[An imported dengue Fever case in Turkey and review of the literature]. / Yurt Disi Kaynakli Bir Dang Atesi Olgusu ve Literatürün Gözden Geçirilmesi.

Dengue fever is an acute viral disease that can affect all age groups in tropical and subtropical countries. The predominant vectors are the mosquitoes namely Aedes aegypti and A.albopictus. Although there have been no case reports in Turkey due to DF, there is seroepidemiological evidence indicating the presence of Dengue virus (DENV) in Turkey. In this case report we presented an imported dengue fever case. The patient was 40 years old, previously healthy male, Switzerland citizen. He had immigrated from Dubai to India two weeks ago and after one week from immigration he attended to a hospital in India because of high fever. The NS1 antigen test (Bio-Rad Laboratories, USA) was found positive and the patient was followed-up with diagnosis of dengue fever in India. During his visit to Turkey, he attended to the hospital for a routine control and his analysis revealed thrombocytopenia (PLT: 48.000/µl), leukopenia (white blood cell: 2800/µL) and elevated liver enzymes (AST: 76 U/L, ALT: 83 U/L). Fever was not detected in follow-up. The patient had petechial rash on his lower extremities. white blood cell and PLT count increased to 4100/µl and 93.000/µl, respectively. Liver function tests revealed a decrease in AST (63 U/L) and ALT (78 U/L) on the third day. The PLT count increased to 150.000/ml. Since the patient had no fever and had normal physical and laboratory findings, he was discharged from the hospital. For the confirmation of dengue fever diagnosis the serum sample was sent to National Public Health Center, Virology Reference and Research Laboratory where IgM and IgG antibodies against DENV types 1-4 were investigated by indirect immunofluorescence method (Euroimmun, Germany). The serum sample yielded positive result at the dilutions of 1/1000 for IgM and 1/10.000 for IgG. The last dilution of type 3 DENV IgM and IgG were determined high density of fluorescein, thus the serotype was identified as "DENV type 3". Travel-related diseases become important with increasing travel opportunities, globalization and transportation, recently. As a result, this imported case with foreign nationality was the first dengue fever case confirmed by clinical and laboratory tests in Turkey.

[Evaluation of antibiotic resistance patterns of Pseudomonas aeruginosa and Acinetobacter spp. strains isolated from intensive care patients between 2000-2002 and 2003-2006 periods in Dokuz Eylul University Hospital, Izmir]. / Izmir dokuz eylül üniversite hastanesi yogun bakim hastalarindan izole edilen Pseudomonas aeruginosa ve Acinetobacter spp. suslarinin 2000-2002 ve 2003-2006 yillarinda saptanan antibiyotik duyarlilik paternlerinin degerlendirilmesi.

Multi-drug resistant Pseudomonas aeruginosa and Acinetobacter spp. infections are becoming an important problem all throughout the world as well as in our country. In this study, we evaluated the drug resistance rates of P. aeruginosa and Acinetobacter spp. in the intensive care units of Dokuz Eylül University Hospital, Izmir, Turkey. Since by the year 2003, antibiotic consumption is started to be controlled by infectious disease and clinical microbiology specialists according to antibiotic policies ruled by the government, the antibiotic resistance rates were evaluated in two periods (2000-2002 and 2003-2006). Seventynine P. aeruginosa and 89 Acinetobacter spp. isolated during January 2000-December 2002 and 66 P. aeruginosa and 48 Acinetobacter spp. isolated during january 2003-December 2006 were included to the study. All the isolates were from deep tracheal aspirate or bronchoalveolar lavage specimens. Susceptibilities of the isolates against meropenem, imipenem, piperacillin-tazobactam, cefepime, cefotaxime, ceftazidime, tobramycine and ciprofloxacin were determined by E-test (AB Biodisk, Sweden). The results indicated high antibiotic resistance rates. P. aeruginosa resistance rate for ceftazidime was 84%, cefepime 83%, carbapenemes 73%, ciprofloxacine 87% and piperacillin-tazobactam 88% while these rates were 98%, 95.6%, 87%, 100% and 100% for Acinetobacter spp., respectively. The data obtained in this study indicated that there were no decrease in the antibiotic resistance rates after 2003. In the year 2005, "Antibiotic use guideline" established in our hospital let the antibiotics used without infectious disease and clinical microbiology specialists consultation. The high antibiotic resistance rates may be attributed to the application of this antibiotic guideline leading to the uncontrolled use of antibiotics.

[The rate of inducible clindamycin resistance and susceptibilities to other antimicrobial agents in staphylococci]. / Stafilokokoklarda indüklenebilir klindamisin direnci ve diger antibiyotiklere duyarlilik oranlari.

