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

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

Efficacy and safety of an inactivated whole-virion SARS-CoV-2 vaccine (CoronaVac): interim results of a double-blind, randomised, placebo-controlled, phase 3 trial in Turkey.

BACKGROUND: CoronaVac, an inactivated whole-virion SARS-CoV-2 vaccine, has been shown to be well tolerated with a good safety profile in individuals aged 18 years and older in phase 1/2 trials, and provided a good humoral response against SARS-CoV-2. We present the interim efficacy and safety results of a phase 3 clinical trial of CoronaVac in Turkey. METHODS: This was a double-blind, randomised, placebo-controlled phase 3 trial. Volunteers aged 18-59 years with no history of COVID-19 and with negative PCR and antibody test results for SARS-CoV-2 were enrolled at 24 centres in Turkey. Exclusion criteria included (but were not limited to) immunosuppressive therapy (including steroids) within the past 6 months, bleeding disorders, asplenia, and receipt of any blood products or immunoglobulins within the past 3 months. The K1 cohort consisted of health-care workers (randomised in a 1:1 ratio), and individuals other than health-care workers were also recruited into the K2 cohort (randomised in a 2:1 ratio) using an interactive web response system. The study vaccine was 3 µg inactivated SARS-CoV-2 virion adsorbed to aluminium hydroxide in a 0·5 mL aqueous suspension. Participants received either vaccine or placebo (consisting of all vaccine components except inactivated virus) intramuscularly on days 0 and 14. The primary efficacy outcome was the prevention of PCR-confirmed symptomatic COVID-19 at least 14 days after the second dose in the per protocol population. Safety analyses were done in the intention-to-treat population. This study is registered with ClinicalTrials.gov (NCT04582344) and is active but no longer recruiting. FINDINGS: Among 11 303 volunteers screened between Sept 14, 2020, and Jan 5, 2021, 10 218 were randomly allocated. After exclusion of four participants from the vaccine group because of protocol deviations, the intention-to-treat group consisted of 10 214 participants (6646 [65·1%] in the vaccine group and 3568 [34·9%] in the placebo group) and the per protocol group consisted of 10 029 participants (6559 [65·4%] and 3470 [34·6%]) who received two doses of vaccine or placebo. During a median follow-up period of 43 days (IQR 36-48), nine cases of PCR-confirmed symptomatic COVID-19 were reported in the vaccine group (31·7 cases [14·6-59·3] per 1000 person-years) and 32 cases were reported in the placebo group (192·3 cases [135·7-261·1] per 1000 person-years) 14 days or more after the second dose, yielding a vaccine efficacy of 83·5% (95% CI 65·4-92·1; p<0·0001). The frequencies of any adverse events were 1259 (18·9%) in the vaccine group and 603 (16·9%) in the placebo group (p=0·0108) with no fatalities or grade 4 adverse events. The most common systemic adverse event was fatigue (546 [8·2%] participants in the vaccine group and 248 [7·0%] the placebo group, p=0·0228). Injection-site pain was the most frequent local adverse event (157 [2·4%] in the vaccine group and 40 [1·1%] in the placebo group, p<0·0001). INTERPRETATION: CoronaVac has high efficacy against PCR-confirmed symptomatic COVID-19 with a good safety and tolerability profile. FUNDING: Turkish Health Institutes Association.

An evaluation of patients with a previous endemic coronavirus infection during the COVID-19 pandemic.

Few studies exist on the clinical manifestation of coronavirus disease 2019 (COVID-19) in patients who previously had a common cold due to an endemic coronavirus (eCoV). In a retrospective scan of the data obtained in our microbiology laboratory, 64 patients who were diagnosed with an eCoV infection between 2016 and 2020 were identified. National COVID-19 surveillance data showed that four (6.2%) of 64 patients were infected with severe acute respiratory syndrome coronavirus 2 by the end of 2020, while, simultaneously, the COVID-19 prevalence in the city of Malatya ranged from 7.8% (polymerase chain reaction-based diagnosis) to 9.2% (total diagnosis). The differences were found statistically significant (6.2% vs. 7.8%, p < .01; 6.2% vs. 9.2%, p < .001). Patient interviews and evaluation of medical records revealed that these four patients did not manifest any severe COVID-19 symptoms despite their substantial comorbidities, and they did not require hospitalization. Consequently, despite a low number of samples, we determined a lower frequency of COVID-19 among the patients who had a prior eCoV infection, and the results of this study support the previous findings that people with a prior eCoV infection develop a milder case of COVID-19. Our results may provide some insights for future studies aiming at vaccine development, but detailed investigations are still required.

