs, NNRTIs, and PIs were 4.2% (5/117), 1.7% (2/117), and 1.7% (2/117), respectively. In this study, various CRFs of HIV-1 were determined, for the first time, in Turkey. The prevalence of HIV-1 primary drug-resistant mutations in ART-naive patients suggested that resistance testing should be incorporated as an integral part of HIV management, and the choice of a first-line therapy regime should be guided by the results of genotypic resistance in Turkey.

A prospective, multi-center study: factors related to the management of diabetic foot infections.

The Turkish Association of Clinical Microbiology and Infectious Diseases, Diabetic Foot Infections Working Group conducted a prospective study to determine the factors affecting the outcomes of diabetic foot infections. A total of 96 patients were enrolled in the study. Microbiological assessment was performed in 86 patients. A total of 115 causative bacteria were isolated from 71 patients. The most frequently isolated bacterial species was Pseudomonas aeruginosa (n = 21, 18.3%). Among cases with bacterial growth, 37 patients (43%) were infected with 38 (33%) antibiotic-resistant bacteria. The mean (±SD) antibiotics cost was 2,220.42 (±994.59) USD in cases infected with resistant bacteria, while it was 1,206.60 (±1,160.6) USD in patients infected with susceptible bacteria (p < 0.001). According to the logistic regression analysis, the risk factors related to the growth of resistant bacteria were previous amputation (p = 0.018, OR = 7.229) and antibiotics administration within the last 30 days (p = 0.032, OR = 3.796); that related to the development of osteomyelitis was wound size >4.5 cm(2) (p = 0.041, OR = 2.8); and that related to the failure of the treatment was the growth of resistant bacteria (p = 0.016, OR = 5.333). Diabetic foot osteomyelitis is usually a chronic infection and requires surgical therapy. Amputation is the accepted form of treatment for osteomyelitis. Limited limb-saving surgery and prolonged antibiotic therapy directed toward the definitive causative bacteria are most appropriate. This may decrease limb loss through amputations. As a result the infections caused by resistant bacteria may lead to a high cost of antibiotherapy, prolonged hospitalization duration, and failure of the treatment.

Tularaemia outbreaks in Sakarya, Turkey: case-control and environmental studies.

INTRODUCTION: Tularaemia is an important zoonotic disease that leads to outbreaks. This study aimed to compare the epidemiological characteristics of two tularaemia outbreaks that occurred in the Sakarya region of Turkey, analyse the risk factors for the development of outbreaks and identify Francisella (F.) tularensis in the water samples. METHODS: Two tularaemia outbreaks occurred in the Kocadongel village in 2005 and 2006. A field investigation and a case-control study with 47 cases and 47 healthy households were performed during the second outbreak. Clinical samples from the patients and filtrated water samples were analysed for F. tularensis via real-time polymerase chain reaction. RESULTS: From the two outbreaks, a total of 58 patients were diagnosed with oropharyngeal tularaemia based on their clinical and serological results. Both outbreaks occurred between the months of January and April, and the number of patients peaked in February. Logistic regression analysis revealed that the consumption of natural spring water was the only significant risk factor for tularaemia infection (odds ratio 3.5, confidence interval 1.23-10.07). F. tularensis was detected in eight clinical samples and in the filtrated natural spring water. CONCLUSION: This study is the first report of tularaemia from this region. The results show that both tularaemia outbreaks were related to the consumption of untreated natural spring water. To prevent waterborne tularaemia, community water supplies should be treated and checked periodically.

An outbreak of oropharyngeal tularaemia linked to natural spring water.

A tularaemia outbreak was investigated involving 188 suspected cases in the Kocaeli region of Turkey between December 2004 and April 2005. A case-control study comprising 135 laboratory-confirmed cases and 55 controls was undertaken to identify risk factors for the development of the outbreak and to evaluate laboratory diagnostic methods. Tularaemia was confirmed by a microagglutination test (MAT) titre of >or=1 : 160 in 90 of the patients. In MAT-negative sera, 23/44 (52 %) were positive by ELISA with Francisella tularensis LPS and 1/9 (11 %) by Western blotting with this antigen. A species-specific PCR was positive in 16/25 (64 %) throat swabs and 8/13 (62 %) lymph node aspirates. Multivariate analysis showed that drinking natural spring water was the leading risk factor for the development of tularaemia (P=0.0001, odds ratio 0.165, 95 % CI 0.790-0.346). The outbreak ceased after abandonment of the suspected natural water springs.

Rifampicin resistance phenotyping of Brucella melitensis by rpoB gene analysis in clinical isolates.

