Outcome of Patients Admitted to Intensive Care Units due to Influenza-Related Severe Acute Respiratory Illness in 2017-2018 Flu Season: A Multicenter Study from Turkey.

BACKGROUND: Influenza can cause severe acute respiratory illness (SARI), which occurs as local outbreaks or seasonal epidemics with high intensive care unit (ICU) admission and mortality rates. Mortality is mainly due to SARI. OBJECTIVE: The aim of this study was to evaluate the outcome of patients admitted to ICU due to influenza-related SARI in 2017-2018 flu season in Turkey. METHODS: A retrospective multicenter study was conducted in 13 ICUs with a total of 216 beds from 6 cities in Turkey. All adult patients (over 18 years) admitted to the ICUs in 2017-2018 flu season (between September 1, 2017, and April 30, 2018) because of SARI and with a positive nasopharyngeal swab for influenza were included in the study. RESULTS: A total of 123 cases were included in the study. The mean age of patients was 64.5 ± 17.5 years, and 66 (53.7%) patients were older than 65 years. The ICU mortality was 33.9%, and hospital mortality was 35.6%. Invasive mechanical ventilation (IMV), acute kidney injury (AKI), hematologic malignancy, and >65 years of age were the factors affecting mortality in influenza. CONCLUSION: SARI due to influenza carries a high mortality rate, and IMV, AKI, presence of hematologic malignancy, and older age are independent risk factors for mortality.

[Mortality prediction ability of phycians in intensive care units of Turkey (MOPAP)]. / Türkiye'de yogun bakim ünitelerinde hekimin mortaliteyi öngörebilme gücü.

INTRODUCTION: Intensive care physicians are increasingly involved in decision making about the prognosis of intensive care unit ICU patients. With this study; we aimed to evaluate the power of clinician foresight at prediction of mortality in patient at triage to intensive care and patient follow-up. MATERIALS AND METHODS: This study was conducted in ICUs located in various geographical regions of Turkey between January 1, 2017-April 30, 2017.The clinical research was planned as observational, multicenter, cross-sectional. RESULT: A total of 1169 intubated patients were followed in 37 different ICU. At the beginning of the follow-up we asked the physician who will follow the patient in the ICU to give a score for the probability of survival of the patients. Scoring included a total of 6 scores from 0 to 5, with the "0" the worst probability "5" being the best. According to this distribution, only 1 (0.9%) of 113 patients who were given 0 points survived. Three (6.1%) of 49 with the best score of 5 died. Survival rates were significantly different in each score group (r: -0.488; p<0.001). After the combined mortality estimation scores based on the clinical observations of the physicians (0 and 1 point score was combined as non-survive, 4 and 5 score was combined as survived) 320 of the 545 patients were estimated to be dead and 225 were predicted survival. Sensitivity and spesifity of scoring system to predict mortality was 91.56% (95% CI: 87.96-94.37), 76.89% (95% CI: 70.82-82.23) respectively. CONCLUSIONS: In this study, we concluded that the physicians who follow the patients in the ICU can predict the poor prognosis at the time of admission and the high mortality rate. The physician's opinion on mortality estimation should be considered in intensive care mortality scoring in addition to other laboratory and clinical parameters.

[The comparison of microscopy and real time polymerase chain reaction methods for the diagnosis of Pneumocystis Jirovecii pneumonia: evaluation of clinical parameters]. / Pneumocystis jirovecii pnömonisi tanisinda mikroskopi ve gerçek zamanli polimeraz zincir reaksiyonu yöntemlerinin karsilastirilmasi: Klinik bulgular ile yorumlanmasi.

INTRODUCTION: Pneumocystis jirovecii pneumonia (PCP) causes serious infections, especially in patients with immunosuppressive diseases. In this study, it was aimed to evaluate the results of samples obtained from PCP suspected patients using two different methods together with clinical data. MATERIALS AND METHODS: Microscopy and real time polymerase chain reaction (real time PCR) methods were performed with bronchoalveolar lavage (BAL) samples sended to Ege University Medical Faculty Direct Parasitology Diagnostic Laboratory between March 2009 and June 2010. Demographic characteristics, clinical and laboratory data were also recorded retrospectively. The data were evaluated using the SPSS 16.0 program. RESULT: A total of 42 BAL samples collected from patients (24 males, mean age: 31.49 ± 26.14) were included. There were totally 16 P. jirovecii positives either one of the tests. Sixteen and three samples were detected positive by real time PCR and microscopy, respectively. Trimethoprim-sulfamethoxazole was prescribed in 11 PCP diagnosed cases and 6 of them died. CONCLUSIONS: Today, despite the growing opportunities in diagnosis and treatment, PCP pneumonia is associated with high mortality. Careful examination of clinical data and immune status of the patients are important. Multidisciplinary approach is required for early PCP diagnosis.