Short-term experiences of a liver transplant centre before and after the COVID-19 pandemic.

BACKGROUND/AIM: With the COVID-19 pandemic, managing the process of solid organ transplantation has become a significant matter for transplant centres. In this study, we report our experiences on evaluating the effects of COVID-19 in patients with recent liver transplants. MATERIALS AND METHODS: We evaluated patients who received liver transplants during three close consecutive periods of time. For transplants conducted between October 1 and December 31, 2019, January 1 and March 10, 2020 and March 11 and June 22, 2020, the lung tomographies of patients were inspected for radiological signs of viral pneumonia. For patients after March 11, 2020, the hospital's electronic database system was scanned for preoperative and postoperative SARS-CoV-2 testing from Real-time Polymerase Chain Reaction (RT-PCR) of the respiratory tract samples. RESULTS: A total of 149 patients over the age of 18 who received liver transplants at our centre between October 1, 2019 and June 22, 2020 were evaluated. During this time span, our centre conducted liver transplants on patients from 34 different provinces and also abroad. Within this time period, a total of nine patients had respiratory samples with a positive SARS-CoV-2 RT-PCR test. PCR of respiratory tract samples was performed in 21 (14%) patients to identify the other potential infective agents in the respiratory tracts; Rhinovirus and Influenza A were detected in two and respiratory syncytial virus (RSV) was detected in one patient. During the transplant periods, 99 (67.1%) patients were evaluated with computed tomography (CT). The CT findings of 18 (12%) patients were consistent with viral pneumonia. There was a statistically significant difference between the groups only in terms of air bronchogram findings (P = .012). CONCLUSION: The clinical status of our short-term liver transplant patients was far better than we originally anticipated, but it remains obvious that the necessary precautions should continue to be taken.

Evaluation of clinical characteristics and outcomes of postoperative infections in living liver donors.

AIM: To analyze developing infections after living donor hepatectomy (LDH) in living liver donors (LLDs). METHODS: Demographic and clinical characteristics of 1106 LLDs were retrospectively analyzed in terms of whether postoperative infection development. Therefore, LLDs were divided into two groups: with (n = 190) and without (n = 916) antimicrobial agent use. RESULTS: The median age was 29.5 (min-max: 18-55). A total of 257 (23.2%) infection attacks (min-max: 1-8) was developed in 190 (17.2%) LLDs. The patients with the infection that were longer intensive care unit (ICU) and hospital stays, higher hospital admissions, emergency transplantation, invasive procedures for ERCP, PTC biloma, and abscess drainage, and the presence of relaparatomies and transcystic catheters. Infection attacks are derived from a 58.3% hepatobiliary system, 13.2% urinary system, 6.6% surgical site, and 5.8% respiratory system. The most common onset symptoms were fever, abdominal pain, nausea, and vomiting. A total of 125 positive results was detected from 77 patients with culture positivity. The most detected microorganisms from the cultures taken are Extended-Spectrum ß-lactamases (ESBL) producing Klebsiella pneumonia (16.8%) and Escherichia coli (16%), Methicillin-Resistant Staphylococcus aureus [(MRSA) (9.6%)], Methicillin-susceptible S aureus [(MSSA) (9.6%)], and Pseudomonas aeruginosa (8.8%), respectively. The average number of ICU hospitalization days was 3 ± 2 (min 1-max 30, IQR:1) and hospitalization days was 14 ± 12 (min 3-max 138, IQR: 8). All infection attacks were successfully treated. No patients died because of infection or another surgical complication. CONCLUSION: Infections commonly observed infected biloma, cholangitis, and abscess arising from the biliary system and other nosocomial infections are the feared complications in LLDs. These infections should be managed multidisciplinary without delay and carefully.

Occult hepatitis B infection in Turkish HIV-infected patients: A multicentre, retrospective, cross-sectional study, Schindler study.

