Probable viremia and positive placental swabs for SARS-CoV-2 in a preterm pregnant woman with mild COVID-19.

This study aimed to report a case of mild novel coronavirus disease (COVID-19) in a pregnant woman with probable viremia, as reverse transcription-polymerase chain reaction (RT-PCR) testing of endometrial and placental swabs for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. A 26-year-old multigravida at 35 weeks 2 days of gestation, who had extensive thigh and abdominal cellulitis, tested SARS-CoV-2 positive by RT-PCR performed on samples from the endometrium and maternal side of the placenta. However, other samples (amniotic fluid, fetal side of the placenta, umbilical cord, maternal vagina, and neonatal nasopharynx) tested negative for SARS-CoV-2. This is one of the rare reports of probable SARS-CoV-2 viremia with the presence of SARS-CoV-2 in the endometrium and placenta, but not leading to vertical transmission and neonatal infection. Because knowledge about transplacental transmission and results is very limited, we conclude that more RT-PCR tests on placental and cord blood samples are needed in order to safely make definite conclusions.

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

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

Evaluation of the implementation of WHO infection prevention and control core components in Turkish health care facilities: results from a WHO infection prevention and control assessment framework (IPCAF)-based survey.

BACKGROUND: The core components (CCs) of infection prevention and control (IPC) from World Health Organization (WHO) are crucial for the safety and quality of health care. Our objective was to examine the level of implementation of WHO infection prevention and control core components (IPC CC) in a developing country. We also aimed to evaluate health care-associated infections (HAIs) and antimicrobial resistance (AMR) in intensive care units (ICUs) in association with implemented IPC CCs. METHODS: Members of the Turkish Infectious Diseases and Clinical Microbiology Specialization Association (EKMUD) were invited to the study via e-mail. Volunteer members of any healt care facilities (HCFs) participated in the study. The investigating doctor of each HCF filled out a questionnaire to collect data on IPC implementations, including the Infection Prevention and Control Assessment Framework (IPCAF) and HAIs/AMR in ICUs in 2021. RESULTS: A total of 68 HCFs from seven regions in Türkiye and the Turkish Republic of Northern Cyprus participated while 85% of these were tertiary care hospitals. Fifty (73.5%) HCFs had advanced IPC level, whereas 16 (23.5%) of the 68 hospitals had intermediate IPC levels. The hospitals' median (IQR) IPCAF score was 668.8 (125.0) points. Workload, staffing and occupancy (CC7; median 70 points) and multimodal strategies (CC5; median 75 points) had the lowest scores. The limited number of nurses were the most important problems. Hospitals with a bed capacity of > 1000 beds had higher rates of HAIs. Certified IPC specialists, frequent feedback, and enough nurses reduced HAIs. The most common HAIs were central line-associated blood stream infections. Most HAIs were caused by gram negative bacteria, which have a high AMR. CONCLUSIONS: Most HCFs had an advanced level of IPC implementation, for which staffing was an important driver. To further improve care quality and ensure everyone has access to safe care, it is a key element to have enough staff, the availability of certified IPC specialists, and frequent feedback. Although there is a significant decrease in HAI rates compared to previous years, HAI rates are still high and AMR is an important problem. Increasing nurses and reducing workload can prevent HAIs and AMR. Nationwide "Antibiotic Stewardship Programme" should be initiated.

Inadequate treatment of ventilator-associated and hospital-acquired pneumonia: risk factors and impact on outcomes.