Evaluation of nephrotoxicity and prognosis in patients treated with colistin due to hospital-acquired pneumonia.

INTRODUCTION: Colistimethate sodium (CMS) is frequently used in the treatment of nosocomial multidrug-resistant gram-negative infections. Nephrotoxicity is the most important side effect. The aim of this study is to evaluate the effect of colistin on nephrotoxicity and to assess prognosis in patients treated with CMS due to hospital-acquired pneumonia (HAP). MATERIALS AND METHODS: Patients treated with CMS for HAP due to multidrug-resistant Pseudomonas aeruginosa or Acinetobacter baumannii were included in this cohort study. RESULT: We evaluated 281 patients treated with two different brands of CMS whose administration dose is different: imported (n= 58, low dose/kg) and domestic (n= 223, high dose/kg). Nephrotoxicity developed in 175 patients (62.3%). The median age (73 vs. 66 years, p= 0.004) and mortality rates were higher (66.9% vs. 52.8%, p= 0.022) in patients having nephrotoxicity. The patients receiving high dose/kg had higher nephrotoxicity rate (67.7% vs. 41.4%, p< 0.001). The clinical, bacteriological response and mortality rates of the whole group were 52.0%, 61.0%, 61.6%, respectively. The clinical and bacteriological response rates were similar in the different dose groups. Multivariate analysis showed that nephrotoxicity was associated with domestic brand depending on use of high dose (OR= 3.97), advanced age (ß= 0.29, p= 0.008), male gender (OR= 2.60), hypertension (OR= 2.50), red blood cells transfusion (OR= 2.54), absence of acute kidney injury (OR= 10.19), risk stage of RIFLE (OR= 11.9). CONCLUSIONS: Nephrotoxicity is associated with the use of high dose colistin, age, gender, hypertension, red blood cells replacement and RIFLE stage. The mortality rate is higher in patients developing nephrotoxicity.

Can fiberoptic bronchoscopy be applied to critically ill patients treated with noninvasive ventilation for acute respiratory distress syndrome? Prospective observational study.

BACKGROUND: Noninvasive ventilation (NIV) is a cornerstone for the treatment of acute respiratory failure of various etiologies. Using NIV is discussed in mild-to-moderate acute respiratory distress syndrome (ARDS) patients (PaO2/FiO2 > 150). These patients often have comorbidities that increase the risk for bronchoscopy related complications. The primary outcome of this prospective observational study was to evaluate the feasibility, safety and contribution in diagnosis and/or modification of the ongoing treatment of fiberoptic bronchoscopy (FOB) in patients with ARDS treated with NIV. METHODS: ARDS patients treated with NIV and who require FOB as the diagnostic or therapeutic procedure were included the study. Intensive care ventilators or other dedicated NIV ventilators were used. NIV was applied via simple oro-nasal mask or full-face mask. Pressure support or inspiratory positive airway pressure (IPAP), external positive end expiratory pressure (PEEP) or expiratory positive airway pressure (EPAP) levels were titrated to achieve an expiratory tidal volume of 8 to 10 ml/kg according to ideal body weight, SpO2 > 90 % and respiratory rate below 25/min. RESULTS: Twenty eight subjects (mean age 63.3 ± 15.9 years, 15 men, 13 women, PaO2/FiO2 rate 145 ± 50.1 at admission) were included the study. Overall the procedure was well tolerated with only 5 (17.9 %) patients showing minor complications. There was no impairment in arterial blood gas and cardiopulmonary parameters after FOB. PaO2/FiO2 rate increased from 132.2 ± 49.8 to 172.9 ± 63.2 (p = 0.001). No patient was intubated within 2 h after the bronchoscopy. 10.7, 32.1 and 39.3 % of the patients required invasive mechanical ventilation after 8 h, 24 h and 48 h, respectively. Bronchoscopy provided diagnosis in 27 (96.4 %) patients. Appropriate treatment was decided according to the results of the bronchoscopic sampling in 20 (71.4 %) patients. CONCLUSION: FOB under NIV could be considered as a feasible tool for diagnosis and guide for treatment of patients with ARDS treated via NIV in intensive care units. However, FOB-correlated life-treathening complications in severe hypoxemia should not be forgotten. Furthermore, further controlled studies involving a larger series of homogeneous ARDS patients undergoing FOB under NIV are needed to confirm these preliminary findings.