OBJECTIVE: Occult hepatitis B infection (OHBI) appears to have a higher prevalence in populations at high risk for hepatitis B virus (HBV) infection with concomitant liver disease. The aim was to assess the prevalence of OHBI in a sample of human immunodeficiency virus -1 positive and HBV surface antigen-negative (HIV-1+/HBsAg-) Turkish patients. METHODS: Ten centres in Turkey were included in the study. Patients were selected on the basis of a power calculation with a known population size of HIV-positive patients and a reported prevalence of OHBI. Gender, age, occupation, place of residence, treatment and clinical status, and laboratory results, including immunodeficiency panel, antibody tests, hemogram, biochemistry, and coagulation studies were evaluated retrospectively. RESULTS: The number of HIV-infected patients followed in these centres was 3172 and the sample population numbered 278. All 278 were HBsAg negative. The mean age of the sample was 37.2 ± 13.1 years and 235 (84.5%) were male. All but one patient (99.6%) had been treated with antiretroviral therapy. Of the 278 patients, 169 (60.6%) were positive for Anti-HBs and 125 (44.8%) were positive for Anti-HBc IgG. HIV RNA was detected in 203/278 (73%) of the patients. Four HBV DNA (1.4%) were diagnosed with OHBI. There was no significant difference in hemogram, hemoglobin or bilirubin concentrations in those with OHBI compared with the other patients. CONCLUSION: In a representative sample of HIV+ patients from 10 Turkish centres, the prevalence of OHBI was found to be 1.4%. In HIV positive patients, it is important to identify those with OHBI for optimal clinical management and prognosis.

Evaluation of extensively drug-resistant gram-negative bacteremia among solid-organ transplant recipients: a multicenter study

Background/aim: The aim of this study is to evaluate the distribution, sources, clinical features, and mortality rates of bacteremia due to evaluation of extensively drug-resistant (XDR) gram negative among solid-organ transplant (SOT) recipients. Materials and methods: A retrospective study of SOT recipients with bacteremia due to XDR gram-negative pathogens in 11 centers between 2016 and 2018 was conducted. Patients' records were evaluated. Results: Of 171 bacteremia that occurred in 164 SOT recipients, 93 (56.7%) were liver, 46 (28%) kidney, 14 (8.5%) heart, and 11 (6.7%) lung recipients. Bacteremia episodes were recorded in the first year in 63.7% of the patients (n = 109), early-onset bacteremia was recorded in 45% (n = 77) of the episodes. In multivariate analysis, catheter-associated bacteremia was an independent risk factor for 7-day mortality (p = 0.037), and early-onset bacteremia was found as an independent risk factor for 30-day mortality (p = 0.017). Conclusion: Difficult-to-treat infections due to XDR bacteria in SOT recipients shadow the success of transplantation. Central venous catheters seem to be the main risk factor. Judicious use of medical devices is of pivotal importance.

Artificial vascular graft migration into hollow viscus organs in patients who underwent right lobe living donor liver transplantation.

BACKGROUND: To share our experience with hollow viscus migration of artificial vascular grafts (AVG) used for venous reconstruction of the right anterior sector in living donor liver transplantations (LDLT). METHODS: Clinical, radiological, and endoscopic data of 13 right lobe LDLT patients (range: 26-67 years) with a diagnosis of postoperative AVG migration into adjacent hollow viscus were analyzed. RESULTS: Biliary complications were detected in 12 patients. A median of four times endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed in 11 patients prior to AVG migration diagnosis. A median of 2.5 times various percutaneous radiological interventional procedures were performed in eight patients prior to AVG migration diagnosis. The site of migration was the duodenum in eight patients, gastric antrum in four, and Roux limb in the remaining one patient. The migrated AVS were made of polytetrafluoroethylene (PTFE) in 10 patients and polyethylene terephthalate (Dacron) in three. The migrated AVGs were endoscopically removed in seven patients and surgically removed in six. Only one patient died due to sepsis unrelated to AVG migration. CONCLUSION: AVG migration into the adjacent hollow viscus following right lobe LDLT is a rare and serious complication. Repetitive ERCP, interventional radiological procedures, infection related to biliary leakage, and thrombosis of AVGs are among the possible risk factors.

Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: A single-center prospective cohort study.

INTRODUCTION: Surgical site infection (SSI) is an important cause of decreased graft survival, prolonged hospital stay, and higher costs following living donor liver transplantation. There are several risk factors for SSI. In this cohort study, we aimed to investigate the incidence of SSI at our center and the associated risk factors. MATERIALS AND METHODS: Adult right lobe living donor liver transplantations were included in this prospective cohort. Patients who died postoperatively within 3 days; patients with infected ascites or open abdomen, cadaveric, or pediatric transplants; and patients with biologic or cryopreserved vascular grafts were excluded. Patients' demographic characteristics and perioperative surgical findings were recorded. SSI follow-up was continued for 90 days. CDC-2017 criteria were used to diagnose SSI. In the presence of superficial, deep, and organ/space SSI, only the organ in the poorest condition was included in SSI evaluation. The patients were administered similar to antibiotic prophylaxes and immunosuppressive protocols. RESULTS: A total of 101 patients were enrolled in this study, of which 30 (29.7%) were diagnosed with SSI. Organ/space, only deep, and only superficial SSI were noted in 90% (27/30), 6.7% (2/30), and 3.3% (1/30) of the patients, respectively. Twenty-five of 30 patients with SSI had a remote site infection. One or more bacteria observed in cultures were obtained from 28 patients. A donor-recipient age difference of >10 years, cold ischemia lasting for ≥150 minutes, surgical duration of ≥600 minutes, intraoperative hemorrhage of ≥1000 mL, intraoperative blood transfusion, biliary leak or stricture, prolonged mechanical ventilation, prolonged intensive care unit and hospital stay, remote site infection, and the need for reoperation were associated with increased SSI incidence. Preoperative and intraoperative levels of blood glucose, albumin, and hemoglobin were not associated with SSI. A donor-recipient age difference of >10 years, remote site infection, and biliary leak were found to be independent risk factors for SSI. Hospital mortality with and without SSIs was 6.7% vs 4.4%, P = .61. DISCUSSION: Organ/space SSIs were the essential part of SSIs following right lobe living donor liver transplantations. Donor-recipient age gap, prolonged cold ischemia time, complicated surgery, and postoperative biliary complications were the main causes of SSIs. Although they did not increase the perioperative mortality, they promote increased rate of reoperations, remote infections, prolonged intensive care unit, and hospital stays.

[Co-production of OXA-48 and NDM-1 Carbapenemases in Providencia rettgeri: the first report]. / Providencia rettgeri'de OXA-48 ve NDM-1 karbapenemaz genlerinin birlikte üretimi: ilk bildirim.

Our country is the epicenter of the OXA-48-like carbapenemase-producing Klebsiella and Escherichia coli; and in the recent years, the concern has been increasing due to both spreading of this resistance to other members of Enterobacteriaceae family and acquiring other carbapenemases by the OXA-48-producing strains. In this study, OXA-48 and NDM-1 co-production was presented in Providencia rettgeri. Two P.rettgeri strains that were resistant to all antimicrobials except colistin and tigecyclin, were isolated from two patients in the burn unit of our hospital, including one from the urine sample of a 68 years female in April 2017, and the other from a burn wound swab of a 35 years old male, in November 2017. Minimal inhibitory concentrations (MICs) of the isolates for imipenem and meropenem were measured as ≥ 32 µg/ml; and for colistin and tigecyclin were 1 ve 0.5 µg/ml, respectively. Multiplex PCR analysis showed that both strains were carrying blaOXA-48 and blaNDM-1 carbapenemases, and blaTEM extended spectrum beta-lactamase genes. By using DNA sequence analysis, the TEM gene was typed as blaTEM-1. The Pulsed Field Gel Electrophoresis (PFGE) analysis indicated that these two strains which were consecutively isolated from two different patients in a single unit within about seven months were genetically indistinguishable. No significant data that could explain the spread of these isolates was obtained from our retrospective analysis of the medical records including the results of environmental surveillance cultures, and patients' history. Nevertheless, hospital infection control committee enforced the infection control measures in that unit, and no further isolation was observed within three months period following the last isolation, neither from environmental nor from clinical samples. With this study, it was emphasized that the co-production of OXA-48 and NDM-1 carbapenemases which was reported from only three Enterobacteriaceae species up to date was ongoing for spreading to other species by using horizontal route, and also showing a potential to be a growing problem in the hospitals, by clonal expansion (vertical route). Effectively using of the molecular epidemiological methods will provide useful data to better understand the transmission dynamics of such rare, but problematic species in hospitals.

