Epidemiology of COVID-19: What changed in one year?

A coronavirus brought the first pandemic attack of this century as a flu virus did a hundred years ago. This greatest pandemic of the century brings us new opportunities to understand and explore the dynamics of a contagious disease. Nearly two years later, we are still collecting the evidence to understand the disease. Some basic epidemiological properties are still urgently needed. Not only the origin of the virus but also Ro value, possible transmission routes, epidemiologic curves, case fatality rates, seasonality, severity and mortality risk factor, effects on the risk groups, differences between countries and so on still require strong evidence prior to making final suggestions. In this review, we tried to evaluate the epidemiological evidence to scrutinize where exactly we are in this pandemic.

Epidemiology of COVID-19

It seems that coronaviruses take an important place in the 21th century history. Five of seven human coronavirus was isolated in this century. Unfortunately, last three of them entered our life with a fear of outbreak, pandemic or death. Last human coronavirus which emerged world from Wuhan China, SARS CoV-2 and its clinical expression, Coronavirus disease (COVID-19) recently taken a significant place in our daily practice. Initial reports showed that, its origin was bats. It transmitted human to human by droplet and contact routes, but some doubt about airborne, fecal or intrauterine transmission also should be removed. Its R0 value is 2.3 but it could be as high as 5.7. Its case fatality rate was 6.3, but it was different in different ages and counties, and it could be over 15%. According to early models total 10­12 weeks is required to control an outbreak in the community. While different countries show different daily case numbers, total number of case, case mortality rates or R0, it seems they show a similar epidemic curve. Every day we learn new data about the current outbreak. Since the outbreak is not over yet, every detail should be evaluated carefully and the updates should be followed closely to monitor the epidemiological properties of COVID-19.

Investigation of 1377C/T polymorphism of the Toll-like receptor 3 among patients with chronic hepatitis B.

The immunopathogenesis of chronic hepatitis B (CHB) has not been clarified yet. Toll-like receptors (TLR) are a receptor family that initiates immunity with exogenous-endogenous ligands and plays a role in the pathogenesis of infections. In this study, we aimed to investigate the frequency of TLR 3 1377C/T (rs3775290) polymorphism and its role in patients with CHB. We included 50 healthy individuals as control group and 73 active and 43 inactive hepatitis B patients. All DNA samples were isolated from blood samples. For the detection of TLR 3 1377C/T single-nucleotide polymorphism, restriction fragment length polymorphism was used. A statistically significant difference was determined in Hepatitis B virus (HBV) DNA levels of CHB patients with the CC, CT, and TT genotypes (p = 0.013). The highest levels of HBV DNA were detected in individuals with TT genotypes. Additionally, the frequency of CC genotype was higher in the active CHB patients compared with that of the inactive CHB patients (p = 0.044). No statistically significant difference in TLR 3 1377C/T polymorphism was detected between healthy controls and the hepatitis B patients (p = 0.342). In conclusion, HBV DNA level was higher in the individuals with TT genotype, and CC genotype was more frequent in the active CHB patients. These results suggest a possible association between CHB and TLR 3 gene (1377C/T) polymorphism.

Evaluation of hepatitis B virus transmission and antiviral therapy among hepatitis B surface antigen-positive pregnant women.

AIM: The aim of the present study was to assess the potential risk of hepatitis B virus (HBV) vertical transmission among Turkish parturient women and to evaluate the efficacy and safety of antiviral agents. MATERIAL AND METHODS: Data were collected retrospectively from 114 HBV-infected pregnant women and their infants in eight health institutions in Turkey. RESULTS: The baseline characteristics of the women were: mean age, 28.3 ± 5.2 years; alanine aminotransferase, 57.4 ± 139.0 U/L; aspartate aminotransferase, 56.6 ± 150.0 U/L; and HBV DNA, 8.3 × 10(7) ± 2.6 × 10(8) copies/mL. Family history of HBV infection was detected in 53.5% (n = 61). In total, 60 (52.6%) pregnant women received tenofovir (60.0%), lamivudine (33.3%) or telbivudine (6.7%) therapy at the median gestational age of 22.2 ± 8.5 (1-36) weeks. All infants were vaccinated and hepatitis B immune globulin was administered, with 81 of them (71.1%) available for follow-up. After completion of HBV vaccination course, 71 (87.7%) infants had protective anti-HBs levels, three (3.7%) were hepatitis B surface antigen-positive, and seven (8.6%) were hepatitis B surface antigen-negative with nonprotective anti-HBs levels. Five of the infants had low gestational birthweight but no other birth defects were observed. CONCLUSION: According to our results, viral load may not be the only effecting factor for transmission of HBV to children of infected mothers. Pregnant women with high viral load should be followed-up closely during pregnancy. They should begin to take tenofovir or telbivudine, which are category B drugs for pregnancy, at the beginning of the third trimester at the latest. We need new treatment strategies; and close follow-up of mothers and children is another important issue.