BACKGROUND: Initial antimicrobial therapy (AB) is an important determinant of clinical outcome in patients with severe infections as pneumonia, however well-conducted studies regarding prognostic impact of inadequate initial AB in patients who are not undergoing mechanical ventilation (MV) are lacking. In this study we aimed to identify the risk factors for inadequate initial AB and to determine its subsequent impact on outcomes in both ventilator associated pneumonia (VAP) and hospital acquired pneumonia (HAP). METHODS: We retrospectively studied the accuracy of initial AB in patients with pneumonia in a university hospital in Turkey. A total of 218 patients with HAP and 130 patients with VAP were included. For each patient clinical, radiological and microbiological data were collected. Stepwise multivariate logistic regression analysis was used for risk factor analysis. Survival analysis was performed by using Kaplan-Meier method with Log-rank test. RESULTS: Sixty six percent of patients in VAP group and 41.3% of patients in HAP group received inadequate initial AB. Multiple logistic regression analysis revealed that the risk factors for inadequate initial AB in HAP patients were; late-onset HAP (OR = 2.35 (95% CI, 1.05-5.22; p = 0.037) and APACHE II score at onset of HAP (OR = 1.06 (95% CI, 1.01-1.12); p = 0.018). In VAP patients; antibiotic usage in the previous three months (OR = 3.16 (95% CI, 1.27-7.81); p = 0.013) and admission to a surgical unit (OR = 2.9 (95% CI, 1.17-7.19); p = 0.022) were found to be independent risk factors for inadequate initial AB. No statistically significant difference in crude hospital mortality and 28-day mortality was observed between the treatment groups in both VAP and HAP. However we showed a significant increase in length of hospital stay, duration of mechanical ventilation and a prolonged clinical resolution in the inadequate AB group in both VAP and HAP. CONCLUSION: Our data suggests that the risk factors for inadequate initial AB are indirectly associated with the acquisition of resistant bacteria for both VAP and HAP. Although we could not find a positive correlation between adequate initial AB and survival; empirical AB with a broad spectrum should be initiated promptly to improve secondary outcomes.

Factors associated with catheter-associated urinary tract infections and the effects of other concomitant nosocomial infections in intensive care units.

BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) are the most common nosocomial infections in intensive care units (ICUs). The objectives of this study were to describe the incidence, aetiology, and risk factors of CAUTIs in ICUs and to determine whether concomitant nosocomial infections alter risk factors. METHODS: Between April and October 2008, all adult catheterized patients admitted to the ICUs of Zonguldak Karaelmas University Hospital were screened daily, and clinical and microbiological data were collected for each patient. RESULTS: Two hundred and four patients were included and 85 developed a nosocomial infection. Among these patients, 22 developed a CAUTI alone, 38 developed a CAUTI with an additional nosocomial infection, either concomitantly or prior to the onset of the CAUTI, and 25 developed nosocomial infections at other sites. The CAUTI rate was 19.02 per 1000 catheter-days. A Cox proportional hazard model showed that in the presence of other site nosocomial infections, immune suppression (hazard ratio (HR) 3.73, 95% CI 1.47-9.46; p = 0.006), previous antibiotic usage (HR 2.06, 95% CI 1.11-3.83; p = 0.023), and the presence of a nosocomial infection at another site (HR 1.82, 95% CI 1.04-3.20; p = 0.037) were the factors associated with the acquisition of CAUTIs with or without a nosocomial infection at another site. When we excluded the other site nosocomial infections to determine if the risk factors differed depending on the presence of other nosocomial infections, female gender (HR 2.67, 95% CI 1.03-6.91; p = 0.043) and duration of urinary catheterization (HR 1.07 (per day), 95% CI 1.01-1.13; p = 0.019) were found to be the risk factors for the acquisition of CAUTIs alone. CONCLUSIONS: Our results showed that the presence of nosocomial infections at another site was an independent risk factor for the acquisition of a CAUTI and that their presence alters risk factors.

In a Real-Life Setting, Direct-Acting Antivirals to People Who Inject Drugs with Chronic Hepatitis C in Turkey.

BACKGROUND: People who inject drugs (PWID) should be treated in order to eliminate hepatitis C virus in the world. The aim of this study was to compare direct-acting antivirals treatment of hepatitis C virus for PWID and non-PWID in a real-life setting. METHODS: We performed a prospective, non-randomized, observational multicenter cohort study in 37 centers. All patients treated with direct-acting antivirals between April 1, 2017, and February 28, 2019, were included. In total, 2713 patients were included in the study among which 250 were PWID and 2463 were non-PWID. Besides patient characteristics, treatment response, follow-up, and side effects of treatment were also analyzed. RESULTS: Genotype 1a and 3 were more prevalent in PWID-infected patients (20.4% vs 9.9% and 46.8% vs 5.3%). The number of naïve patients was higher in PWID (90.7% vs 60.0%), while the number of patients with cirrhosis was higher in non-PWID (14.1% vs 3.7%). The loss of follow-up was higher in PWID (29.6% vs 13.6%). There was no difference in the sustained virologic response at 12 weeks after treatment (98.3% vs 98.4%), but the end of treatment response was lower in PWID (96.2% vs 99.0%). In addition, the rate of treatment completion was lower in PWID (74% vs 94.4%). CONCLUSION: Direct-acting antivirals were safe and effective in PWID. Primary measures should be taken to prevent the loss of follow-up and poor adherence in PWID patients in order to achieve World Health Organization's objective of eliminating viral hepatitis.