[Carriage of Streptococcus pyogenes in primary school children: M-protein types, pyrogenic toxin genes, and investigation of the clonal relationships between the isolates]. / Ilkokul çocuklarinda Streptococcus pyogenes tasiyiciligi: M-protein tipleri, pirojenik toksin genleri ve izolatlar arasi klonal iliskinin arastirilmasi.

M-protein and pyrogenic toxins are the most important virulence factors of Streptococcus pyogenes, and they play significant role in the pathophysiology of acute rheumatoid fever and scarlet fever, respectively. In this study, the pharyngeal carriage of S.pyogenes of the primary school children, clonal relationship of the strains, M-protein types, and the presence of pyrogenic toxin genes were aimed to be investigated. A total of 668 throat cultures obtained from children (age range: 6-16 years) in two primary schools in our region, were included in the study. The clonal relationships of the isolated group A streptococci (GAS) strains were investigated by DiversiLab assay (BioMérieux, France), and the clonal relatedness was confirmed by pulsed-field gel electrophoresis (PFGE) method. M-protein (emm) typing was performed by DNA sequencing as suggested by Centers for Disease Control and Prevention (CDC). The genes encoding pyrogenic toxins, speA and speC, were investigated by an in-house multiplex polymerase chain reaction (PCR) method. S.pyogenes was isolated from 134 (20.05%) of the throat samples. The GAS carriage rate of the students aged ≥10 was statistically higher than those 7-9 years age group (%22 vs %16.4, p<0.05). The M protein gene could be characterized only among 123 isolates by DNA sequencing, and 20 different emm types were detected. The most frequent emm type was emm1 (n=38, 30.9%) followed by emm12 (n=18, 14.6%), emm89 (n=10, 8.1%), emm118 (n=9, 7.3%), and emm4 (n=7, 5.7%). Pyrogenic toxin genes were found in 25 (18.6%) of the isolates, including speA in 11 isolates (8.2%) and speC in 12 isolates (8.9%) and both genes were detected in 2 isolates (1.5%). Sixty-two different Rep (Repetitive extragenic palindromic)-PCR profiles were detected in 134 S.pyogenes isolates by DiversiLab method. Thirteen different clusters were formed by a total of clonally related 36 isolates revealing a strain clustering ratio of 26.9%. Clonal relationship of all isolates in the same cluster was confirmed by PFGE method. In this study, relatively high percentage of GAS carriage was observed among primary school children in our region. The coverage rate of the 30-valent vaccine was determined to be over 90% with respect to M-protein types. Since the pyrogenic toxin-encoding genes were found in one fifth of the isolates from the studied subjects, we concluded that the carrier population may also have high risk for scarlet fever. We also concluded that, the clonal relationship ratio determined among the isolates may be a risk in school transmission of GAS.

Evaluation of chronic hepatitis B patients who voluntarily discontinued oral antiviral therapy: is there an answer to the controversial topic?

OBJECTIVE: The uncertain treatment duration for nucleos(t)ide analogues (NA) used in the treatment of chronic hepatitis B (CHB) is an important problem for both patients and physicians. The aim of this study was to evaluate the determinants of virologic relapse (VR) and the optimum time of treatment discontinuation in the follow-up of CHB patients who voluntarily discontinued treatment after virological suppression was achieved under NA use. METHODS: Data from 138 patients from 11 centers were included in this registry-based study. Factors associated with VR were investigated using multivariate Cox regression analysis. RESULTS: Ninety-nine (71.7%) of the patients were HBeAg (Hepatitis B e antigen) negative. During the 24-month follow-up period after treatment discontinuation, VR occurred in 58.7% (n = 81) of all patients and 57.6% (n = 57) of HBeAg-negative patients. The duration of NA treatment was significantly shorter (cutoff 60 months) in HBeAg-negative patients who later developed VR. In addition, the duration of virologic remission achieved under NA treatment was significantly shorter (cutoff 52 months) in those who later developed VR. In the Cox multivariate regression model of HBeAg-negative patients, having less than 60 months of NA treatment (HR = 2.568; CI:1.280-5.148; P  = 0.008) and the levels of alanine aminotransferase being equal to or higher than twice the upper level of normal at the beginning of treatment (HR = 3.753; CI:1.551-9.081; P  = 0.003) were found to be statistically significant and independently associated with VR. CONCLUSION: The findings of this study may provide clinical guidance in terms of determining the most appropriate discontinuation time for NA.