Hypersensitivity to chemotherapeutics: a cross sectional study with 35 desensitisations.

BACKGROUND: Chemotherapy is one of the main treatments for lung cancer, and in these patients, discontinuation of treatment due to uncontrollable hypersensitivity reactions (HSRs) is an important problem. AIM: To determine the frequency of HSRs during chemotherapy and to review current approaches. METHODS: We did a cross sectional study in patients undergoing chemotherapy for lung cancer in a reference chemotherapy unit from January 2012 to January 2013. Patients who developed immediate-HSRs or delayed-HSRs to chemotherapeutics and gave consent were included into study. The effectiveness of a standardised 12-step "rapid drug desensitisation" (RDD) procedure was investigated in patients with immediate-HSRs. RESULTS: In total, 1,099 cycles of chemotherapy were administered to 292 patients in 1 year. We observed ten HSRs, during ten cycles in ten patients (~3 % of the patients). Two HSRs were delayed-type, eight were immediate-type at grade 1-3. Of those with immediate-type HSR, five patients with grade 2-3, and additional two referred patients with grade 4 HSRs were successfully given their culprit drug in 35 cycles of chemotherapy with 12-step or modified 20-step RDD protocol. CONCLUSIONS: HSRs to chemotherapeutics are not so rare. Premedication alone does not prevent such reactions. The results of RDD treatment look promising for continuing treatment with the culprit chemotherapeutic agent.

[The effect of fluoroquinolone use in the respiratory intensive care unit on the development of hospital-acquired MRSA infection and its prognosis]. / Solunumsal yogun bakim ünitesinde florokinolon kullaniminin hastane kökenli MRSA enfeksiyonu gelisimine ve prognoza etkisi.

Methicillin-resistant Staphylococcus aureus (MRSA) which exhibits a worldwide spread, has become a serious public health problem. There are several studies indicating that there may be a relationship between the high rate of MRSA infections and long-term use of fluoroquinolones. The aim of this study was to investigate the effect of fluoroquinolone (FQ) use in the respiratory intensive care unit (ICU) on the development of the hospital-acquired MRSA infection and mortality. This was a single center experience, in which the clinical and laboratory data of the patients who were hospitalized in the respiratory ICU for two years, were retrospectively evaluated. The relationship between FQ use and the development of MRSA infection was evaluated with correlation analysis, and its relationship with the mortality was evaluated with regression analysis. A total of 302 patients were included in the study and 93 (30.7%) of them were found to be treated with FQs. Sixty-four of those 93 patients were male and the mean age was 71.1 ± 12.5 years. During the follow-up, MRSA infections developed in 11.9% (36/302) of the patients, and the rate of MRSA infection in FQ using patients was 15.1% (14/93), of them eight were ventilator-associated pneumonia (VAP) and six were secondary bacteremia. Although a positive correlation was found between FQ use and the development of MRSA infection, it was not statistically significant [P= 0.521 (Spearman), p= 0.037 (Pearson)]. In addition cut-off values for CRP and leukocyte counts, which were checked when a patient with FQ use admitted to the ICU, were determined as 7.85 mg/L and 7.650/mm3, respectively. The analysis of the relationship between CRP, leukocyte counts and the development of MRSA infection revealed a statistically significant positive relationship between high leukocyte levels (> 7.650/mm3) and the development of MRSA infection (P= 0.017, p= 0.246), but no such relationship for the CRP levels (P= 0.121, p= 0.178). The mortality rate in patients with FQ use was found as 42% (39/93), and it was determined that malignancy, history of admission to hospital in the previous six months and the presence of a hospital-acquired infection increased the risk of mortality (p= 0.020, p= 0.038 and p= 0.024, respectively). In the multivariate analysis, four independent risk factors related to the mortality in patients under FQ treatment were determined, namely malignancy (OR: 2.280, p= 0.002), re-intubation practices (OR: 4.071, p= 0.005), VAP (OR: 5.097, p= 0.009) and the use of FQ > 7 days (OR: 3.63, p= 0.003). In conclusion, our data indicated that the use of FQs in the ICU did not increase the development of hospital-acquired MRSA infection significantly, and FQ use for more than seven days was an independent risk factor for mortality. Additionally, it was thought that high leukocyte counts might be a predictive marker for the development of MRSA infection.

[The role of endotracheal aspiration in the diagnosis of ventilator associated pneumonia]. / Ventilatörle iliskili pnömoni tanisinda endotrakeal aspiratin degeri.