Efficacy and Safety of Direct-Acting Antivirals in Elderly Patients with Chronic Hepatitis C: A Nationwide Real-Life, Observational, Multicenter Study from Turkey.

BACKGROUND: The number and proportion of elderly patients living with chronic hepatitis C are expected to increase in the coming years. We aimed to compare the real-world efficacy and safety of direct-acting antiviral treatment in elderly and younger Turkish adults infected with chronic hepatitis C. METHODS: In this multicenter prospective study, 2629 eligible chronic hepatitis C patients treated with direct-acting antivirals between April 2017 and December 2019 from 37 Turkish referral centers were divided into 2 age groups: elderly (≥65 years) and younger adults (<65 years) and their safety was compared between 2 groups in evaluable population. Then, by matching the 2 age groups for demographics and pretreatment risk factors for a non-sustained virological response, a total of 1516 patients (758 in each group) and 1244 patients (622 in each group) from the modified evaluable population and per-protocol population were included in the efficacy analysis and the efficacy was compared between age groups. RESULTS: The sustained virological response in the chronic hepatitis C patients was not affected by the age and the presence of cirrhosis both in the modified evaluable population and per-protocol population (P = .879, P = .508 for modified evaluable population and P = .058, P = .788 for per-protocol population, respectively). The results of the per-protocol analysis revealed that male gender, patients who had a prior history of hepatocellular carcinoma, patients infected with non-genotype 1 hepatitis C virus, and patients treated with sofosbuvir+ribavirin had a significantly lower sustained virological response 12 rates (P < .001, P = .047, P = .013, and P = .025, respectively). CONCLUSION: Direct-acting antivirals can be safely used to treat Turkish elderly chronic hepatitis C patients with similar favorable efficacy and safety as that in younger adults.

Piperacillin-tazobactam versus carbapenem therapy with and without amikacin as empirical treatment of febrile neutropenia in cancer patients: results of an open randomized trial at a university hospital.

OBJECTIVE: Empirical beta-lactam monotherapy has become the standard therapy in febrile neutropenia. The aim of this study was to compare the efficacy and safety of piperacillin-tazobactam versus carbapenem therapy with or without amikacin in adult patients with febrile neutropenia. METHODS: In this prospective, open, single-center study, 127 episodes were randomized to receive either piperacillin-tazobactam (4 x 4.5 g IV/day) or carbapenem [meropenem (3 x 1 g IV/day) or imipenem (4 x 500 mg IV/day)] with or without amikacin (1 g IV/day). Doses were adjusted according to renal function. Clinical response was determined during and at completion of therapy. RESULTS: One hundred and twenty episodes were assessable for efficacy (59 piperacillin-tazobactam, 61 carbapenem). Mean duration of treatment was 14.8 +/- 9.6 days in the piperacillin-tazobactam group and 14.7 +/- 8.8 days in the carbapenem group (P > 0.05). Mean days of fever resolution were 5.97 and 4.48 days for piperacillin-tazobactam and carbapenem groups, respectively (P > 0.05). Similar rates of success without modification were found in the piperacillin-tazobactam (87.9%) and in the carbapenem groups (75.4%; P > 0.05). Fungal infection occurrence rates were 30.5 and 18% in piperacillin-tazobactam and carbapenem groups, respectively (P = 0.05). Antibiotic modification rates were 30.5 and 13.1% (P = 0.02) and the addition of glycopeptides to empirical antibiotic regimens rates were 15.3 and 44.3% for piperacillin-tazobactam and carbapenem groups, respectively (P = 0.001). The rude mortality rates were 14% (6/43) and 29.3% (12/41) in piperacillin-tazobactam and carbapenem groups, respectively (P = 0.08). CONCLUSIONS: The effect of empirical regimen of piperacillin-tazobactam regimen is equivalent to carbapenem in adult febrile neutropenic patients.

[An adult case of visceral leishmaniasis in a province of Black-Sea region, Turkey]. / Zonguldak'ta eriskin viseral leysmaniyaz olgusu.

