Treatment of ventilator-associated pneumonia (VAP) caused by Acinetobacter: results of prospective and multicenter ID-IRI study.

Ventilator-associated pneumonia (VAP) due to Acinetobacter spp. is one of the most common infections in the intensive care unit. Hence, we performed this prospective-observational multicenter study, and described the course and outcome of the disease. This study was performed in 24 centers between January 06, 2014, and December 02, 2016. The patients were evaluated at time of pneumonia diagnosis, when culture results were available, and at 72 h, at the 7th day, and finally at the 28th day of follow-up. Patients with coexistent infections were excluded and only those with a first VAP episode were enrolled. Logistic regression analysis was performed. A total of 177 patients were included; empiric antimicrobial therapy was appropriate (when the patient received at least one antibiotic that the infecting strain was ultimately shown to be susceptible) in only 69 (39%) patients. During the 28-day period, antibiotics were modified for side effects in 27 (15.2%) patients and renal dose adjustment was made in 38 (21.5%). Ultimately, 89 (50.3%) patients died. Predictors of mortality were creatinine level (OR, 1.84 (95% CI 1.279-2.657); p = 0.001), fever (OR, 0.663 (95% CI 0.454-0.967); p = 0.033), malignancy (OR, 7.095 (95% CI 2.142-23.500); p = 0.001), congestive heart failure (OR, 2.341 (95% CI 1.046-5.239); p = 0.038), appropriate empiric antimicrobial treatment (OR, 0.445 (95% CI 0.216-0.914); p = 0.027), and surgery in the last month (OR, 0.137 (95% CI 0.037-0.499); p = 0.003). Appropriate empiric antimicrobial treatment in VAP due to Acinetobacter spp. was associated with survival while renal injury and comorbid conditions increased mortality. Hence, early diagnosis and appropriate antibiotic therapy remain crucial to improve outcomes.

Urogenital Myiasis Caused by Psychoda albipennis.

Myiasis is one of the reasons for urogenital parasitosis in our country. Psychoda albipennis is a fly that leads to urogenital myiasis. In this case, a 28-year-old female with complaints of dysuria, nausea, vomiting, abdominal pain, and dropping larvae with urine was referred to our hospital. Larvae in the urine sample were macroscopically and microscopically examined. Subsequently, the patient was diagnosed with urogenital myiasis due to P. albipennis fourth phase larvae. The symptoms were relieved with antibiotic and urinal antiseptic treatments. A diagnosis of urogenital myiasis should be considered in patients with urogenital complaints.

The Preseptic Period and Inflammatory Markers in the Prediction of the Course of Sepsis.

BACKGROUND The aim of this study was to find a simple and easily accessible scoring system that could predict the development of sepsis in the preseptic period. MATERIAL AND METHODS The study included 161 patients with a basal sequential organ failure assessment (SOFA) value of 2 or more. The sepsis group (n=83) comprised patients with infection reported in culture results; the control group (n=78) comprised patients not showing evidence of infection in blood, urine, and phlegm cultures; samples were taken on three consecutive days. RESULTS The patients in both groups were divided into subgroups of non-survivor and survivor patients. The preseptic and septic SOFA score, neutrophil lymphocyte ratio (NLR), and procalcitonin (PRC) and lactate (Lac) values were determined to be statistically significantly higher in the sepsis group than in the control group. When the values related to sepsis were examined, a strong relationship was determined between sepsis and SOFA score, PRC values, and Lac values in the preseptic period and a weak relationship with NLR. In the model formed using multiple regression analysis with defined cutoff values for the preseptic and the septic periods, we found that in the septic period, a diagnosis of sepsis could be made with 83.8% accuracy. The diagnostic value of the same parameters evaluated in the preseptic period was 77.9%. CONCLUSIONS The diagnostic value of the combination of Lac, PRC, SOFA, and NLR were found to be similar in the preseptic period as the sepsis period; thus these combined values could safely be used for the early diagnosis of sepsis.

Cranial imaging findings in neurobrucellosis: results of Istanbul-3 study.