INTRODUCTION: Ventilator associated pneumonia (VAP) is one of the most important causes of mortality in patients treated with invasive mechanical ventilation (IMV) in intensive care unit (ICU). Microbiological examinations are required as clinical and radiological findings are usually insufficient in the diagnosis. MATERIALS AND METHODS: Twenty four patients who were receiving IMV because of respiratory failure, had a Clinical Pulmonary Infection Score (CPIS) of ≥ 6 in the follow-up and died with the suspicion of VAP were enrolled in our study. Six patients were excluded as post-mortem biopsy could not be performed. The patients who had pre-mortem CPIS ≥ 6, in whom a causative organism was identified from the culture of post-mortem lung biopsy and/or histopathological examination of lung biopsy was compatible with pneumonia were diagnosed as VAP. In the 18 patients in whom a post-mortem lung biopsy was performed, quantitative culture results of endotracheal aspirate performed 48 hours prior to death were compared with microbiological and histopathological results of post-mortem lung biopsy specimens, and the role of endotracheal aspirate in the diagnosis of VAP was evaluated retrospectively. RESULTS: Out of 18 patients (12 men, mean age 67.0 ± 13.0 years) included in the study, 11 (61.1%) were diagnosed as VAP. The quantitative culture of endotracheal aspirate was positive in 9 (81.8%) out of 11 patients diagnosed as VAP. The sensitivity, specificity, positive and negative predictive values of endotracheal aspirate culture for identifying VAP were found to be 81.8%, 14.3%, 60.0% and 33.3%, respectively. CONCLUSION: Our study shown that quantitative culture of endotracheal aspirate is a practical and reliable method that can be used for the diagnosis of VAP in patients receiving IMV in ICU and having CPIS ≥ 6.

Serum estradiol level predicts acute kidney injury in medical intensive care unit patients.

Previous studies have shown that serum estradiol (E2) levels can predict mortality in intensive care unit patients. Our study investigated the predictive role of admission estradiol level on patient mortality and development of acute kidney injury in medical intensive care unit patients with a wide range of diagnoses. We conducted a prospective cohort study using serum samples from hospitalized patients in medical, cardiac, and pulmonary intensive care units at the Ege University Hospital within 6 months. Serum estradiol levels from 118 adult patients were collected within 48 h of hospitalization. Receiver operating curves and multiple logistic regression analyses were performed to investigate its relationship with acute kidney injury development and mortality. Serum estradiol levels were significantly higher in non-survivor patients than in survivor patients [85 (19-560) pg/mL vs. 32 (3-262) pg/mL, p < 0.001]. Admission estradiol levels were significantly higher in patients with AKI on admission than in patients with chronic kidney disease (p = 0.002) and normal renal function (p = 0.017). Serum E2 levels were higher in patients with renal deterioration during follow-up than patients with stable renal functions [62 (11-560) pg/mL vs. 38 (3-456) pg/mL, p = 0.004]. An admission estradiol level of 52.5 pg/mL predicted follow-up renal deterioration with 63% sensitivity and 74% specificity. A combined (APACHE II-E) score using APACHE II and serum estradiol level predicted overall mortality with 66% sensitivity and 82% specificity. Admission estradiol level is a good marker to predict the development of acute kidney injury and mortality in medical intensive care unit patients.

Comparison of bronchoalveolar lavage and mini-bronchoalveolar lavage in the diagnosis of pneumonia in immunocompromised patients.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in immunocompromised patients. Bronchoalveolar lavage (BAL) is commonly used to help diagnose and characterize pneumonia in these patients. Mini-BAL is a less-invasive, less-costly and less-cumbersome diagnostic tool than BAL. OBJECTIVES: In this study, we compared the diagnostic value of BAL and mini-BAL in the evaluation of pneumonia in immunocompromised patients with respiratory failure. METHODS: Sixty-four respiratory samples were collected from 32 immunocompromised patients admitted to our respiratory intensive care unit with a clinical diagnosis of pneumonia and respiratory failure requiring invasive mechanical ventilation. A single BAL sample and a single mini-BAL sample were collected from each patient. Samples were examined for bacteriologic, mycologic, mycobacteriologic, and viral organisms. RESULTS: The mean age of the patients was 56.0 ± 14.4 years. Of the 32 BAL samples, bacterial isolates were detected in 11 patients (34.4%) and on the other hand bacterial isolates were detected in 10 patients (31.3%) of the mini-BAL samples. Fungal isolates were detected in 11 patients (34.4%) from BAL samples and 13 patients (40.6%) from mini-BAL samples. Our analysis demonstrated a strong positive correlation between the results of BAL and mini-BAL testing (r = 0.850 and r = 0.821, respectively). CONCLUSION: In this study, we demonstrated a strong correlation between the isolation rates of bacteria and fungi in BAL and mini-BAL samples obtained from immunocompromised patients with pneumonia and respiratory failure. The data strongly support the use of mini-BAL sampling in such patients as a less-invasive, less-costly and simpler alternative to traditional BAL.