Visceral leishmaniasis (VL) which is a chronic disease caused by the protozoon, Leishmania, occurs widely worldwide and it is widespread in most of the countries in the Mediterranean basin. The infection which is transmitted by a sandfly (Phlebotomus) vector, has a prolonged incubation period and insidious onset. VL generally affects children and may be fatal if not treated. In this report, a 31 years old male patient, who was the first adult VL case from Zonguldak (a province located at western Black-Sea region of Turkey) was presented. He was admitted to the hospital with two-months history of fever, chills, sweating and weight loss. There was no history of travel outside the city nor insect bites, however, he indicated that there would be unnoticed sandfly bites since sandflies were very common in the coal mines he worked. His physical examination revealed body temperatue of 39.2°C and hepatosplenomegaly, while laboratory findings yielded anemia, leucopenia, hypoalbuminemia and hypergamaglobulinemia. Erythrocyte sedimentation rate was 62 mm/h, C-reactive protein was 113 mg/L and liver transaminases were 2 to 5 folds higher than the reference values. The only pathological finding was hepatosplenomegaly in the abdominal ultrasound and computerized tomography. He was further examined to rule out infections with similar signs and symptoms, connective tissue diseases and malignancies and all were found negative. Hypercellular bone marrow were detected in the aspiration material. Bone marrow smears, bone marrow samples inoculated in NNN medium and serum samples of the patient were sent to the reference parasitology laboratory of Refik Saydam National Public Health Agency for evaluation in terms of VL. The diagnosis was confirmed by the detection of Leishmania IgG titer as 1/512 with in-house indirect immunofluorescence antibody test, by positivite rK39 Dipstick (InBios, USA) test and by the observation of Leishmania amastigote forms in the bone marrow smears. Bone marrow culture in NNN medium also revealed positive result by the determination of Leishmania promastigote forms on the 7th day. The treatment was initiated by pentavalent antimony [glucantime 1 x 10 mg/kg/day intramuscular (IM)] however, due to severe adverse effects it has switched to liposomal amphotericin B (3 mg/kg/day). The patient completely recovered without complication. In conclusion VL should be considered in the differential diagnosis of patients, even adults, with persistent fever, hepatosplenomegaly and pancytopenia, in endemic countries such as Turkey.

Syringomyelia and intradural extramedullary tuberculoma of the spinal cord as a late complication of tuberculous meningitis.

Intradural extramedullary (IDEM) tuberculomas account for only 1% of all spinal tuberculomas. Concurrent IDEM tuberculoma and syringomyelia arising as a complication of tuberculous meningitis (TM) is extremely rare and only two cases have been reported to date. There is yet no report in the literature describing syringomyelia presenting as a delayed complication of IDEM tuberculoma. Here we present such a case. A 21 year-old male patient underwent partial decompression for thoracolumbar IDEM tuberculoma as a late complication of tuberculous meningitis. Spinal magnetic resonance imaging (MRI) of the patient suffering from progression of paraparesia six months after the operation revealed a syringomyelia occupying the space from T1 to T9, remote from the operation site, and syringo-peritoneal shunt placement was performed.

Specific risk factors for SARS-CoV-2 transmission among health care workers in a university hospital.

AIM: To investigate the specific risk factors for novel coronavirus (SARS-CoV-2) transmission among health care workers (HCWs) in a tertiary care university hospital. METHODS: Upper respiratory samples of HCWs were tested for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. A case-control study was conducted to explore the possible risk factors that lead to SARS-CoV-2 transmission to HCWs. RESULTS: Of 703 HCWs screened between March 20 and May 20, 2020, 50 (7.1%) were found to be positive for SARS-CoV-2. The positivity rates for SARS-CoV-2 among physicians, nurses, cleaning personnel, and the other occupations were 6.3%, 8.0%, 9.1%, and 2.6%, respectively. The infection rate was 8.3% among HCWs who worked in COVID-19 units and 3.4% among those who did not work in coronavirus disease 2019 (COVID-19) units (RR = 2.449, confidence interval = 1.062-5.649, P= .027). The presence of a SARS-CoV-2 positive person in the household (P = .016), inappropriate use of personnel protective equipment while caring for patients with COVID-19 infection (P = .003), staying in the same personnel break room as an HCW without a medical mask for more than 15 minutes (P = .000), consuming food within 1 m of an HCW (P = .003), and failure to keep a safe social distance from an HCW (P = .003) were statistically significant risk factors for infection. CONCLUSION: HCWs have a high risk for SARS-CoV-2 transmission while providing care to COVID-19 patients. Transmission may also occur in nonmedical areas of the hospital while speaking or eating. Periodic screening of HCWs for SARS-CoV-2 may enable early detection and isolation of infected HCWs.