Staphylococci are one of the most common pathogens isolated from nosocomial and community acquired infections. Antibiotics used by oral route such as erythromycin, clindamycin, trimethoprim-sulphamethoxazole (TMP-SMX) and quinolones are of value especially in the treatment of community acquired infections and resistance to those antibiotics may lead to therapeutic failure. Therefore in this study, susceptibility of staphylococci to TMP-SMX, rifampin, tetracycline, gentamicin, ciprofloxacin and vancomycin and the presence of inducible clindamycin resistance were investigated in two distinct university hospitals in Turkey. A total of 286 staphylococcus strains [184 Staphylococcus aureus, 102 coagulase negative staphylococci (CoNS)] were studied. Of the 90 hospital-acquired S. aureus, 44.6% were methicillin-resistant while all of the community acquired strains were methicillin-susceptible. All of the CoNS strains were isolated from nosocomial infections and 71.6% of them were resistant to methicillin. Inducible clindamycin resistance rate of CoNS strains (34.3%) was higher than that of S. aureus strains (7.1%) and the difference was statistically significant (p= 0.00001). Positive D-test among CoNS were significantly higher in S. hominis strains (p= 0.00001). Susceptibilities of S. aureus strains to tetracycline, rifampin, ciprofloxacin, gentamicin and TMP-SMX were 56%, 59%, 56%, 56% and 99%, respectively. Susceptibilities of CoNS strains to tetracycline, rifampin, ciprofloxacin, gentamicin and TMP-SMX were 73%, 72%, 39%, 40% and 46%, respectively. None of these strains were vancomycin resistant. Differences between tetracycline, rifampin, ciprofloxacin and gentamicin resistance rates among D-test positive and negative S. aureus strains were found statistically significant. Although among CoNS isolates, no statistically significant difference was found between the resistance rates, D-test positive strains were determined to be more resistant. Differences between tetracycline, rifampin, ciprofloxacin and gentamicin resistance rates among D-test positive S. aureus and CoNS strains were found statistically significant. It can be concluded that inducible clindamycin resistance should be tested for staphylococci during routine antibiotic susceptibility testing. According to the presented data, clindamycin still can be used empirically in methicillin-susceptible S. aureus infections in our region, however, the routine use of rapid, easy, reproducible and economic D-test for the determination of inducible clindamycin resistance in erythromycin resistant strains should be considered in clinical microbiology laboratories. Inducible clindamycin resistance must be anticipated carefully while considering therapeutic options especially for CoNS infections.

Compatibility of pulsed-field gel electrophoresis findings and clinical criteria commonly used to distinguish between true coagulase-negative staphylococcal bacteremia and contamination.

OBJECTIVES: To evaluate the specificity and sensitivity of the clinical criteria widely used to differentiate true coagulase-negative staphylococcal (CoNS) bacteremia from contamination, using pulsed-field gel electrophoresis (PFGE) as the reference test. DESIGN: The study sample consisted of 79 CoNS isolates recovered from cultures of blood from 38 patients. Medical charts of the patients were reviewed for demographic and clinical information. The relatedness of CoNS strains recovered from 2 or more successive blood cultures was analyzed by PFGE. Patients from whom similar strains were recovered were assumed to have true bacteremia, whereas patients from whom different strains were recovered were considered to have contaminated blood cultures. The clinical criteria comprised Centers for Disease Control and Prevention (CDC) surveillance definitions for bloodstream infection (BSI), as well as an alternative criterion based on the presence of fever, the presence of leukocytosis, the absence of another recognized infection, and the recovery of CoNS from 2 or more successive blood cultures. RESULTS: Nineteen (50%) of the 38 patients had bacteremia due to similar strains; the remaining patients had bacteremia due to different strains. Criterion 2a of the CDC definition for BSI had a sensitivity of 100% and a specificity of 31.6% for distinguishing between true bacteremia and contamination. CDC criterion 2b had a sensitivity of 78.9% and a specificity of 52.6%. CONCLUSIONS: Molecular typing correlated poorly with the clinical criteria for true bacteremia. In view of the limited applicability of clinical criteria, more studies are needed to improve them. Periodic cross-sectional studies based on PFGE findings might be useful to estimate local contamination rates in an institution, which in turn can be used to improve the accuracy of the clinical diagnosis of bacteremia.

Infectious disease consultations and antibiotic usage in a Turkish university hospital.

OBJECTIVES: The aim of this study was to investigate the various features of infectious disease (ID) consultations and the usage of antibiotics in a Turkish university hospital. METHODS: A total of 395 consultation requests were recorded during a three-year period. RESULTS: The departments most frequently requesting the consultation services of the ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) and Internal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever (42.3%) and for antibiotic modification according to culture results (18%). Diagnoses made by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%), bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients, no infectious focus was determined. It was recognized that the use of antibiotics had already been initiated in the great majority of patients (67.1%) before the consultation request. While the current therapy was changed in 57.4% of these patients, antibiotics were not necessary for 9.8%. CONCLUSIONS: Since the most common diagnoses were respiratory and urinary tract or bone and joint prosthesis infections, the ID specialists should have detailed knowledge of these problems. Usage of antibiotics without ID consultation was prevalent, therefore a continuous educational program is a necessity for healthcare workers in the hospital.