Sonographic findings in patients with Crimean-Congo hemorrhagic fever.

OBJECTIVES: Crimean-Congo hemorrhagic fever (CCHF) has been endemic in Turkey since 2002. Some radiologic findings are considered common by clinicians and radiologists. In this regard, we aimed to assess the sonographic findings in patents with CCHF in a pilot study to obtain basic knowledge for planning further controlled studies. METHODS: An observational descriptive study was planned. Patients with a CCHF diagnosis monitored by the infectious diseases department of a tertiary care hospital were included. Sonographic examinations were conducted by 2 radiologists for each patient, and the findings were recorded. RESULTS: Twenty-five patients with CCHF were included. Hepatomegaly (40%), splenomegaly (28%), paraceliac lymphadenopathy (48%), gallbladder wall thickening (36%), increased echogenicity in the renal parenchyma (40%), and fluid/effusion in the perihepatic, perisplenic, pleural, and hepatorenal recesses of the subhepatic space (Morison pouch) as well as between the intestinal loops (52%) were the primary findings. A decrease in the gallbladder wall thickening and limited resorption of intraperitoneal and pleural effusion were noted during follow-up. CONCLUSIONS: Hepatosplenomegaly, paraceliac lymphadenopathy, and gallbladder wall thickening as well as intraperitoneal and pleural effusion were the primary findings in CCHF, and they became prominent on the third day of the disease in some patients. The relationship between sonographic findings and disease severity will be investigated in an upcoming study.

[Comparison of GeneXpert® vanA/vanB PCR system and culture methods in the surveillance of vancomycin-resistant enterococci]. / Vankomisine dirençli enterokoklarin sürveyansinda GeneXpert® vanA/vanB PCR sistemi ile kültür yönteminin karsilastirilmasi

Vancomycin-resistant enterococci (VRE) are important agents of hospital infections worldwide. Early recognition of VRE colonization is important in the control of hospital infections. The aim of this study was to compare a real-time PCR (Rt-PCR) system and culture methods in the detection of VRE colonization. A total of 210 perirectal swab samples obtained from the patients (142 were in internal and 68 were in surgical intensive care units) hospitalized at Ankara Training and Research Hospital, Turkey between January-September 2013 were included in the study. The samples were simultaneously evaluated with both Rt-PCR (GeneXpert®vanA/vanB, Cepheid, USA) and the culture methods. The samples were cultivated in enterococcosel agar and incubated at 370C for culture. Culture plates were evaluated for three days on a daily basis. Bacterial identification was done by conventional methods and automated Vitek 2.0 system (BioMérieux, France). Antibiotic susceptibility testing was performed by the E-test. VRE was detected in 76 (36.1%) of the samples by the Rt-PCR method; of them 70 were positive for vanA, two for vanB, and four for vanA + vanB. On the other hand, VRE was detected in 71 (33.8%) of the samples by the culture method. Out of 71 samples, colony growth was observed on the first day in 39 cases, on the second day in 29 cases, and on the third day in three cases. The two strains identified as vancomycin-sensitive enterococci by the Vitek 2 Compact system were determined as vanB positive by PCR. These samples were also confirmed as VRE by E-test. The PCR result of a sample which was found to be invalid, also yielded negative result by culture. Five out of the seven culture-negative samples were positive for vanA, and two for vanB by the GeneXpert® system. In our study, the sensitivity, specificity, positive and negative predictive values of the GeneXpert vanA/vanB PCR system were determined as 97.4%, 98.4%, 97.4%, and 97.4%, respectively. Although the GeneXpert® vanA/vanB RT-PCR method seems to be more attractive regarding the turn around time, it has a higher cost than the culture method. Thus, it was concluded that all laboratories should choose the most appropriate method for screening VRE in the hospital setting according to their own capacities.