Eikenella corrodens, cause of a vulvar abscess in a diabetic adult.

We report a case of Eikenella corrodens causing vulvar abscess in a diabetic patient. Eikenella corrodens is a slow growing, nonmotile, facultative anaerobic, Gram-negative bacillus which is commensal of the oral cavity, intestinal and genital tracts. The most common clinical sources of this organism are human bite wounds, head and neck infections and respiratory tract infections. In our knowledge, the presented case is the first report of Eikenella corrodens causing vulvar abscess in a diabetic patient.

[Factors effecting the duration of hospitalization and mortality in patients with community-acquired pneumonia]. / Toplum kökenli pnömoni olgularinda hastanede yatis süresi ve mortaliteyi etkileyen faktörler.

Community-acquired pneumonia (CAP) is a common infectious disease with high morbidity and mortality. In this study, demographic features, underlying conditions, causative pathogens and factors affecting length of hospital stay and mortality were retrospectively investigated in patients who were diagnosed as CAP and followed-up in our unit between January 2005-December 2007. Among 97 patients 65 (67%) were male, 32 (33%) were female and the mean age was 62.7 (age range: 18-94) years. Patients were grouped according to criteria of Turkish Thoracic Society into four groups; 22 were group 2 (patients with risk factors, without aggrevating factors), 59 were group 3 (patients with aggrevating factors), and 16 were group 4 (patients who have necessity for intensive care) CAP. The patients have also been grouped according to criteria of American Thoracic Society (CURB-65 score = Confusion, Urea > 7 mmol/L, Respiratory rate > or = 30/min, low Blood pressure and being > or = 65 years old), as group I (n = 65), group II (n = 20), and group III (n = 12). During follow-up 11 (11.3%) patients required mechanical ventilation support and 6 (6.2%) patients have died. Causative pathogens were isolated from 14 (23.3%) out of 27 well-qualified sputum samples obtained from 60 patients who could produce sputum (8 Streptococcus pneumoniae, 2 methicillin-sensitive Staphylococcus aureus, 2 Klebsiella pneumoniae, 1 Haemophilus influenzae, 1 Moraxella catarrhalis). Thirty-seven of cases were treated with levofloxacin, 10 with moxifloxacin, 24 with ceftriaxone +/- clarithromycin, 16 with sulbactam-ampicillin +/- ciprofloxacin, 10 with beta-lactam/beta-lactamase inhibitor combinations, and fever declined within 2.5 days in 83 (85.6%) of them. The mean duration of hospital stay was estimated as 11.1 days. In the evaluation of the factors that affect the length of hospital stay, being > or = 65 years old, gender, underlying conditions, central venous catheterisation, presence of nasogastric tube, positive culture result, previous antibiotic treatment, fever continuing for > 3 days despite antibiotic therapy and scoring groups were not determined as risk factors (p > 0.05 for all of these parameters). However, mechanical ventilation was found as a significant risk factor (p < 0.05). In the evaluation of the factors that affect mortality, mechanical ventilation (p < 0.001), staying in intensive care unit (p < 0.001), being group 4 CAP (p < 0.001) and fever continuing for > 3 days despite antibiotic therapy (p = 0.05) were found to be significant risk factors. In conclusion, length of hospital stay, mortality and treatment costs in CAP patients could be reduced by defining the risk factors and starting empirical antibiotic therapy according to the national and international guidelines.

[Necrotising endocarditis of mitral valve due to Staphylococcus lugdunensis]. / Staphylococcus lugdunensis'e bagli nekrotizan mitral kapak endokarditi.