OBJECTIVE: Neuroimaging abnormalities in central nervous system (CNS) brucellosis are not well documented. The purpose of this study was to evaluate the prevalence of imaging abnormalities in neurobrucellosis and to identify factors associated with leptomeningeal and basal enhancement, which frequently results in unfavorable outcomes. METHODS: Istanbul-3 study evaluated 263 adult patients with CNS brucellosis from 26 referral centers and reviewed their 242 magnetic resonance imaging (MRI) and 226 computerized tomography (CT) scans of the brain. RESULTS: A normal CT or MRI scan was seen in 143 of 263 patients (54.3 %). Abnormal imaging findings were grouped into the following four categories: (a) inflammatory findings: leptomeningeal involvements (44), basal meningeal enhancements (30), cranial nerve involvements (14), spinal nerve roots enhancement (8), brain abscesses (7), granulomas (6), and arachnoiditis (4). (b) White-matter involvement: white-matter involvement (32) with or without demyelinating lesions (7). (c) Vascular involvement: vascular involvement (42) mostly with chronic cerebral ischemic changes (37). (d) Hydrocephalus/cerebral edema: hydrocephalus (20) and brain edema (40). On multivariate logistic regression analysis duration of symptoms since the onset (OR 1.007; 95 % CI 1-28, p = 0.01), polyneuropathy and radiculopathy (OR 5.4; 95 % CI 1.002-1.013, p = 0.044), cerebrospinal fluid (CSF)/serum glucose rate (OR 0.001; 95 % CI 000-0.067, p = 0.001), and CSF protein (OR 2.5; 95 % CI 2.3-2.7, p = 0.0001) were associated with diffuse inflammation. CONCLUSIONS: In this study, 45 % of neurobrucellosis patients had abnormal neuroimaging findings. The duration of symptoms, polyneuropathy and radiculopathy, high CSF protein level, and low CSF/serum glucose rate were associated with inflammatory findings on imaging analyses.

Causative pathogens and antibiotic resistance in diabetic foot infections: A prospective multi-center study.

AIM: Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials. METHODS: The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate (NCT02026830). RESULTS: A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group. CONCLUSIONS: Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.

Serum Telomerase Levels and COPD Exacerbations.

BACKGROUND: To our knowledge, there is no study on the level of telomerase in subjects with COPD during an exacerbation period. The objective of this work was to compare lipid peroxidation, telomerase, zinc (Zn), copper (Cu), and malondialdehyde levels in asymptomatic smokers and subjects with COPD exacerbation. METHODS: The study included 45 subjects with COPD exacerbation and 42 healthy subjects with tobacco use as a control group. Samples were taken from blood and after the serum levels of telomerase malondialdehyde, Cu, and Zn were measured, the values were compared between the 2 groups. Tests for respiratory function were performed, and sedimentation and C-reactive protein levels were measured. RESULTS: The COPD exacerbation group had a significantly (P < .001) lower Cu/Zn ratio compared with the control group; however, the COPD exacerbation group had significantly (P < .001) higher levels of telomerase malondialdehyde, Cu, and Zn compared with the control group. Malondialdehyde, Cu, Zn, and FEV1 were found negatively correlated in the COPD exacerbation and control groups (P < .001). The COPD exacerbation group had lower FEV1 and FVC compared with the control group. The COPD exacerbation group had significantly (P < .001) higher levels of C-reactive protein and a higher blood cell sedimentation rate compared with the control group. CONCLUSIONS: The reason why the subjects had a reduced Cu/Zn ratio and increased levels of telomerase, Cu, and Zn is likely to be oxidative stress, which can be defined as an increased exposure to oxidants and/or decreased antioxidant capacities It is obvious from this study that lung oxidant-antioxidant balance is abnormal in subjects with COPD exacerbation and also that the increased level of telomerase is associated with this imbalance.

Comparison of brucellar and tuberculous spondylodiscitis patients: results of the multicenter "Backbone-1 Study".

BACKGROUND CONTEXT: No direct comparison between brucellar spondylodiscitis (BSD) and tuberculous spondylodiscitis (TSD) exists in the literature. PURPOSE: This study aimed to compare directly the clinical features, laboratory and radiological aspects, treatment, and outcome data of patients diagnosed as BSD and TSD. STUDY DESIGN: A retrospective, multinational, and multicenter study was used. PATIENT SAMPLE: A total of 641 (TSD, 314 and BSD, 327) spondylodiscitis patients from 35 different centers in four countries (Turkey, Egypt, Albania, and Greece) were included. OUTCOME MEASURES: The pre- and peri- or post-treatment spinal deformity and neurologic deficit parameters, and mortality were carried out. METHODS: Brucellar spondylodiscitis and TSD groups were compared for demographics, clinical, laboratory, radiological, surgical interventions, treatment, and outcome data. The Student t test and Mann-Whitney U test were used for group comparisons. Significance was analyzed as two sided and inferred at 0.05 levels. RESULTS: The median baseline laboratory parameters including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate were higher in TSD than BSD (p<.0001). Prevertebral, paravertebral, epidural, and psoas abscess formations along with loss of vertebral corpus height and calcification were significantly more frequent in TSD compared with BSD (p<.01). Surgical interventions and percutaneous sampling or abscess drainage were applied more frequently in TSD (p<.0001). Spinal complications including gibbus deformity, kyphosis, and scoliosis, and the number of spinal neurologic deficits, including loss of sensation, motor weakness, and paralysis were significantly higher in the TSD group (p<.05). Mortality rate was 2.22% (7 patients) in TSD, and it was 0.61% (2 patients) in the BSD group (p=.1). CONCLUSIONS: The results of this study show that TSD is a more suppurative disease with abscess formation requiring surgical intervention and characterized with spinal complications. We propose that using a constellation of constitutional symptoms (fever, back pain, and weight loss), pulmonary involvement, high inflammatory markers, and radiological findings will help to differentiate between TSD and BSD at an early stage before microbiological results are available.