Effects of community-acquired infections on fever, leukocyte count and the length of stay in elderly. A cross-sectional study of 240 cases.

OBJECTIVE: To evaluate the relationships between community acquired infections in elderly cases (> or =65 ages) not living in a nursing home and factors such as, fever and white blood cell (WBC) counts; age, gender and the presence of underlying chronic diseases as compared to the length of stay. METHODS: We conducted this study in Dokuz Eylul University Hospital in Turkey as a defining cross-sectional research covering a 5-year period between January 1999 and December 2003. The data of 240 elderly cases were investigated, forms, which includes gender, existence of chronic diseases, fever, WBC counts, diagnosis, applied treatment and prognosis were prepared, and results were presented. RESULTS: The most frequently encountered infections were urinary system infections (35.4%), acute gastroenteritis (17.9%), pneumonia (15.9%) and soft tissue infections (13.3%). We observed that WBC counts were significantly elevated, parallel with high fever (p=0.021). In elderly cases we determined the existence of underlying disease and that living in the community lengthens the hospital staying periods (p=0.001). It was determined that elderly patients with an elevated WBC are 2.02 times more likely to have a temperature of 38.3 degrees C or higher compared with patients with a normal temperature (p<0.05). CONCLUSION: There was a strong association between leucocytosis and high fever in elderly cases. However, the absence of fever and leucocytosis in 78 (32.5%) of our cases, makes it hard for us to decide whether there was an infection or not. The most frequently encountered infections in elderly cases living in the community were similar to those living in nursing homes. These cases must be followed in the geriatric wards of hospital or geriatric hospitals whenever possible.

[Two cases of herpes encephalitis with normal cerebrospinal fluid findings]. / Olgu sunumu: beyin omurilik sivisi bulgulari normal olan iki herpes ensefaliti olgusu.

In this report, characteristics of two cases of Herpes simplex virus (HSV) encephalitis with normal cerebrospinal fluid (CSF) findings at the time of admission have been discussed and the current literature has been reviewed. The diagnosis of the cases (one was 23 years old male, and the other was 75 years old female patient) was made on the magnetic resonance imaging (MRI) findings concordant with HSV encephalitis, together with HSV-1 DNA positivity by polymerase chain reaction (PCR). Both of the patients were treated with acyclovir (3 x 750 mg/day) lasting for 15 days and 21 days, respectively. The first male patient recovered with mild neurological defects, whereas the second female patient died because of nosocomial pneumonia and septicemia. In conclusion, even the CSF findings are normal, in cases considered to be HSV encephalitis, MRI should be the first radiological diagnostic step and the diagnosis should be confirmed by the detection of HSV DNA in CSF by PCR.

Investigation of colonization with methicillin-resistant and methicillin-susceptible Staphylococcus aureus in an outpatient population in Turkey.

Methicillin-resistant Staphylococcus aureus (MRSA), known as a nosocomial pathogen, has been isolated from community-acquired infections since the 1980s. It has been reported that there are carriers of MRSA in the community although the rate of carriers is low and the most important risk factor of community-acquired carriage is hospitalization or referral to healthcare facilities. We attempted to investigate methicillin-resistant and methicillin-susceptible S. aureus colonization, respectively, in nasal and axillary swabs obtained from 500 patients without a history of hospitalization who were admitted to outpatient clinics and from 102 healthcare workers chosen as a control group. Of the patients, 9.4% had nasal S. aureus colonization without methicillin-resistant strains. Of the health care workers, 8.8% had S. aureus colonization without methicillin-resistant strains and only one worker had MRSA. The nasal carriage ratio of S. aureus in children was found to be 19.1% (22 of 115), and that in adults was 6.5% (25 of 385). The difference between the two age groups was determined as statistically significant (P = 0.006).

[Seropositivity against atypical pneumonia agents demonstrated in patients with community-acquired pneumonia]. / Toplum kökenli pnömoni tanisi alan hastalarda atipik pnömoni etkenlerine karsi seropozitifligin arastirilmasi.