Staphylococcus lugdunensis is an infrequent cause of infective endocarditis (IE) and usually involves native valves of the heart. It causes life-threatening events such as rupture of cardiac valve or cerebral or pulmonary embolism due to necrosis on the endocardial tissue involved by the bacteria. Antibiotic therapy without cardiac surgery or delayed cardiac surgery usually follows a fatal course in S. lugdunensis endocarditis. In this report the first case of S. lugdunensis endocarditis from Turkey was presented. A 37-year-old man was admitted to the emergency department with a 2-weeks history of fever chills and accompanying intermittent pain on the left side of the thorax. Other than recurrent folliculitis continuing for 20 years, his history was unremarkable. Echocardiography revealed vegetation on the mitral valve of the patient and vancomycin plus gentamicin were initiated with the diagnosis of IE. All blood cultures (5 sets) taken on admission and within the initial 48 hours of the antibiotic therapy yielded S. lugdunensis. According to the susceptibility test results, the antibiotic therapy was switched to ampicillin-sulbactam plus rifampin. Blood cultures became negative after the third day of therapy, however, cardiac failure was emerged due to rupture of mitral valve and chorda tendiniea on the 12th day of the therapy. Cardiac surgery revealed that mitral valve and surrounding tissue of the valve were evidently necrotic and fragile, anterior leaflet of the mitral valve was covered with vegetation, posterior leaflet and chorda tendiniea were ruptured. Vegetation was removed and the destructed mitral valve was replaced with a mechanical valve. Vegetation culture remained sterile, however, antibiotics were switched to vancomycin plus rifampin due to persistent fever on the 21st day of the therapy (9th day of operation). Fever resolved four days after the antibiotic switch. Antibiotics were stopped on the 9th weeks of admission and the patient was discharged. He had no problem in follow-up controls for one year. In conclusion, proper antibiotic therapy combined with early cardiac surgery seems to be the optimal therapeutic approach in IE caused by S. lugdunensis.

Risk factors and clinical responses of pneumonia patients with colistin-resistant Acinetobacter baumannii-calcoaceticus.

BACKGROUND: Nosocomial infections with carbapenem-resistant Acinetobacter baumannii-calcoaceticus complex (ABC) strains are great problem for intensive care units. ABC strains can develop resistance to all the antibiotics available. Carbapenem resistance is common and colistin resistance is rare in our country. Knowing the risk factors for colistin resistance is important since colistin seems to be the only remaining therapeutic option for the patients with pneumonia due to extensively drug resistant ABC for our country. AIM: To investigate the comparison of clinical responses and outcomes between pneumonia patients with colistin-susceptible and -resistant Acinetobacter sp. Strains. METHODS: During the study period, 108 patients with pneumonia due to colistin-susceptible strains and 16 patients with colistin-resistant strains were included retrospectively. Continuous variables were compared with the Mann-Whitney U test, and categorical variables were compared using Pearson's chi-square test or Fisher's Exact chi-square test for two groups. A binary logistic regression model was developed to identify the potential independent factors associated with colistin resistance in patients with colistin-resistant strains. RESULTS: High Acute Physiology and Chronic Health Evaluation II scores (OR = 1.9, 95%CI: 1.4-2.7; P < 0.001) and prior receipt of teicoplanin (OR = 8.1, 95%CI: 1.0-63.3; P = 0.045) were found to be independent risk factors for infection with colistin-resistant Acinetobacter sp. Different combinations of antibiotics including colistin, meropenem, ampicillin/sulbactam, amikacin and trimethoprim/sulfamethoxazole were used for the treatment of patients with colistin-resistant strains. Although the median duration of microbiological cure (P < 0.001) was longer in the colistin-resistant group, clinical (P = 0.703), laboratory (P = 0.277), radiological (P = 0.551), microbiological response (P = 1.000) and infection related mortality rates (P = 0.603) did not differ between the two groups. Among the patients with infections due to colistin-resistant strains, seven were treated with antibiotic combinations that included sulbactam. Clinical (6/7) and microbiological (5/7) response rates were quite high in these patients. CONCLUSION: The optimal therapy regimen is unclear for colistin-resistant Acinetobacter sp. infections. Although combinations with sulbactam seems to be more effective in our study patients, data supporting the usefulness of combinations with sulbactam is very limited.

Dynamics of Puumala hantavirus outbreak in Black Sea Region, Turkey.