Distribution and predominance of genotype 3 in hepatitis C virus carriers in the province of kahramanmaras, Turkey.

BACKGROUND: The hepatitis C virus (HCV) has six major genotypes and more than 100 subtypes, and the determination of the responsible genotype, collection of epidemiological data, tailoring antiviral therapy, and prediction of prognosis have an important place in disease management. OBJECTIVES: The aim of the present study was to determine the distribution of HCV genotypes across geographic regions and compare these data with those obtained from other geographic locations. PATIENTS AND METHODS: The HCV genotypes were identified in HCV RNA positive blood samples, obtained from different centers. The HCV genotype was determined using molecular methods [Real-Time Polymerase Chain Reaction (RT-PCR)] in 313 patients, who were found to be positive for HCV RNA. The presence of HCV RNA was investigated using the RT-PCR method in serum samples delivered to the Microbiology Laboratory at Kahramanmaras Necip Fazil City Hospital, Kahramanmaras, Turkey, from the centers located in Kahramanmaras City center and peripheral districts of the province, between March 2010 and August 2014. The HCV genotype analysis was performed in HCV RNA positive samples, using RT-PCR reagents kit. Urine samples from the patients were tested for amphetamine with an Amphetamines II (AMPS2) kit, cocaine was tested with a Cocaine II (COC2) kit, opiates were tested with an Opiates II (OPI2) kit, and cannabinoids were tested with a Cannabinoids II (THC2) kit in Roche/Hitachi Cobas c501 device. RESULTS: The blood samples collected from 313 patients were included in the study. Of these patients, 212 (67.7%) were male and 101 (32.3%) were female. The mean age of the patients was 41.29 ± 20.32 years. In terms of HCV genotype distribution, 162 patients (51.7%) had genotype 1, 144 patients (46%) had genotype 3, four patients (1.3%) had genotype 2, and three patients (1%) had genotype 4. The results of urine drug tests were available in only 65 patients (20.2%). Of these, 61 (93.8%) patients had HCV genotype 3. CONCLUSIONS: In conclusion, the prevalence of HCV genotype 1 was 51.7%, which was lower than the rates reported in other studies in Turkey, while the prevalence of HCV genotype 3 was 46%, which was remarkably higher than the reported Turkish data. In addition, the prevalence rate for genotype 3 reported in the present study is the highest that has ever been reported in the literature.

Tuberculous and brucellosis meningitis differential diagnosis.

BACKGROUND: The Thwaites and Lancet scoring systems have been used in the rapid diagnosis of tuberculous meningitis (TBM). However, brucellar meningoencephalitis (BME) has similar characteristics with TBM. The ultimate aim of this study is to infer data to see if BME should be included in the differential diagnosis of TBM when these two systems suggest the presence of TBM. METHOD: BME and TBM patients from 35 tertiary hospitals were included in this study. Overall 294 adult patients with BME and 190 patients with TBM were enrolled. All patients involved in the study had microbiological confirmation for either TBM or BME. Finally, the Thwaites and Lancet scoring systems were assessed in both groups. RESULTS: The Thwaites scoring system more frequently predicted BME cases (n = 292, 99.3%) compared to the TBM group (n = 182, 95.8%) (P = 0.017). According to the Lancet scoring system, the mean scores for BME and TBM were 9.43 ± 1.71 and 11.45 ± 3.01, respectively (P < 0.001). In addition, TBM cases were classified into "probable" category more significantly compared to BME cases, and BME cases were categorized into the "possible" category more frequently. CONCLUSIONS: When the Thwaites or Lancet scoring systems indicate TBM, brucellar etiology should also be taken into consideration particularly in endemic countries.

Evaluation of pulmonary and extrapulmonary tuberculosis in immunocompetent adults: a retrospective case series analysis.