[The comparison of patients with hospitalized health-care-associated pneumonia to community-acquired pneumonia]. / Saglik bakimi ile iliskili pnömoni ve toplumkökenli pnömoni tanilari ilehastanede yatan olgularin karsilastirilmasi.

Health-care-associated pneumonia (HCAP) is defined as pneumonia that develops in patients with a history of recent hospitalization, hemodialysis as an outpatient, residence in a nursing home, outpatient intravenous therapy and home wound care. We aimed to compare the initial demographic characteristics, causative agents and prognosis between hospitalized HCAP and community-acquired pneumonia (CAP) patients. HCAP and CAP patients hospitalized between 01 September 2008-01 September 2009 were evaluated retrospectively. Out of 187 patients (131 males, mean age 66.3 ± 14.3 years) who were hospitalized during one-year period, 98 were diagnosed as HCAP and 89 as CAP. Among HCAP patients, 64 (65.3%) had a history of hospitalization in the last 90 days, 26 (26.5%) received outpatient intravenous therapy, 17 (17.3%) had home wound care, 6 (6.1%) were on hemodialysis program in the last 30 days and 4 (4.1%) lived in a nursing home. The causative pathogen was detected in 39 (39.8%) HCAP and 8 (9.0%) CAP patients. The most frequently isolated microorganisms were Pseudomonas aeruginosa and Acinetobacter baumannii in HCAP, and Streptococcus pneumoniae and Haemophilus influenzae in CAP patients. Inappropriate empiric antibiotic treatment was documented in 8 (25.8%) of 39 HCAP patients, in whom a causative agent was isolated whereas the antibiotic treatment was appropriate in all CAP patients. The duration of hospitalization (14.4 ± 11.4 vs. 10.7 ± 7.9 days, p= 0.011) and mortality rate (34.7% vs. 9.0%, p< 0.001) were higher in HCAP compared with CAP patients. As HCAP is different than CAP in terms of patients' characteristics, causative microorganisms and prognosis, it should be considered in all patients hospitalized as CAP. Potentially drug-resistant microorganisms should be taken into consideration in the empirical antibiotic treatment of these patients.

[A case of ventilator-associated pneumonia caused by Cupriavidus pauculus]. / Cupriavidus pauculus'un neden oldugu ventilatör ile iliskili bir pnömoni olgusu.

Cupriavidus pauculus (formerly CDC Group IVc-2) is a non-fermentative, motile, gram-negative bacillus, rarely associated with human infections. It has been isolated from water, water from ultrafiltration systems and bottled mineral water. To date, 19 cases of bacteremia, two cases of peritonitis and one case of tenosynovitis associated with C. pauculus have been reported in English literature. In this paper, we report the first case of C. pauculus ventilator-associated pneumonia (VAP) in Turkey. A 47 years-old female with breast cancer was performed total mastectomy six years ago and received six cures of chemotherapy after surgery. The patient was hospitalized in medical oncology clinic with complaints of weight loss, nausea and vomiting for one year. Since she had problems of consiousness, dysphagia and pitosis, lumbar puncture was performed to rule out central nervous system infection or metastasis. Cryptococcal meningitis was diagnosed upon the examination of Indian-ink stained smear of cerebrospinal fluid and amphotericin B was initiated. On the 11th day of her follow up, she developed respiratory distress and was transferred to pulmonary intensive care and underwent invasive mechanical ventilator (IMV) therapy. On the 4th day of IMV; a new infiltration was detected on the upper zone of chest X-ray in addition to fever (38.3 degrees C) and intense endotracheal secretion. Therefore, bronchoscopic examination was performed and bronchoalveolar lavage and bronchoscope aspiration materials were obtained and cultivated. Bacteria grown at blood agar and EMB agar after 48 hours of incubation were stained as gram-negative bacilli and identified as C. pauculus by VITEK 2 compact system (bioMérieux Inc, USA). The strain was susceptible to ceftazidime, ciprofloxacin, imipenem, trimethoprim-sulfamethoxazole, piperacilin/tazobactam and resistant to amikacin. The case was considered as C. pauculus VAP and imipenem (500 mg, 4 x 1) for 14 days was initiated. Clinical and microbiological resolution was achieved by imipenem therapy. In conclusion, rare pathogens like C. pauculus should be considered among the possible causative agents in infections that develop in immunocompromised host.