BACKGROUND: Some of the hantavirus species in Euro-Asia cause haemorrhagic fever with renal syndrome (HFRS) in humans. The first documented human hantavirus infection in Turkey was diagnosed in 2009. This report describes the dynamics of the first hantavirus outbreak that emerged in humans in the Western Black Sea Region of Turkey. METHODS: All the suspected cases of hantavirus infection were admitted to the Infectious Diseases and Clinical Microbiology Department at the Zonguldak Bülent Ecevit University Hospital in Zonguldak, Turkey. The patients were carefully interviewed, examined and evaluated using routine laboratory tests and hantavirus diagnostic tools. Hantavirus-reactive antibodies (IgM and IgG) in serum samples were detected via enzyme immune assay (EIA) and immunofluorescence assay (IFA) in the acute and convalescence stages of the disease. The presence of hantavirus ribonucleic acid (RNA) was analysed via reverse transcription polymerase chain reaction (RT-PCR) in serum and urine samples. A focus reduction neutralization test (FRNT) was performed to confirm specific hantavirus serotypes. In addition, a case-control study was conducted to identify possible risk factors for hantavirus transmission in the outbreak area. A control group was composed of asymptomatic individuals who were seronegative for hantavirus IgM and IgG and living in the outbreak area. RESULTS: A total of 55 suspected cases of hantavirus infection were admitted to the inpatient clinic between February and June of 2009. Twenty-four patients were diagnosed with acute HFRS via EIA or IFA. In 22 of the 24 infected patients, Puumala virus (PUUV) was identified as the causative hantavirus type by detecting IgM in the acute stage and an increase in the IgG level in follow-up serum samples. PUUV was also verified as the infecting agent by FRNT in two of the 24 cases. Among the 24 laboratory-confirmed HFRS cases, 21 (87.5%) were males and 3 (12.5%) were females, and the mean age was 45.92 years (standard deviation ± 16.90 years). Almost all these individuals were living in villages or rural areas. The 24 HFRS cases were matched with 26 healthy controls for statistical analyses and according to binary logistic regression analysis, and dealing with rodent control activities in gardens or in annexes of their homes (p = 0.021 and Odds ratio [OR] = 17.11) and being male (p = 0.019 and OR = 22.37) were detected as statistically significant risk factors for hantavirus infection. The most commonly observed clinical complaints were fatigue (95.8%), shivering (91.7%), fever (87.1%), headache (70.8%) and nausea (70.8%). Haemodialysis was required for four patients (16.7%). Except for the first case diagnosed with acute hantavirus infection, no patient died. The mean delay time to hospital admission from initiation of symptoms was 5.3 days, the mean duration of febrile days was 2.6 days, and the mean duration of hospital stay was 8.5 days. CONCLUSION: Hantaviruses are circulating in Turkey and causing sporadic or epidemic infection in humans. Additional investigations are needed to better understand the dynamics of hantaviruses in this country.

[Nosocomial meningitis with dual agents and treatment with intraventricular gentamicin]. / Gift etkenli nozokomiyal menenjit ve intraventriküler gentamisin tedavisi.

Nosocomial central nervous system infections constitute 0.4% of all nosocomial infections. The responsible pathogens of nosocomial meningitis are quite different from community-acquired meningitis with high rates of morbidity and mortality. The most important prognostic factor is the appropriate choice of pathogen-specific antibacterial therapy. In this report, a 64 years old woman with nosocomial meningitis caused by Klebsiella pneumoniae and Acinetobacter spp. after lumbar disc hernia operation, has been presented. The risk factors were detected as recent history of neurosurgical operation for three times and long term (29 days) use of external ventricular drainaige (EVD) catheter. Empirical meropenem (3 x 2 g, IV) and vancomycin (2 x 1 g, IV) therapy was initiated upon the diagnosis of nosocomial meningitis based on the clinical and laboratory findings on the postoperative fifth day. Extended-spectrum beta-lactamase (ESBL) producing K. pneumoniae (susceptible to amikacin, imipenem, meropenem, cefoxitine, ciprofloxacin, piperasillin-tazobactam and trimethoprim/sulfamethoxazole) was recovered from cerebrospinal fluid (CSF) and blood samples obtained on the same day. There was no change in the status of the patient on the eighth day of meropenem therapy, with high leukocyte number (1300/mm3) and presence of gram-negative bacilli in CSF, and ESBL positive K. pneumoniae (antibiotic susceptibility pattern same with the previous isolate) growth in CSF culture. Thereupon intravenous ciprofloxacin (3 x 400 mg) was added to the therapy and her EVD has been changed. However, ESBL positive K. pneumoniae (antibiotic susceptibility pattern same with the previous isolate) together with Acinetobacter spp. (susceptible to gentamycin, tobramycin, netilmicin, ciprofloxacin, levofloxacin and cefepime) were isolated from CSF and blood cultures obtained on the 13th day of meropenem and fifth day of ciprofloxacin therapy. Therefore intraventricular and intravenous gentamicin (15 mg/days and 3 x 120 mg, respectively) were added to the therapy. The patient recovered at the end of three weeks treatment without any additional sequela other than her primary illness. This case was the first case of nosocomial meningitis due to ESBL positive K. pneumoniae together with Acinetobacter spp. in the available literature.