R Rifampicin resistance of Brucella melitensis by rpoB gene analysis has not yet been performed in Turkey, where brucellosis is endemic. In this study, we investigated the efficacy of E-test and single nucleotide polymorphism (SNP) analysis of the B. melitensis rpoB gene, for the detection of mutations conferring rifampicin resistance, by sequencing 21 human B. melitensis strains from the Southeast and Marmara regions of Turkey. On CLSI slow-growing bacteria standards, all isolates were sensitive to rifampicin except for 6 which showed intermediate resistance to rifampicin. MIC(50) and MIC(90)values were 1 microg/ml and 1.5 microg/ml respectively (range 0.50 -1.5 microg/ml). The rifampicin-resistant phenotype was investigated at Cd 154 (GTT/TTT), Cd 526 (GAC/TAC, GAC/AAC, GAC/GGC), Cd 536 (CAC/CTC, CAC/TAC), Cd 539 (CGC/AGC), Cd 541 (TCG/TTG) and Cd 574 (CCG/CTG) of the rpoB gene in B. melitensis 16M and B115 strains, and in clinical isolates. No missense mutations were found in any of the B. melitensis isolates, which indicates that all isolates were rifampicin-susceptible. In conclusion, SNP analysis was useful as a molecular tool for rifampin resistance testing. Although resistance to rifampicin was not detected in our strains of B. melitensis; the presence of strains with intermediate resistance to rifampicin indicates that susceptibility testing should be performed periodically.

Peritonitis due to Pseudomonas putida in a patient receiving automated peritoneal dialysis.

A patient, who had recently undergone a laparoscopic ovarian cyst operation, receiving nightly automated peritoneal dialysis treatment, was discovered to have peritonitis due to Pseudomonas putida. She was successfully treated with a 21-day course of intraperitoneal ceftazidime and gentamicin, without needing to remove the dialysis catheter. No recurrence was observed over 3 months of follow-up.

Case report: peritonitis by Penicillium spp. in a patient undergoing continuous ambulatory peritoneal dialysis.

Even though prominent technical improvements in continuous ambulatory peritoneal dialysis (CAPD) treatments during the last decade, peritonitis keeps its place as an important cause of morbidity and mortality in these patients. Among them fungal peritonitis is happened to be the most difficult one to deal with and comes out serious clinical presentation. It is presented here a case of CAPD related fungal peritonitis caused by Penicillium spp. This case experienced recently relapsing bacterial episodes of peritonitis and received long term antibiotics intraperitoneally and systemically. Eventually, Penicillium spp. was detected in several cultures of peritoneal effluent and also tip of Tenckhoff catheter, therefore it was considered as a causative agent. Then, the catheter was removed and amphotericin B therapy was performed. But the general condition of the patient did not improve till surgically drainage of peritoneal collection which was determined by MR (Magnetic Resonance) examination of abdomen after antifungal treatment was completed and Penicillium spp. in the drainage samples was not determined anymore.

Primary brucellar psoas abscess: presentation of a rare case of psoas abscess caused by Brucella melitensis without any osteoarticular involvement.

The psoas abscess is an entity, sometimes forgotten in our daily practice, because of infrequency and difficulties in diagnosis. Primary psoas abscess is very rare and gram-positive micro-organisms account for more than 80% of the cases. Our case, a 62-year-old man was admitted with a 5-year history of back pain and fever. Physical examination was normal, except a palpable hepatomegaly with a mild tenderness over his lower right abdominal quadrant. The Brucella agglutination test was strongly positive with a titre of 1/640, as Rose Bengal Spot test. Blood cultures for brucella were positive on the fourth day and became negative, as the specific therapy started. Further examination with ultrasonography and computed tomography revealed an abscess of 40 + 75 mm in the psoas muscle. Complete resolution of symptoms achieved within 6 weeks. Although clinical presentation of psoas abscesses is often similar and non-specific, early aetiological diagnosis is extremely important, because of high achievement with appropriate antibiotic regimens. Brucellar psoas abscess seems very rare even in Turkey, where Brucella is still highly endemic. Such a case has not been previously reported from Turkey, as far as we know.

A probable case of herpes simplex encephalitis despite negative PCR findings.

A 54-year-old woman was admitted to the hospital suffering from fever and personality changes. Laboratory examination of her cerebrospinal fluid (CSF) showed 270 mononuclear cells, 30 polynuclear cells and a clinically low number of erythrocytes/mm3. Empirical clinical findings from this case suggested treatment with acyclovir. Magnetic resonance imaging (MRI) showed bilateral temporal hyperintense signals in T2-weighted images. PCR with specific primer for herpes simplex virus type 1 (HSV-1) and HSV-2 were negative. There was no elevation of oligoclonal antibodies specific to HSV in CSF after 2 weeks. Although we did not prove the presence of the agent microbiologically at the clinical onset of the disease, the MRI and electroencephalogram (EEG) findings, erythrocytes in CSF and the dramatic response to acyclovir therapy are suggestive of a diagnosis of herpes simplex encephalitis (HSE).