OBJECTIVE: It was the aim of this study to evaluate the demographic factors and clinical features of extrapulmonary tuberculosis (EPTB) compared to those of pulmonary tuberculosis (PTB) among adult immunocompetent patients. SUBJECTS AND METHODS: A total of 427 patients with clinically, radiologically and histopathologically confirmed TB were enrolled in the study, in our clinic at a tertiary care hospital in Turkey, during a 5-year period (2007-2012). Patient data were obtained retrospectively. Among the 427 patients, 55 patients with both PTB and EPTB and who were using steroids or had taken immunosuppressive drugs were excluded from the study. RESULTS: Of the 372 patients, 227 (61%) were males and 168 (45.2%) had EPTB; 204 (54.8%) patients had PTB. The most frequent sites of EPTB were the lymph nodes (n = 45, 12.1%), pleura (n = 40, 10.7%) and brain (n = 7, 1.8%). The most common symptoms were cough (n = 174, 46.7%), night sweats (n = 127, 34.1%) and fever (n = 123, 33%). Compared to EPTB patients, PTB patients were less likely to have received Bacillus Calmette-Guérin vaccination (odds ratio 0.41, 95% confidence interval 0.2-0.63; p < 0.001). Eighty-one (48.2%) of the EPTB and 146 (71.6%) of the PTB patients were males. Pulmonary involvement was more common among men (n = 146, 71.6%) than among women (n = 58, 28.2%; p = 0.000). CONCLUSION: There was a high incidence of EPTB in our study. Early diagnosis of EPTB is crucial for treatment, and atypical presentations of TB should be kept in mind for immunocompetent patients living in endemic areas. Females especially should be investigated for EPTB.

Human brucellosis in Turkey: different clinical presentations.

INTRODUCTION: Brucellosis is still endemic in Turkey and presents a major public health risk. The aim of this study wasto investigate the clinical and laboratory properties and complications of brucellosis cases. METHODOLOGY: The files of 370 patients (162 males, 208 females) with brucellosis between March 2006 and January 2012 were analyzed retrospectively. RESULTS: The mean age of patients was 39, 6±18.2 years. The major risk factor was unpasteurized dairy products in 155 (41.8%) cases. The complications included hematological (58.1%), osteoarticular (48.3%), hepatobiliary (26.7%), gastrointestinal (10%), and genitourinary system involvement (4.8%). The most frequently seen symptoms were weakness (64.3%), fever (63.2%), sweating (62.7%), arthralgia (59.1%), and lack of appetite (47.8%). A total of 261 patients (70.5%) were acute, 73 patients (19.7%) were subacute, and 36 patients (9.7%) were chronic. In the laboratory tests, AST, ALT and CRP levels were found as elevated in 27.6%, 21.6%, and 69.6% of the patients, respectively. On complete blood count analysis, leukopenia (21.4%), thrombocytopenia (23%), and anemia (70%) were determined. Pancytopenia was more common in acute cases (p = 0.019). Osteoarticular complications increased significantly with increased age (p = 0.005). CONCLUSIONS: Brucellosis is a common disease that may be accompanied by serious complications. In endemic regions of brucellosis, people should be taught to avoid unpasteurized dairy products. Clinicians must be aware of multiple system involvement in brucellosis, especially hematological and musculoskeletal systems. Hematological abnormalities occurring during the course of the disease may be misdiagnosed as hematological malignancies.

Giant nasolabial cyst.

Nasolabial (nasoalveolar) cysts are nonodontogenic soft tissue lesions derived from epithelial remanant of the nasolacrimal duct. These are generally slow-growing painless lesions. Additionally, they can cause obstruction, facial deformity and pain. This case report evaluates the facial deformity and boat-shaped resorption demonstrated on computerized tomography (CT) in a 28 years-old patient presenting with facial swelling and pain as a result of a nasolabial cyst. Nasolabial cysts must be kept in mind in patients suffering from facial deformity and infection as an underlying predisposing factor. Recurrences may be seen in cases not amenable to treatment by surgical excision.

Infective endocarditis developing serious multiple complications.

A 20-year-old female patient with no history of heart disease presented to the hospital with high fever, cough and sputum. On the third day of hospitalisation, left facial paralysis developed and cranial revealed an infarct in the right frontoparietotemporal lobe. Transthoracic echocardiography revealed 1.5 × 2 cm-sized vegetation on the mitral valve and severe mitral regurgitation. On the 11th day of hospitalisation, multiple emboli were shown to be present in the left iliac artery. Since the patient had recurrent septic emboli despite 3 weeks of treatment, a surgical intervention was planned. The vegetation was removed and the mitral valve was replaced by mechanical prostheses. During the postoperative period, acute renal failure developed in the patient. The treatment was completed in 6 weeks with full recovery. This case confirms that infective endocarditis may present with various clinical situations, and that a high index of suspicion and surgical intervention, in addition to aggressive antibiotic therapy, is lifesaving.