Latent Tuberculosis Infection Management in Solid Organ Transplantation Recipients: A National Snapshot.

OBJECTIVE:  Latent tuberculosis infection (LTBI) screening is strongly recommended in the pre-transplant evaluation of solid organ transplant (SOT) recipients, although it remains inadequate in many transplant centers. We decided to investigate pre-transplant TB risk assessment, LTBI treatment, and registry rates in Turkey. MATERIAL AND METHODS:  Adult SOT recipients who underwent tuberculin skin test (TST) and/or interferon-gamma release test (IGRA) from 14 centers between 2015 and 2019 were included in the study. An induration of ≥5 mm on TST and/or probable/positive IGRA (QuantiFERON-TB) was considered positive for LTBI. Demographic features, LTBI screening and treatment, and pre-/post-transplant TB history were recorded from the electronic database of transplantation units across the country and pooled at a single center for a unified database. RESULTS:  TST and/or IGRA were performed in 766 (33.8%) of 2266 screened patients most of whom were kidney transplant recipients (n = 485, 63.4%). LTBI screening test was positive in 359 (46.9%) patients, and isoniazid was given to 203 (56.5%) patients. Of the patients treated for LTBI, 112 (55.2%) were registered in the national registry, and 82 (73.2%) completed the treatment. Tuberculosis developed in 6 (1.06%) of 563 patients who were not offered LTBI treatment. CONCLUSION:  We determined that overall, only one-third of SOT recipients in our country were evaluated in terms of TB risk, only 1 of the 2 SOT recipients with LTBI received treatment, and half were registered. Therefore, we want to emphasize the critical importance of pretransplant TB risk stratification and registration, guided by revised national guidelines.

ABO-incompatible liver transplantation in acute and acute-on-chronic liver failure.

BACKGROUND/AIMS: ABO-incompatible (ABO-I) liver transplantation (LTx) may be mandatory in urgent conditions such as acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) when deceased donor (DD) is unavailable or living donor (LD) selection is limited. This study specifically addresses the problem of urgent ABO-I LTx in critically ill adult patients having ALF or severely decompensated end-stage liver disease. METHODOLOGY: This series included 16 patients, 10 underwent ABO-I LD LTx and 6 underwent 7 ABO-I DD LTx. Multiple sessions of plasmapheresis reduced isoaglutinin titres to 1/16 or below, before and after LTx. RESULTS: Mean follow-up period was 10.37 months (1 to 38). Median for MELD scores was 22.5 (17 to 30). Median survival was 9 months and mean survival was 19.5 months. Hospital mortality was 3 (18.7%). Two patients died due to small for size graft syndrome and cerebrovascular bleeding respectively. Hepatic artery thrombosis developed in 3 patients. Two of them died at postoperative 4th and 9th months. Third patient is still alive with hepatic necrosis problem. CONCLUSIONS: ABO-I LTx remains an important and unavoidable therapeutic option in adult patients with ALF or ACLF and urgent need for an allograft without the possibility to allocate a blood group compatible liver graft.

Single-center analysis of the first 304 living-donor liver transplantations in 3 years.