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

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

Synthesis of some N-arylazole acetamide derivatives and their anticonvulsant and antimicrobial activities.

Some new N-arylazole acetamide derivatives have been prepared by the reaction of alpha-bromo-N-arylacetamide with imidazole, pyrazole and 1,2,4-triazole. The structures of these compounds have been confirmed by UV, IR, 1H-NMR and elementary analysis. Their anticonvulsant activities were determined by maximal electroshock (MES) and subcutaneous metrazol (Scmet) tests. Most of the compounds showed anticonvulsant activity with significantly low neurotoxicity according to Phase I tests. Compound 6 carrying alpha-naphthyl and 1,2,4-triazole was found active in the MES test with ED50 = 64.9 mg/kg and TD50 = 221.0 mg/kg but it was not active in corneally stimulated rats. Antibacterial and antifungal activities of the compounds were determined against S. aureus, E. coli, P. aeruginosa, C. albicans, C. parapsilosis, C. pseudotropicalis and C. stellatoidea by using the microdilution broth method. Compounds 8 and 10 showed significant activity (MIC < 32 micrograms/ml) against various Candida species.

In vitro activity of eight antibiotics against Salmonella and Shigella species.

The minimum inhibitory concentrations (MICs) of ampicillin, chloramphenicol, trimetoprimsulfamethoxazole (TMP-SMX), ofloxacin, ciprofloxacin, pefloxacin, enoxacin and fleroxacin for Salmonella spp. (n = 72) and Shigella spp. (n = 52) were established. S. typhi isolates were all susceptible to all of the antibiotics tested. In non-typhi salmonellae and Shigella spp., resistance to ampicillin, chloramphenicol and TMP-SMX with various rates were encountered, but all isolates were susceptible to fluoroquinolones.

[Food-borne botulism and its epidemiological features as seen in our country during the last few years]. / Ulkemizde son yillarda görülmeye baslayan Botulismus olgulari ve epidemiyolojik özellikleri.

We evaluated and presented here, the features of the eleven cases of food-borne botulism who admitted to the Infectious Diseases Department of Ibni Sina Hospital of Ankara University. Three of the cases admitted in 1984 and eight of them admitted in 1987. All of the cases were caused by home-prepared foods which had been eaten without cooking; the types of the food were green beans and pepper with sauce. In these cases the main symptoms and signs were generalized muscular weakness, dry mouth, dysphagia, diplopia, ptosis of the eyelids; besides these the other clinical symptoms and signs were seen in some patients. Although toxin couldn't be detected in the patients' sera by mouse-toxin neutralization, the EMG findings supported our diagnoses. To the three patients in the first group, botulinal anti-toxin was not given and two of them died. Anti-toxin was administered to the seven patients in the second group, none of them died.

[In vitro activity of various antibiotics against Shigella strains]. / Cesitli antibiyotiklerin Shigella suslarina in-vitro etkinlikleri.

The in-vitro activity of ampicillin, chloramphenicol, oxytetracycline, trimethoprim-sulfamethaxazole (TMP-SMX), cefoperazone, ceftriaxone, cefotaxime, ceftizoxime, ofloxacin, pefloxacin, ciprofloxacin and fleroxacin against clinically isolated strains of Shigella spp. (n 42) have been determined in this study. The minimum inhibitory concentrations (MICs) were established using the microtube dilution technique. In shigella strains relatively high percentage of resistance was found against ampicillin (% 36.5), chloramphenicol (% 34), oxytetracycline (% 35), and TMP-SMX (% 25.6). The antibiotic therapy proposals reviewed according to these results.

[Susceptibility of Vibrio cholerae El-Tor strains to various antibiotics]. / Vibrio cholerae El-Tor suslarinin çesitli antibiyotiklere duyarliliklarinin arastirilmasi.

In this study, the in-vitro activity of ampicillin, chloramphenicol, oxytetracycline, trimethoprim-sulfamethoxazole (TMP-SMX), cefoperazone, ceftriaxone, cefotaxime, ceftizoxime, ofloxacin, pefloxacin, ciprofloxacin, and fleroxacin against clinically isolated strains of V. cholerae biotype El-Tor have been investigated. The minimum inhibitory concentrations (MICs) were determined using the microtube dilution technique except for TMP-SMX which was tested by agar dilution technique. All of El-Tor strains tested have been found to be susceptible to all the antibiotics used in this study. The antimicrobial therapy proposals on cholera in adults reviewed.