[Evaluation of Candida colonization in intensive care unit patients and the use of Candida colonization index]. / Yogun bakim ünitesinde yatan hastalarda Candida kolonizasyonunun degerlendirilmesi ve kolonizasyon indeksinin kullanilmasi

Parallel to the developments in the field of diagnosis and treatment, an increase in the incidence of fungal infections and the number of patients who are in the risk group for the development of opportunistic fungal infections have been observed in the recent years. Among the hospitalized patients, those most at risk in terms of fungal infections are intensive care unit (ICU) patients. The rate of Candida colonization of mucous membranes in hospitalized patients may reach to 80%, and this may predispose to the establishment of severe infections especially in patients under risk. The aim of this study was to evaluate the rate of Candida colonization and to use Candida colonization index in the intensive care unit patients in Ankara Training and Research Hospital, Ankara, Turkey. A total of 100 adult patients (46 female, 54 male; age range: 18-93 years, mean age: 65.28 ± 17.53 years) who were hospitalized for ≥ 7 days in the neurology (n= 56), anesthesia-reanimation (n= 24) and neurosurgery (n= 20) intensive care units between September 2008 to February 2009, were included in the study. Throat, nose, skin (axilla), urine, rectal swab cultures and additionally when necessary tracheal aspirates, drain and central vascular catheter cultures were taken weekly from each patient. Candida colonies were identified by using germ tube test, CHROMagar Candida Medium (Becton Dickinson, Germany) and ID 32 C (BioMeriux, France) yeast identification kit. Candida colonization index (CI) was calculated for each patient, and CI was defined as the ratio of the number of culture-positive distinct body sites to the total number of body sites cultured. Patients with CI > 0.2 were considered as Candida colonized. In our study, Candida colonization was found in 42 of 100 (42%) patients, of them 8 were heavily colonized (CI ≥ 0.50), and 34 were slightly colonized (C I < 0.50). The highest Candida colonization was detected in throat, urine and rectal swab samples, while none of the tracheal aspirate samples yielded Candida spp. growth. Invasive Candida infections subsequently developed in 21.4% (9/42) of the colonized patients, namely candidemia in five and Candida associated urinary tract infections in four cases. Our data indicated that, the number of colonized patients were higher in the surgical (anesthesia-reanimation and neurosurgery) intensive care units (p< 0.05), in patients staying in the ICU for longer periods (p= 0.000) and in patients with higher number of application of invasive instruments (p< 0.05) compared to those of non-colonized cases. Additionally Candida colonization emerged more often in patients with bacterial sepsis and in those exposed to broad spectrum antibiotics (p< 0.05). Use of broad spectrum antibiotics in the ICU, length of stay in the ICU and having central venous catheter were found as independent risk factors for Candida colonization. The sensitivity, specificity, positive and negative predictive values of colonization index for the detection of developing Candida infections in colonized patients were estimated as 100%, 64%, 21% and 100%, respectively. In conclusion, Candida colonization and Candida colonization index may be used as useful parameters to predict invasive Candida infections.

[The effectiveness of hand hygiene products on MRSA colonization of health care workers by using CHROMagar MRSA]. / El Hijyen Ürünlerinin Saglik Çalisanlarinda MRSA Kolonizasyonuna Etkilerinin CHROMagar MRSA ile Arastirilmasi

The aims of this study were; to investigate the hand hygiene compliance of the health care workers (HCWs) during their routine patient care, to determine the methicillin-resistant Staphylococcus aureus (MRSA) hand colonization of the HCWs, to investigate the effect of different hand hygiene products on MRSA colonization and to evaluate the effectiveness of chromogenic agar for detecting MRSA. HCWs were investigated during their routine patient care and hand cultures were taken before and after hand wash/hygiene. Two different techniques were used to obtain the hand cultures: fingertip method (CHROMagar MRSA containing HygiSlide); and direct swab method and then inoculation to CHROMagar MRSA media. MRSA strains grown on those cultures were confirmed with conventional methods. A total of 100 HCWs (of them 61 were female; mean age: 32.7 ± 5.2 years; age range: 25-51 years) involving physicians (n= 33), nurses (n= 38) and health care assistants (n= 29), were included in the study. MRSA was detected in 39% and 11% before hand hygiene and in 13% and 6% after hand hygiene, with HygiSlide CHROMagar media and with CHROMagar in plate media, respectively. No difference were found regarding clinics, occupations, or the type of patient handling in those HCWs who were positive (n= 13) for MRSA colonization following hand hygiene, and those who were negative (n= 26). However, the type of the hand hygiene product used exhibited a statistical difference. None of the seven HCWs who used alcohol based hand rub revealed growth in the second culture while 10 of 19 (53%) HCWs who used soap and three of 13 (23%) HCWs who used chlorhexidine were still colonized with MRSA. In terms of reduction in the MRSA counts, the most effective one was the alcohol based hand rub while the soap was the least, since seven of 19 (37%) HCWs who used soap showed no reduction at all in the MRSA counts. A high ratio of hand colonization with MRSA was detected in our hospital staff (39%). It was shown that the colonization could be reduced significantly (with a rate of 66%) with hand hygiene. Alcohol based hand rub was found to be the most effective method in hand hygiene. The fingertip technique was found to be superior to inoculation to plate media for obtaining hand cultures and CHROMagar MRSA media was found to be rapid, effective and practical for detecting the MRSA hand colonization.