The aim of this study was to investigate the IgG and IgM antibody positivities against atypical pneumonia agents in patients with community-acquired pneumonia (CAP), and to compare the results with the controls. The serum samples which were collected from 53 adult patients and 20 healthy donors have been investigated by a commercial indirect immunofluorescent assay (IFA, Pneumo-slide, Vircell SL, Spain) in which nine different antigens were fixed onto a slide. In both of the study groups. IgG and IgM seropositivities were detected in different rates against one or more etiologic agents. In the patient group. IgG and IgM positivity rates for the agents were as follows, respectively; 22.6% and 28.3% for Legionella pneumophila, 9.4% and 5.6% for Mycoplasma pneumoniae, 30.1% and 7.5% for Coxiella burnetii, 33.9% and 3.7% for Chlamydia pneumoniae, 28.3% and 0 for adenovirus, 71.6% and 1.8% for respiratory syncytial virus, 30.1% and 24.5% for influenza A virus, 35.8% and 7.5% for influenza B virus, 71.6% and 1.8% for parainfluenza viruses type 1-3. The rates of IgG positivities in the control group varied between 5-55% for all of the agents except M. pneumoniae and 3 of these controls were positive for L. pneumophila IgM, 3 were positive for C. pneumoniae IgM and one was positive for influenza A virus IgM. According to the statistical evaluation, there were no significant differences for IgM seropositivities to any of the agents, between the patient and control groups (p > 0.05). These results could be attributed to one or more of the following; a) none of these microorganisms were the primary etiologic agents, b) IgM positivities were the result of reinfections with these agents, c) longer duration of IgM antibodies after the acute infections. In terms of IgG positivities between the patient and control groups, only C. burnetii showed statistically significant difference (p = 0.029). Since the type of the pathogens causing CAP are of crucial importance both for the epidemiological purposes and for planning the empirical treatment strategies, more detailed multicenter studies should be performed in our country.

Risk of infection in health care workers following occupational exposure to a noninfectious or unknown source.

BACKGROUND: The major concern after occupational exposures is the possible transmission of blood-borne pathogens, especially hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). This study was undertaken to evaluate the risk of infection after exposure to blood or body fluids of an unknown or an HBV-, HCV-, and HIV-negative source and to determine the epidemiologic characteristics of these incidents in health care workers. METHODS: The survey was conducted over a 6-year period at a university hospital in Turkey, using a questionnaire to elicit demographic and epidemiologic information. Serologic tests for HBV, HCV, and HIV were performed and repeated after 3 months. RESULTS: Of the 449 incidents, complete follow-up was achieved in 320 (71.3%), and no seroconversion was observed for HBV, HCV and HIV. Most of the incidents occurred in medical (34.7%) and surgical (25.4%) work areas. The most frequent type of exposure was percutaneous injury (94%), most commonly caused by handling of garbage bags (58.4%), needle recapping (16.5%), and invasive interventions (13.4%). CONCLUSION: Infection risk seems to be extremely low for HCV and HIV, because of low endemicity, and for HBV in groups immunized against HBV.

The seroprevalence of diphtheria among adults in Izmir-Turkey.

A serological survey to determine the immunity to diphtheria in the adult population in Izmir-Turkey was conducted according to the recommendations of the World Health Organization. A total of 339 blood samples were collected from subjects aged between 20 and 81, and diphtheria antitoxin levels were measured by the enzyme linked immunosorbent assay method. Titers below 0.1 IU/ml were considered to show insufficient immunity. Of the studied population, 56.3% had showed insufficient immunity against diphtheria. Diphtheria protection rates showed a gradual age-related decrease. The lowest immunity rate was observed in 40-49-year age group (30.6%) (p<0.05). There was no significant difference in the rate of immunity between subjects in terms of sex, levels of education, urban-rural region (p>0.05). These results emphasize the need for booster immunization of adults. The present vaccination policy should include re-vaccinations of the adult population every 10 years in order to provide a complete protection of the population.

Nosocomial bloodstream infections associated with Candida species in a Turkish University Hospital.

In recent years, a progressive increase in the frequency of nosocomial candidaemia has been observed, especially among the critically ill or immunocompromised patients. The aim of this study was to evaluate the trend in incidence of candidaemia together with potential risk factors in an 850-bed Turkish Tertiary Care Hospital in a 4-year period. A total of 104 candidaemia episodes were identified in 104 patients. The overall incidence was 0.56 per 1000 hospital admissions and the increase in incidence of candidaemia from 2000 to 2003 was found to be statistically significant (P = 0.010). Candida albicans was the most common species (57.7%) and non-albicans species accounted for 42.3% of all episodes. The most common non-albicans Candida sp. isolated was C. tropicalis (20.2%) followed by C. parapsilosis (12.5%). The most frequent risk factors possibly associated with the candidaemia were previous antibiotic treatment (76.9%), presence of central venous catheter (71.2%) and total parenteral nutrition (55.8%). Our results show the fact that the incidence of candidaemia caused by non-albicans species is frequent and increasing significantly, although the most common isolated Candida species were C. albicans and further investigations are necessary to evaluate the mechanisms of increasing incidence of candidaemia caused by non-albicans species.