BACKGROUND/AIMS: Living donor liver transplantations (LDLT) is a definitive treatment for patients with end-stage liver disease (ESLD), especially in the countries with donation problem. Between April 2007 and April 2010, we performed LDLT in 289 patients. Fifteen of the cases required re-transplantations. This study evaluates these 304 consecutive LDLTs donor and recipient outcomes. METHODOLOGY: Complication rates and survival data of the recipients and donors of 304 LDLT cases were analyzed. RESULTS: All donors are alive and well. Overall complication rate was 27%. Early postoperative recipient complication rate was 51%. Most frequent complication was infection. In the long-term there were 57 biliary stricture and 5 chronic bile fistula cases. Chronic and acute rejection attacks developed in 7 and 103 patients, respectively. Hepatic artery thrombosis rate was 8%. One, two and three year survival rates were 82%, 79% and 75%, respectively. Recipient mortality was 25%, mostly due to vascular complications, septic complications, liver dysfunction and chronic rejection. CONCLUSIONS: More than 150 liver tranplantations per year in a single center is a challenge in Turkey, where there is a shortage of deceased donor grafts. LDLT is a safe procedure for donors and effective for ESLD. Improvement in surgical technique would provide better outcomes.

Effect of Pre-Transplant Covid-19 Exposure on Post-Liver Transplant Clinical Outcomes.

BACKGROUND: COVID-19 has led to an unprecedented global health crisis. This situation caused an immediate reduction in solid organ transplantation activity. This study aimed to present the follow-up results of patients with chronic liver disease who underwent liver transplantation (LT) after a history of COVID-19 infection. METHODS: Sociodemographic characteristics and clinicopathological data of 474 patients who underwent LT at Inonu University Liver Transplant Institute between March 11, 2020 and March 17, 2022 were prospectively recorded and analyzed retrospectively. Among these, the data of 35 patients with chronic liver disease who were found to be exposed to COVID-19 infection in the pre-LT period were analyzed for this study. RESULTS: The median body mass index, Child score, and Model for end-stage liver disease/ Pediatric end-stage liver disease scores of the 35 patients were calculated as 25.1 kg/m2 (IQR: 7.4), 9 points (IQR: 4), and 16 points (IQR: 10), respectively. Graft rejection occurred in 4 patients at a median of 25 days post-transplant. Five patients underwent retransplantation at a median of 25 days post-transplant. The most common cause of retransplantation is early hepatic artery thrombosis. There were 5 deaths during postoperative follow-up. Mortality developed in 5 (14.3%) patients exposed to COVID-19 infection in the pretransplant period, whereas mortality occurred in 56 (12.8%) patients not exposed to COVID-19 infection. There was no statistically significant difference in mortality between the groups (P = .79). CONCLUSIONS: The results of this study showed that exposure to COVID-19 before LT does not affect post-transplant patients and graft survival.

Effect of COVID-19 Pandemic on Patients Who Have Undergone Liver Transplantation: Retrospective Cohort Study.

BACKGROUND: In liver transplant (LT) recipients, immunosuppressive therapy may potentially increase the risk of severe COVID-19 and may increase the mortality in patients. However, studies have shown conflicting results, with various studies reporting poor outcomes while the others show no difference between the LT recipients and healthy population. The aim of this study is to determine the impact of the COVID-19 pandemic on survival of LT recipients. METHODS: This is a retrospective cohort study analyzing the data from 387 LT recipients diagnosed with COVID-19. LT recipients were divided into two groups: survival (n = 359) and non-survival (n = 28) groups. A logistic regression model was used to determine the independent risk factors for mortality. Machine learning models were used to analyze the contribution of independent variables to the mortality in LT recipients. RESULTS: The COVID-19-related mortality rate in LT recipients was 7.2%. Multivariate analysis showed that everolimus use (p = 0.012; OR = 6.2), need for intubation (p = 0.001; OR = 38.4) and discontinuation of immunosuppressive therapy (p = 0.047; OR = 7.3) were independent risk factors for mortality. Furthermore, COVID-19 vaccination reduced the risk of mortality by 100 fold and was the single independent factor determining the survival of the LT recipients. CONCLUSION: The effect of COVID-19 infection on LT recipients is slightly different from the effect of the disease on the general population. The COVID-19-related mortality is lower than the general population and vaccination for COVID-19 significantly reduces the risk of mortality.

First year real life experience with tenofovir alafenamide fumarate: The pythagorean cohort.