[Assessment of diagnostic methods for the catheter-related bloodstream infections in intensive care units]. / Yogun Bakim Ünitelerinde Gelisen Kateter ile Iliskili Kan Dolasimi Enfeksiyonlarinin Tanisinda Kullanilan Yöntemlerin Degerlendirilmesi.

The majority of catheter-related bloodstream infections (CR-BSI) are associated with central venous catheters (CVCs) and most of them develop in patients staying at intensive care units (ICUs). The aim of this study was to assess the performance of different methods for the diagnosis of CR-BSI in neurology and neurosurgery ICUs of our hospital. This prospective study was carried out between January 2007 and January 2008 and all of the patients were followed daily for CR-BSI after the insertion of CVCs. Blood cultures were taken simultaneously from the catheter lumen and from at least one peripheral vein when there was a suspicion of CR-BSI. Additionally, from patients whose CVCs were removed, catheter tip cultures were taken and from patients with exit site infection, cultures of the skin surrounding the catheter entrance were taken. Catheter tip cultures were done by using quantitative and semiquantitative culture methods. Blood cultures taken from the catheter lumen and peripheral vein were incubated in the BACTEC 9050 (Becton Dickinson, USA) automated blood culture system. Gram and acridine orange (AO) staining were used for the smears prepared from the catheter tips and blood cultures. To evaluate the value of culture and staining methods in the diagnosis of CR-BSI; sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively) of each method were determined. A total of 148 patients (66 male, 82 female; age range: 1-94 years, mean age: 58.7 ± 21.8 years) were included in the study, of whom 67 (45.3%) were from neurology and 81 (54.7%) were from neurosurgery ICUs. One hundred ninety-nine CVC application performed in 148 patients were evaluated. Mean duration of catheterization was 8.5 ± 5.2 days. Thirty-two episodes of CR-BSI among 199 catheterizations (16%) in 29 patients among a total of 148 patients (19.6%) were determined. The most frequently isolated microorganisms were methicillin-resistant coagulase-negative staphylococci (8/32; 25%), penicillin-resistant Enterococcus spp. (8/32; 25%) and Candida albicans (4/32; 12.5%). Sensitivity, specificity, PPV and NPVs of the quantitative and semiquantitative culture methods of the catheter tip and the differential time to positivity (positive result obtained at least two hours earlier in blood cultures drawn through the catheter than the peripheral blood cultures which were taken simultaneously) between blood cultures drawn through the catheter and those drawn from the peripheral vein were 100% for the diagnosis of CR-BSI. Sensitivity and NPV of the isolation method of the same microorganism from blood culture drawn through the catheter and drawn from the peripheral vein were 100%, specificity was 85% and PPV was 88% for the diagnosis of CR-BSI. Sensitivity, specificity, PPV and NPVs of Gram and drawn simultaneously from the peripheral vein and quantitative and semiquantitative cultures of the catheter tip in patients with removed catheter, were important factors in terms of diagnosis of CR-BSI. It was also concluded that AO staining could provide additional benefit in the diagnosis of CR-BSI since it has higher sensitivity, specificity, PPV and NPVs for peripheral blood cultures and catheter tip cultures compared to Gram staining.

[Protozoal antigen positivity in diarrheal patients admitted to emergency service: a point prevalence study]. / Acil Servise Basvuran Ishalli Olgularda Protozoal Antijen Pozitifligi: Bir Nokta Prevalans Çalismasi