A sandfly fever virus outbreak in the East Mediterranean region of Turkey.

OBJECTIVES: To report a sandfly fever virus (SFV) outbreak that occurred in Kahramanmaras Province, Turkey. METHODS: We investigated the cases of 40 patients with a history of sandfly bites and with clinical findings, who were referred to our emergency service between July and August 2010. Serum samples of 19 patients were selected and analyzed using a commercial mosaic immunofluorescence test (IFT) to detect IgM and IgG antibodies against SFV. RESULTS: Sandfly fever was diagnosed in nine patients. All cases had a history of fly bite, and the clinical findings included fever, headache, myalgia, conjunctival hyperemia, and gastrointestinal symptoms such as diarrhea, nausea, and vomiting. In two patients, the diagnosis was confirmed by real-time PCR as sandfly Sicilian virus (SFSV). Laboratory findings in the patients included leukopenia, thrombocytopenia, and elevated levels of aspartate aminotransferase, alanine aminotransferase, creatine kinase, and C-reactive protein. All patients made a complete recovery with symptomatic treatment. CONCLUSIONS: SFV is endemic in the Mediterranean Basin and data regarding SFV activity in Turkey are limited. This is the first report of an SFV outbreak from Kahramanmaras Province, Turkey, and provides information on epidemiological, clinical, and laboratory aspects of SFV infections.

Cerebral Venous Thrombosis and Pulmonary Embolism with Prothrombin G20210A Gene Mutation.

A 25-year-old man presented with symptoms of syncope, cough, headache and hemoptysis. Cranial MR and venography showed thrombus formation in the right transverse sinus and superior sagittal sinus. Computed tomographic pulmonary angiography (CTPA) showed an embolic thrombus in the right pulmonary truncus and lung abscess. The patient was young, and there were no signs of lower extremity deep venous thrombosis or other major risk factors for pulmonary embolism (PE) including cardiac anomaly. The only risk factor we were able to identify was the presence of the prothrombin G20210A gene mutation. Anticoagulant treatment with oral warfarin (10 mg daily) and imipenem (4X500 mg) was started. The patient was hospitalized for antibiotic and anticoagulation therapies for three weeks and was discharged on lifelong treatment with warfarin (5 mg daily).

Diffuse cystic bronchiectasis associated with left microtia and external auditory canal atresia: a very rare coincidence.

OBJECTIVE: To present a case in which diffuse cystic bronchiectasis was associated with left microtia/external auditory canal atresia. CLINICAL PRESENTATION: A 10-year-old girl suffering from cough, fever, dyspnea and sputum for 6 months was transferred to our clinic due to the diagnosis of bronchopneumonia. She had recurrent episodes of bronchopneumonia. On examination, left microtia and left external auditory canal atresia were detected. Thorax CT revealed diffuse cystic bronchiectasis on the left lung. Radiological examination showed atresia of the left external auditory canal. We could not find any etiopathological reason causing bronchiectasis. INTERVENTION: The patient underwent left pneumonectomy and postoperative histopathology was reported as bronchiectasis. CONCLUSION: This report shows a unique case in which an association of diffuse cystic bronchiectasis and left microtia/external auditory canal atresia was observed. Hence in newborns with microtia and/or external auditory canal atresia, the probability of development of bronchiectasis should be borne in mind and such patients should be followed up more carefully regarding this rare association.

Epididymoorchitis and pancytopenia caused by brucellosis.

A 15 year old boy presented with fever and acute painful scrotal swelling. Complete blood count showed pancytopenia. Serum brucella antibodies were positive. Pancytopenia and epididymoorchitis are rare complications of brucellosis and clinicians must consider this entity in the differential diagnosis of adolescents with epididiymoorchitis associated with pancytopenia.

Tularemia presenting with tonsillopharyngitis and cervical lymphadenitis: report of two cases.

Tularemia is a zoonotic disease caused by Francisella tularensis. Francisella tularensis is transmitted to humans by direct contact or ingestion of infected animal tissues, through the bite of infected arthropods, by consumption of contaminated food or water, or from inhalation of aerolized bacteria. In this report we describe 2 cases with oropharyngeal tularemia who presented with tonsillopharyngitis and cervical lymphadenitis.