[Comparison of teicoplanin and linezolid therapies in patients with methicillin-resistant Staphylococcus aureus pneumonia acquired from respiratory intensive care unit]. / Solunumsal yogun bakim ünitesinde yatan hastalarda gelisen metisiline dirençli Staphylococcus aureus pnömonisinde teikoplanin ve linezolid tedavilerinin karsilastirilmasi

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the high-risk and potential multi-drug resistant microorganisms that leads to infection in intensive care unit (ICU). Although standard antibiotics used for its treatment are glycopeptides, linezolid is considered as an alternative treatment especially in hospital-acquired pneumonia (HAP). The aim of this retrospective study was to compare the results of linezolid and teicoplanin treatments in patients with MRSA isolated from their respiratory samples in ICU. In our respiratory ICU, 41 consecutive patients (28 males, mean age 66.0 ± 16.0 years) diagnosed as HAP due to MRSA were included in the study. Teicoplanin was used in 22 patients and linezolid treatment was given to 19 patients. In the linezolid group, mean age and Acute Physiology Assessment and Chronic Health Evaluation (APACHE) II score were found higher (68.9 ± 12.5 vs. 63.5 ± 18.5 and 25.7 ± 6.4 vs. 23.2 ± 4.9, respectively), and PaO2/FiO2 ratio was lower (176.4 ± 58.2 vs. 191.6 ± 91.3) however, the differences between the two groups were not statistically significant. There was no difference between the two groups in terms of hospitalization indications, co-morbid diseases, other baseline findings and risk factors for development of HAP caused by MRSA. Invasive mechanical ventilation was applied to 86.4% of the patients in teicoplanin group and 84.2% in linezolid group (p> 0.05). The rates of bacteremia were found as 22.7% and 31.6% in teicoplanin and linezolid groups, respectively (p>0.05). Bacteriological eradication was achieved in all patients given linezolid, whereas this rate was 72.7% in patients on teicoplanin therapy (p= 0.048). There was no difference with regards to durations of ICU and hospital stay between the two groups. The mortality rate was found lower in the linezolid group than the teicoplanin group (42.1% vs. 63.6%), however this difference was not found statistically important (p> 0.05). In conclusion; the present study demonstrated that better microbiological eradication was achieved by linezolid therapy in pneumonia caused by MRSA in ICU, however, the clinical efficacy and survival rates were similar to teicoplanin therapy.

[Comparison of the patients with pandemic (H1N1) influenza A virus pneumonia and community-acquired pneumonia]. / Pandemik (H1N1) influenza A virüsü pnömonisi ve toplum kökenli pnömoni olgularinin karsilastirilmasi.

Prognosis of pandemic influenza A (H1N1) virus pneumonia is worse than community-acquired pneumonia (CAP), therefore it is important to know distinctive clinical features of both pneumonias. The aims of this study were to compare clinical features and prognosis of patients with pandemic influenza A (H1N1) pneumonia and CAP due to other agents. Demographic features, symptoms and findings of 20 pandemic influenza A (H1N1) pneumonia and 18 CAP patients hospitalized between October 1st and December 30th, 2009 were evaluated. One patient (5.0%) with pandemic Influenza A (H1N1) pneumonia and 55.6% of CAP patients were over 65 years (p= 0.001). Symptoms of fever, dyspnea, fatigue, muscle and joint pain, nausea, vomiting and headache were more frequent (p< 0.05), platelet count (p= 0.024) and PaO(2)/FiO(2) ratio (p= 0.006) were lower, number of thrombocytopenic patients (p= 0.024) and LDH levels (p= 0.016) were higher, duration of hospitalization was longer (p= 0.038) in patients with pandemic influenza A (H1N1) pneumonia. There was no difference in terms of radiological findings between two groups. None of the CAP patients were followed-up in the intensive care, whereas five pandemic influenza A (H1N1) pneumonia patients (25.0%) required intensive care and three of them died despite invasive mechanical ventilation. In conclusion, in the presence of fever, dyspnea with non-pulmonary symptoms and accompanying radiological alveolar opacities should be considered as pandemic influenza A (H1N1) pneumonia should be suspected in patients admitted with findings of pneumonia during influenza season. Admission to the intensive care unit and mechanical ventilation should be considered in patients with dyspnea and diffuse radiological findings.

[Multidrug-resistant Acinetobacter baumannii infection in respiratory intensive care unit]. / Solunumsal yogun bakim ünitesinde çoklu antibiyotik dirençli Acinetobacter baumannii enfeksiyonu.