Intestinal parasites are the important etiological agents of water and food related diarrhea cases which are frequently seen during summer/early autumn seasons in developing countries. This point prevalence study was aimed to determine the protozoal antigen positivity rate in diarrhea cases admitted to the emergency service in one single day. A total of 198 diarrheal patients (90 male, 108 female; age range: 1-82 years, mean age: 29 years) who were admitted to the emergency service of Ankara Training and Research Hospital were included in the study. Macroscopic and direct microscopic examinations were performed for the stool samples of patients, and the samples which yielded pathological microscopic findings (e.g. presence of leukocytes, erythrocytes, and trophozoits) were investigated in terms of Entamoeba histolytica adhesin antigen, Giardia intestinalis cyst antigen and Cryptosporidium oocyst antigen by commercial ELISA kits (Techlab, USA). Macroscopic examination of the stool samples revealed that 60 (30%) of them had blood and mucous, 137 (69%) were watery and one sample had normal appearance. Pathologic results were obtained for 96 (48.5%) of the samples by microscopic examination: 36 (37.5%) revealed erythrocytes, 90 (93.7%) had leukocytes and 3 (1.5%) had G.intestinalis trophozoites. Since Shigella spp. were cultured in two of these 96 samples, these two cases were omitted from the study and 94 samples were investigated by ELISA assays. G.intestinalis was detected in 13 (13.8%) and E.histolytica in 2 (2.1%) samples while Cryptosporidium antigen was not detected in any of the samples by the ELISA assays. It was concluded that ELISA antigen assays were rapid and cost-effective methods for the determination of the causative agent in cases of diarrhea.

Evaluation of clinical and laboratory predictors of fatality in patients with Crimean-Congo haemorrhagic fever in a tertiary care hospital in Turkey.

The fatality rate of Crimean-Congo haemorrhagic fever (CCHF) disease has been reported as 5.4-80%. In this prospective study our aim was to evaluate the clinical and laboratory predictors of fatality in patients with CCHF. Among probable CCHF patients admitted to our clinic between 2005 and 2008, patients with positive IgM antibodies and/or polymerase chain reaction for CCHF virus were included in the study. To determine the predictors of fatality, we compared epidemiological, clinical and laboratory findings of the fatal cases with survivors. Ninety-three confirmed CCHF patients were included in the study; 56 (60.2%) of them were female. Mean patient age was 48.4+/-17.7 y and mean hospital stay was 7.9+/-3.0 days. Five patients died (5.4%). The rates of haemorrhage, diarrhoea and confusion were higher in fatal cases compared with non-fatal cases (p<0.05). Aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, lactate dehydrogenase (LDH), and C-reactive protein levels were higher in fatal cases; the international normalized ratio (INR) and activated partial thromboplastin time (aPTT) were longer and mean platelet counts were lower (p<0.05). By multivariate analysis, diarrhoea, melena, haematemesis, haematuria, elevated ALT and LDH, and prolongation of aPTT were independent clinical and laboratory predictors associated with fatality. We suggest that for patients who have diarrhoea, melena, haematemesis, haematuria, elevated AST and LDH, and a prolonged aPTT, physicians should be aware of the high fatality risk.

Acupuncture for depression and myalgia in patients with hepatitis: an observational study.

BACKGROUND: Depressive symptoms and myalgia are commonly seen in patients with chronic hepatitis B and chronic hepatitis C. OBJECTIVE: To investigate the efficacy of acupuncture treatment on depressive symptoms and myalgia in patients with hepatitis. METHODS: Of 44 patients with hepatitis screened for depression and myalgia, 28 were enrolled and included in the study. The main outcome measure for depressive symptoms was Beck's Depression Inventory (BDI). For pain/myalgia, patients rated their pain on a scale from 0 to 10. Patients with a score greater than the cut-off point in either score were allocated to acupuncture treatment. The Chinese method of acupuncture was used. Treatment continued for 6 weeks. RESULTS: At baseline, 17/44 patients (39%) had a BDI score ≥17 and 24 (55%) had a pain score ≥5. A total of 28 patients were allocated to acupuncture treatment, forming three groups: group 1, 13 patients with high BDI and high myalgia scores; group 2, 11 patients with low BDI score but high myalgia score; group 3, 4 patients with high BDI score but low myalgia score. Adherence to treatment was good; all patients completed the sessions and there were no drop-outs. Significant improvements in end-treatment BDI and in myalgia scores compared with baseline levels was found. CONCLUSION: Acupuncture seems to be a promising treatment for patients with hepatitis. Further studies are warranted in large populations to establish the therapeutic role of acupuncture.

[An overlooked disease of tick bites: Lyme disease]. / Kene isiriklarinda gözden kaçan bir hastalik: Lyme hastaligi.