Background and Aim: In chronic hepatitis B infection, antiviral therapy significantly reduces the incidence of complications. This study aimed to present real-life 12-month effectiveness and safety data for TAF. Materials and Methods: This Pythagoras Retrospective Cohort Study included patients from 14 centers in Turkiye. The study presents 12-month results of 480 patients treated with TAF as initial therapy or after switching from another antiviral drug. Results: The study shows treatment of about 78.1% patients with at least one antiviral agent (90.6% tenofovir disoproxil [TDF]). The rate of undetectable HBV DNA increased in both treatment-experienced and naive patients. In TDF-experienced patients, the rate of alanine transaminase (ALT) normalization increased slightly (1.6%) within 12 months, but the change was not statistically significant (p=0.766). Younger age, low albumin, and high body mass index and cholesterol were identified as risk factors for abnormal ALT after 12 months, but no linear relationship was detected. In TDF-experienced patients, renal and bone function indicators showed significant improvement three months after the transition to TAF and remained stable for 12 months. Conclusion: Real-life data demonstrated effective virological and biochemical responses with TAF therapy. After switching to TAF treatment, gains in kidney and bone functions were achieved in the early period.

The Impact of Vaccination Among Hospitalized Patients with the Diagnosis of COVID-19.

Objective: We aimed to investigate the vaccination status and the risk factors for the intensive care unit (ICU) support need of the laboratory-confirmed breakthrough COVID-19 infection inpatients. Materials and Methods: This multi-center point-prevalence study was conducted on inpatients, divided into two groups as 'fully' and 'partially' vaccinated according to COVID-19 vaccination status. Results: Totally 516 patients were included in the study. The median age was 65 (55-77), and 53.5% (n=276) of the patients were male. Hypertension (41.9%, n=216), diabetes mellitus (DM) (31.8%, n=164), and coronary artery disease (CAD) (16.3%, n=84) were the predominant comorbidities. Patients were divided into two groups ICU (n=196) and non-ICU (n=301). Hypertension (p=0.026), DM (p=0.048), and congestive heart failure (CHF) (p=0.005) were significantly higher in ICU patients and the median age was younger among non-ICU patients (p=0.033). Of patients, 16.9% (n=87) were fully vaccinated, and this group's need for ICU support was statistically significantly lower (p=0.021). Conclusion: We conclude that older age, hypertension, DM, CHF, and being partially vaccinated were associated with the need for ICU support. Therefore, all countries should continuously monitor post-vaccination breakthrough COVID-19 infections to determine the national booster vaccine administration approach that will provide vulnerable individuals the highest protection.

Efficacy and tolerability of antibiotic combinations in neurobrucellosis: results of the Istanbul study.

No data on whether brucellar meningitis or meningoencephalitis can be treated with oral antibiotics or whether an intravenous extended-spectrum cephalosporin, namely, ceftriaxone, which does not accumulate in phagocytes, should be added to the regimen exist in the literature. The aim of a study conducted in Istanbul, Turkey, was to compare the efficacy and tolerability of ceftriaxone-based antibiotic treatment regimens with those of an oral treatment protocol in patients with these conditions. This retrospective study enrolled 215 adult patients in 28 health care institutions from four different countries. The first protocol (P1) comprised ceftriaxone, rifampin, and doxycycline. The second protocol (P2) consisted of trimethoprim-sulfamethoxazole, rifampin, and doxycycline. In the third protocol (P3), the patients started with P1 and transferred to P2 when ceftriaxone was stopped. The treatment period was shorter with the regimens which included ceftriaxone (4.40 ± 2.47 months in P1, 6.52 ± 4.15 months in P2, and 5.18 ± 2.27 months in P3) (P = 0.002). In seven patients, therapy was modified due to antibiotic side effects. When these cases were excluded, therapeutic failure did not differ significantly between ceftriaxone-based regimens (n = 5/166, 3.0%) and the oral therapy (n = 4/42, 9.5%) (P = 0.084). The efficacy of the ceftriaxone-based regimens was found to be better (n = 6/166 [3.6%] versus n = 6/42 [14.3%]; P = 0.017) when a composite negative outcome (CNO; relapse plus therapeutic failure) was considered. Accordingly, CNO was greatest in P2 (14.3%, n = 6/42) compared to P1 (2.6%, n = 3/117) and P3 (6.1%, n = 3/49) (P = 0.020). Seemingly, ceftriaxone-based regimens are more successful and require shorter therapy than the oral treatment protocol.