Multidrug-resistant Acinetobacter boumannii is a challenge in the treatment and control of nosocomial infections. This retrospective study was aimed to investigate the prevalence of multidrug resistant A. boumannii in a respiratory intensive care unit (ICU), related risk factors and its impact on disease prognosis. Of 218 patients who were hospitalized in our ICU during the last two years; 37 (17%) patients (21 males, mean age 61.6 +/- 19.8 years) developed pneumonia and/or bacteremia due to multidrug-resistant A. baumannii. Previous antibiotic therapy was detected in 51.4% and hospitalization in 70.3% of the cases. Pneumonia (59.5%) was the most frequent cause of hospitalization and chronic obstructive pulmonary disease (21.6%) was the second one; 81.1% of patients had co-morbidity. Invasive mechanical ventilation was performed in 31 (83.7%) patients during the follow-up. Ventilator-associated pneumonia developed in 22 (59.5%) patients and bacteraemia in 9 (24.3%) patients. Multidrug-resistance was observed in 23 (62.2%) of patients. Highest rates of resistance (100%) was detected against piperacillin-tazobactam, ampicillin-sulbactam and ciprofloxacin, followed by imipenem and cefepime (78%), meropenem and ceftazidime (55%), cefoperazone-sulbactam (43%) and netilmicin (35.1). The rates of re-intubation and tracheotomy were higher in patients infected with A. boumannii compared to the control group (59.5% vs. 7.7%, p < 0.0001 and 21.6% vs. 3.9%, p = 0.001, respectively). There was no significant difference between two groups in terms of mortality, however, durations of ICU and hospital stays were longer in patients with multidrug-resistant A. baumannii infection than without infection (24.2 +/- 18.3 vs. 8.2 +/- 8.3 days, p < 0.001 and 33.3 +/- 19.8 vs. 15.4 +/- 11.4 days, p < 0.001, respectively). In conclusion, due to the high rates of drug-resistance in nosocomial A.baumannii isolates, the use of invasive procedures and durations of ICU and hospital stays exhibit an increasing trend.

[Colistin use in ventilator-associated pneumonia due to panresistant Pseudomonas aeruginosa and Acinetobacter baumannii]. / Panrezistan Pseudomonas aeruginosa ve Acinetobacter baumannii ile gelisen ventilatörle iliskili pnömonilerde kolistin kullanimi.

Nosocomial infections by resistant gram-negative microorganisms are important causes of mortality in intensive care unit (ICU)'s. The treatment choices are limited in infections due to Acinetobacter baumannii and Pseudomonas aeruginosa, especially if they are panresistant. In these type of resistant infections, colistin--an old antibiotic--has become a current issue. The aim of this study was to evaluate the efficacy of colistin in 9 cases (6 males, mean age 75.8 +/- 9.4 years), with ventilator associated pneumonia (VAP) caused by panresistant A. baumannii and P. aeruginosa in respiratory ICU. All cases were referred to ICU from other hospitals or clinics. It was detected that 7 of 9 cases were treated with anti-pseudomonal antibiotics before the development of VAP. Panresistant A. baumannii was isolated in 5 cases and P. aeruginosa in 4 cases. VAP by these microorganisms was detected on the 26.6 +/- 12.4th days of invasive mechanical ventilation and the cases were followed up for 54.2 +/- 25.7 days in ICU. During colistin treatment, dermatitis (one case) and nephrotoxicity (one case) were observed as side effects. Microbiological response to colistin was obtained in 6 cases. Three cases died due to non-eradication of panresistant microorganisms and three cases died due to other infections during ICU follow-up. The data presented in this study demonstrates that colistin can be considered as a safe and effective antibiotic in the treatment of panresistant A. baumannii and P. aeruginosa infections.

[Tuberculin skin test reactivity in patients with chronic renal failure]. / Kronik böbrek yetmezligi olan olgularda tüberkülin cilt testi yaniti.