The exact prevalence of Lyme disease caused by Borrelia burgdorferi is unknown in Turkey. However, B. burgdorferi seropositivity ranges between 6-44% among high risk groups. B. burgdorferi is transmitted to humans by the bite of infected ticks belonging to the genus Ixodes, which may be seen throughout our country. Since the Crimean-Congo Hemorrhagic Fever (CCHF) is attracting attentions to tick bites more than ever in Turkey, the patients with tick bites are followed up more cautiously and have been referred to central hospitals. In this study 4 patients who were referred to our center with prediagnosis of CCHF but later appeared to be Lyme cases, were presented. All of the cases were women, age ranging between 25-67 years old. The patients were from areas where there is high risk of CCHF. CCHF were ruled out in these patients by agent specific polymerase chain reaction and IgM results. All of the patients were clinically diagnosed as Lyme disease since they had lesions compatible with erythema migrans. B. burgdorferi total antibodies investigated by ELISA (Zeus Scientific Inc., USA) were found positive in all patients. Since Western blot method could not be performed, positive serologic results have not be confirmed. However, the diagnosis of Lyme disease was done according to Centers for Disease Control and Prevention (CDC) criteria and all of the cases have recovered following treatment with antibiotics (cefuroxime axetil or sulbactam ampicillin or amoxicillin clavulanic acid). When the increase in the incidence of arthropod-borne infections in our country is considered, it should be noted that tick-bite cases should also be evaluated in terms of Lyme disease besides CCHF. Differential diagnosis of these infections is of critical value since early appropriate therapy is important to prevent the development of serious complications in both of the disease settings.

[Peritonitis due to Kocuria rosea in a continuous ambulatory peritoneal dialysis case]. / Sürekli ayaktan periton diyalizi yapilan bir olguda Kocuria rosea'ya bagli peritonit.

Micrococcus strains which are the normal flora members of skin, mucosa and oropharynx, may lead to infections associated with intravenous catheter, chronic ambulatory peritoneal dialysis, venticular shunt and prosthetic valve. In this paper, a case of peritonitis due to Kocuria rosea of Micrococcea family, in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD), was presented. Fiftysix years old female patient was admitted to the hospital by complaints of abdominal pain, nausea and fever. The patient was undergoing CAPD due to chronic renal failure for one and a half year and turbidity was detected in the peritoneal fluid during dialysis. Examination of the peritoneal fluid revealed 1800 cells/mm3, with no evidence of bacteria in Gram and Ziehl-Neelsen stained smears. No bacterial growth was detected in conventional culture media, however, bacteria was isolated from the peritoneal fluid culture on second day by Bactec (Becton Dickinson, USA) automated blood culture system. By means of API identification system (bioMerieux, USA), the causative agent was identified as Kocuria rosea. The patient was successfully treated with intraperitoneal teicoplanin (4 x 40 mg) for 14 days. In conclusion, in patients undergoing CAPD, rare pathogens should be considered in case of peritonitis and peritoneal fluid samples should be inoculated into automated culture systems.

[Two Crimean-Congo hemorrhagic fever cases without history of tick contact from Ankara region]. / Ankara bölgesinde kene temasi öyküsü olmayan iki Kirim-Kongo kanamali atesi olgusu.

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral disease presenting with flu-like symptoms, fever, hemorrhage and petechia. The virus (CCHFV) is a member of the Nairovirus genera of Bunyaviridae family and can be transmitted to humans by Hyalomma tick-bite, by exposure to infected blood and fomites of patient with CCHF or contact with animal tissue in viremic phase. In this study we present two cases with CCHF but without history of tick bite or exposure to infected fomites, even not coming from endemic areas. The first case was a 67 years old male patient presented with fever, fatique and shortness of breath. Physical examination revealed rales in right lower segments of lung. Laboratory findings showed elevation of liver enzymes with thrombocytopenia and prolonged prothrombin time. Serological markers for viral hepatitis, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) were negative. The patient was found to be IgM and RNA positive for CCHFV by ELISA and polymerase chain reaction (PCR) methods, respectively. His history indicated a contact with livestock. The second patient was a 60 years old male dealing with husbandry. He had fever, fatique and myalgia. Physical examination revealed petechial rash on legs. Laboratory findings showed elevated liver enzymes, prolonged phrothrombin time and thrombocytopenia. Viral hepatitis markers, CMV-IgM and EBV-IgM were found negative. He was also found to be IgM and RNA positive for CCHFV in the reference laboratory. In conclusion, CCHF should be considered in the differential diagnosis of patients who contact with livestock and present with fever, fatigue, rash, elevated liver enzymes, thrombocytopenia and prolonged prothrombin time eventhough they do not reside in endemic areas for CCHF.

Risk factors for linezolid-associated thrombocytopenia and negative effect of carbapenem combination.

INTRODUCTION: Linezolid is a synthetic antimicrobial agent with a broad spectrum of activity against virtually all Gram-positive bacteria. Although linezolid is generally well tolerated, the prolonged use of linezolid can lead to myelosuppression, including neutropenia, thrombocytopenia, and anemia. The aim of this study was investigating the risk factors for thrombocytopenia in patients who received linezolid therapy. METHODOLOGY: This retrospective study was performed on patients who received linezolid therapy between July 2007 and December 2017. Thrombocytopenia was defined as either a platelets count of < 100×109/L or a 25% reduction from the baseline platelet count. RESULTS: A total of 371 patients, (198 (53%) male and 173(47%) female were included into the study. Mean duration of therapy was 12.81 ± 5.19 days. Linezolid-induced thrombocytopenia was detected in a total of 111 patients. Using the univariate analysis advanced sex, serum urea concentration, baseline platelet level and low eGFR value were found to be risk factors for linezolid associated thrombocytopenia (p < 0.05). According to a multivariate analysis, patients undergoing carbapenem treatment combination therapy (p = 0.003) and with a baseline platelet level of < 200×109/L (p = 0.00) were found to have a high risk of developing thrombocytopenia. CONCLUSIONS: Several factors may influence of linezolid associated thrombocytopenia. Platelet count should be monitored during therapy and thrombocytopenia should be kept in mind in patients with baseline platelet level of < 200×109/L, low eGFR, linezolid-carbapenem combination therapy.

Investigation of risk factors for community-acquired urinary tract infections caused by extended-spectrum beta-lactamase Escherichia coli and Klebsiella species.

PURPOSE: The aim of this study was to determine the prevalence and risk factors for community-acquired urinary tract infections (CA-UTIs) caused by extended-spectrum ß-lactamase (ESBL) producing Escherichia coli and Klebsiella species. MATERIALS AND METHODS: The patients diagnosed with CA-UTIs caused by E. coli or Klebsiella spp. were included in the study. All of the patients were compared to demographic characteristics, underlying diseases, urinary tract pathology, history of hospitalization, use of antibiotics according to ESBL positivity. RESULTS: A total of 322 urine isolates were studied. Sixty-six patients (37.1%) of a total of 178 patients were ESBL positive E. coli and Klebsiella spp. Being over the age of sixty (odds ratio [OR], 1.90; p=0.03), history of renal stone (OR, 3.00; p=0.03), urinary tract anatomical of physiological disorder (OR, 2.17; p=0.01), urologic intervention (OR, 3.43; p<0.001), history of urinary tract surgery (OR, 3.10; p=0.01), history of urinary catheterization (OR, 3.43; p<0.001), and hospitalization for last 1 year (OR, 3.70; p=0.01) and antibiotic usage in the last 3 months (OR, 1.90; p=0.04) were found as significant risk factors for the producing of ESBL. However, gender and underlying disease were not related for ESBL production. CONCLUSIONS: In present study, high rate of ESBL positivity was detected in CA-UTIs. The increasing of infections caused by ESBL positive E. coli and Klebsiella spp. are bringing together a lot of the problem, such as antibiotic resistance and reducing treatment options for outpatients. Identification of underlying risk factors would be important for the development of preventive strategies.

[A rare cause of nosocomial bacteremia: Sphingomonas paucimobilis]. / Sphingomonas paucimobilis: nadir bir hastane kaynakli bakteriyemi etkeni.

Sphingomonas paucimobilis, is a yellow-pigmented, aerobic, non-fermentative, non-spore-forming, gram-negative bacillus. Infections by S. paucimobilis which is widely found in nature and hospital environments are rarely serious or life threatening. In this report we present a case of hospital acquired bloodstream infection due to S. paucimobilis. The patient had a history of hydrocephalus diagnosed at sixth months of his birth and had experienced two ventriculoperitoneal shunt surgery. He was hospitalized and been treated for bronchopneumonia. On the 47th day of hospitalization, blood cultures (BACTEC, Becton Dickinson, USA) were taken because of a body temperature of 38.5 degrees C. One of the blood cultures was positive for gram-negative rods. After 48 h of incubation, the sub-cultures on blood agar medium yielded pure growth of a yellow, non-fermentative, gram-negative, rod-shaped bacterium. The microorganism was positive for oxidase, and esculin hydrolysis, while negative for urea and nitrate reduction and citrate utilisation. Motility was negative as well. The isolate has been identified as S. paucimobilis by using mini API (bioMerieux, France) system. The antibiotic susceptibility test was also performed with the same system and the strain was found susceptible to ceftazidime, ceftriaxone, cefoperazone, cefepime, cefotaxime, ciprofloxacin, imipenem, piperacillin-tazobactam, aztreonam, amikasin and gentamicin. Treatment with intravenous ceftriaxone (2 x 750 mg/day) was initiated. He responded well to the treatment and discharged on the tenth day. This case was reported to emphasize that S. paucimobilis should be kept in mind as a nosocomial infectious agent and the infections should be treated according to the sensitivity test results.