The aim of this study was to evaluate the response of tuberculin skin test (TST) and the parameters that affect the response in patients with chronic renal failure (CRF) on different treatment regimens. The study population consisted of 150 patients (78 females, mean age 48.1 + or - 16.7 years, the mean disease duration 6.6 + or - 6.1 years). Of these patients, 50 were on haemodialysis (HD), 50 were renal transplant patients, 26 were on peritoneal dialysis (PD) and 24 were treated medically. TST was performed to all patients, an induration with a diameter of 10 mm or more was accepted as positive response in HD, PD, medical treatment groups, whereas 5 mm or more was considered as positive in transplant group. TST was positive in 52% of the study population (56% in HD group, 54% in PD group, 44% in transplant group, 58% in medical treatment group, p> 0.05). There was a positive correlation between TST and age in patients older than 60 of transplant and medical treatment groups (p= 0.008). In HD patients with negative TST, the number of female patients was higher (p= 0.02). In transplant patients with positive TST, duration of HD was shorter (p= 0.01), the blood urea level was lower (p= 0.04), hemoglobin level was higher (p= 0.04). The ratio of negative TST was higher (p< 0.05), TST reactivity was smaller (p= 0.01) in only transplant patients with no BCG scar. The number of BCG scar was correlated positively with TST (p= 0.04). In the medical treatment group, patients with positive TST response were older (p= 0.02) and in PD group the tuberculin reactivity was not affected by any of the patient-related parameters. It must be considered that the response to TST is low in young patients with uncontrolled CRF and under immunosuppressive therapy.

Lophomonas blattarum Associated Broncho-Pulmonary Infection After Immunotherapy: A Case Report and A Smart-phone Based Video of Trophozoite

The frequency of bronchopulmonary protozoan infections has raised due to increased number of immunosuppressed patients in recent years. One of them is Lophomonas blattarum which is a multi-flagellated protozoan parasite of termites and several cockroach species. The drug regimens commonly used in bronchopulmonary infections are not effective against L. blattarum. Therefore, rapid and accurate diagnosis of L. blattarum infection is of great importance in the treatment success. The laboratory diagnosis of L. blattarum infection is made on the basis of observation of the characteristic trophozoite in various samples. It is of a great importance to distinguish the protozoon from ciliated respiratory epithelium to avoid wrong positivity. The presented case developed an acute respiratory distress syndrome a short while after taking nivolumab immunotherapy. The morphological features of L. blattarum were demonstrated by examining the bronchoalveolar lavage fluid of the patient under light microscopy. Additionally, URL (https://youtu.be/EQIAsFl6AJY) of a smart-phone based video of trophozoite of this patient was added into this report.

[Investigation of the virulence genes in methicillin-resistant Staphylococcus aureus strains isolated from biomaterial surfaces]. / Biyomalzeme yüzeylerinden izole edilen metisiline dirençli Staphylococcus aureus suslarinda virülans genlerinin arastirilmasi.

Staphylococci are the most important agents of nosocomial infections originating from biomaterials. The aim of this study was to investigate the presence of virulence genes and their phenotypic expressions in 11 methicillin-resistant Staphylococcus aureus strains isolated from the surfaces of clinically used biomaterials of 48 thorasic intensive-care unit patients. By the use of specific primers, the presence of genes encoding the attachment and biofilm production (icaA, icaC, bap), methicillin resistance (mecA), enterotoxins A-E (sea, seb, sec, sed, see), toxic shock syndrome toxin (tst), exfoliative toxins A and B (eta and etb), alpha- and beta-hemolysins (hla and hlb), staphylococcal exotoxin-like protein-1 (set1), proteases (sspA, sspB, aur, serine proteaz gene), lipase (geh) and the regulatory genes (sarA and agrCA) were investigated by polymerase chain reaction (PCR). The phenotypic properties of the isolates such as biofilm formation, antibiotic susceptibility, extracellular protease and lipase production were also evaluated. None of the isolates were found to be biofilm and/or slime producers, however, all strains were found to have icaA gene which is responsible for biofilm formation. Nevertheless the presence of icaC and bap genes that are also responsible for biofilm formation were not detected. All the strains have had mecA gene and were resistant to oxacillin, penicilin G and gentamicin, while 10 were also resistant to erythromycin and nine were also resistant to ofloxacin. The isolates were susceptible to vancomycin, teicoplanin and co-trimoxazole. Screening of toxin and regulatory genes revealed that all the strains harboured sea, set1, hla, hlb and sarA genes. The phenotypic tests for the determination of extracellular protease production revealed that all the strains formed very weak zones on skim milk and milk agar plates, and yielded negative results on casein agar plates. Furthermore, all strains were found to harbour sspA, sspB, aur and serine protease genes. Tween 20, Tween 80 and tributyrin containing media were used to detect lipase production and all strains gave late-positive results (on the third day of incubation), although they all lacked for lipase gene (geh). As a result, S. aureus strains isolated from biomaterial surfaces yielded positivity for some of the tested virulence genes, of which some of them have not been expressed phenotypically. Although there were some limitations in the study, it could be concluded that the presence of these virulence genes in S. aureus strains might be considered as potential threats especially in intensive care unit patients.