[Evaluation of the epidemiological, clinical and laboratory findings in continuous ambulatory peritoneal dialysis related peritonitis attacks]. / Sürekli ayaktan periton diyalizi ile iliskili peritonit ataklarinda epidemiyolojik, klinik ve laboratuvar bulgularinin degerlendirilmesi.

The aims of this study were to assess epidemiological features, clinical outcomes, laboratory findings, causative organisms and treatment approach for continuous ambulatory peritoneal dialysis (CAPD) -related peritonitis cases. A total of 50 patients (35 male, 15 female; age range: 18-83 years, mean age: 49 +/-17 years) with CAPD related peritonitis treated in Infectious Diseases and Clinical Microbiology Department of Ankara Training and Research Hospital between February-July 2006 were enrolled into this study. Demographic characteristics, symptoms, physical examination findings and laboratory parameters of patients were recorded and evaluated at the baseline, 48 hours and at the end of treatment. Fifty six peritonitis episodes occurred during the study period, and overall incidence of peritonitis was calculated as 1.6 episodes/patient-year. The most common presenting symptoms were cloudiness of the peritoneal dialysis fluid (100%), abdominal pain (98%), nausea (74%) and vomiting (54%). Abdominal tenderness and rebaund (100%) were the most common physical examination findings. Increased levels of C-reactive protein, erythrocyte sedimentation rate and procalcitonin were detected in 88%, 94% and 42% of the patients, respectively. The mean white blood cell count of peritoneal dialysate fluids was 905/mm3 (170-17900/mm3) in 56 episodes. In direct microscopic examination of peritoneal fluid samples with Gram stain, positivity was detected in 10 (18%) of the attacks, in which eight yielded gram-positive cocci and two gram-negative bacilli. The rate of culture positivity was 74% in the peritonitis episodes, and no microorganism was isolated from the cultures of 26% of the episodes. The most frequently isolated microorganisms were coagulase-positive staphylococci, followed by Staphylococcus aureus (n:4) and E. coli (n:4) with the rates of 7% of each, Enterococcus spp. (n:3), Klebsiella spp. (n:3) and Pseudomonas spp. (n:3) with the rates of 5% of each, and Streptococcus spp. (n:1), diphtheroid bacillus (n:1) and Candida albicans (n:1) with the rates of 2% of each. Eightyfour percent of patients were successfully treated with intraperitoneal cefazolin and gentamicin empirically. Three of the patient's CAPD therapy was converted to hemodialysis, while two patients have died. As a result, since peritonitis is still the major complication of CAPD despite the technological developments, the informations about causative microorganisms and their antimicrobial susceptibilities would be helpful for the early and accurate treatment of peritonitis.

Evaluation of the increase in invasive device associated infections in cardiovascular surgical intensive care unit.

INTRODUCTION: Infections related to the use of invasive instruments leads to the risk of treatment difficulties, prolonged hospitalization, increased health care costs, and increased mortality and morbidity rates. The present study examines the results of an infection surveillance study that showed an increased incidence of infections related to the use of invasive instruments in the cardiovascular surgery intensive care unit of the Ankara Training and Research Hospital and mitigating measures were taken following the surveillance program. METHODOLOGY: Compared with previous surveillance data, an increase was observed in the incidence of infections related to the use of invasive instruments in cardiovascular surgery intensive care unit (CVS-ICU) during the first six months of 2014. A research team was formed comprising one infectious diseases and microbiology specialist, one cardiovascular surgeon, and two infection-control nurses. Patient data was collected. The compliance of the surgeons, nurses, and other health care professionals to the infection control measures was evaluated. RESULTS: The rate of ventilator-associated pneumonia was 8.20% and the rate of catheter-associated urinary tract infection was 4.47% in the CVS-ICU. There were missing or inadvertent practices regarding antibiotic prophylaxis, asepsis and antisepsis and isolation measures in patient preparation and patient care before and after the operations. The rate of inappropriate antibiotic as prolonged use was 72%. CONCLUSIONS: It is one of the basic tasks to take appropriate measures to prevent outbreaks of hospital infections. It is possible to prevent an outbreak of hospital infections only by the accurate analysis of data and establishing strict infection control procedures.