[Infective endocarditis due to high level aminoglycoside resistant Enterococcus faecalis and methicillin resistant coagulase-negative staphylococci presenting with rheumatic manifestations]. / Romatolojik bulgularla seyreden, yüksek düzey aminoglikozid direnci gösteren Enterococcus faecalis ve metisiline dirençli koagülaz-negatif stafilokokun etken oldugu enfektif endokardit olgusu.

Infective endocarditis has variable clinical presentations and may present with rheumatologic manifestations. Infective endocarditis due to high level aminoglycoside resistant enterococci represents a severe therapeutic challenge as none of the currently recommended treatment regimens are bactericidal against these isolates. In this report, a case of infective endocarditis with double aetiology, high level aminoglycoside resistant Enterococcus faecalis together with methicillin-resistant coagulase-negative staphylococci (MR-CNS), presenting with leukocytoclastic vasculitis and rapidly progressive glomerulonephritis, has been presented. A 48-years-old woman was admitted to our hospital with malaise and non-pruritic purpural rush on her lower extremities. On admission she had no fever or leukocytosis. Skin biopsy showed leukocytoclastic vasculitis and steroid therapy was started. On 12th day of admission rapidly progressive glomerulonephritis was diagnosed and she received plasmapheresis and haemodialysis support. Transthoracic echocardiography (TTE) demonstrated 1 x 1.5 cm vegetation on the mitral valve. An initial diagnosis of infective endocarditis was made and empirical treatment with vancomycin and gentamicin was started. All blood cultures yielded high level aminoglycoside resistant E. faecalis and additionally two of them yielded MR-CNS. Vancomycin was administered in combination with high dose ampicillin and repeated blood cultures taken after administration of ampicillin, revealed no growth. The patient remained afebrile, renal functions improved and a repeat TTE done on 20th day of ampicillin therapy showed waning of the vegetation. On 42nd day of treatment repeat TTE showed new vegetation on the mitral valve and severe valve insufficiency, so the patient was scheduled for mitral valve replacement. She was treated for 12 weeks with vancomycin and ampicillin and recovered successfully. In conclusion; infective endocarditis should be considered in the differential diagnosis of leukocytoclastic vasculitis and rapidly progressive glomerulonephritis. Physicians should document their treatment outcomes and experience with high level aminoglycoside resistant enterococcal infective endocarditis, which is a therapeutic challenge, so that the best therapeutic options can be identified.

[Cryptococcus neoformans meningitis in a HIV negative miliary tuberculosis-suspected patient]. / Hiv negatif miliyer tüberküloz süpheli bir hastada Cryptococcus neoformans menenjiti.

Cryptococcosis caused by Cryptococcus neoformans has a wide range of clinical presentations, varying from asymptomatic colonization of the respiratory airways to the dissemination of infection into different parts of body. It is more common among immunosupressed patients such as human immunodeficiency virus (HIV) positive ones. In this report we present a case with C. neoformans meningitis and miliary pulmonary infiltrates suggesting pulmonary tuberculosis without HIV infection. A-70-years-old male was admitted to the hospital with mental confusion, 3-weeks history of headache, weight loss, dry cough and fatigue. Physical examination was normal except neck stiffness. Cerebrospinal fluid (CSF) white cell count was 120/mm3 (80% polimorphonuclear cells). Gram staining of CSF revealed poorly stained gram-positive yeast cells. Empirical therapy with lipozomal amphotericin B, ceftriaxone and ampicillin combination was started. When C. neoformans growth was detected on CSF culture, ceftriaxone and ampicillin were discontinued. Patient became conscious at 24th hour of the treatment. Peripheric blood flow-cytometric analysis revealed a significant decrease in absolute CD4+ T lymphocytes, and in CD8+28+ T lymphocytes in addition a significant increase in natural killer cell ratio. Blood immunoglobulin and complement levels were found normal. Cranial magnetic resonance imaging and computerized tomogralphy (CT) of the abdomen were normal, however, chest CT revealed multiple parenchymal millimetric nodular infiltrations on both sides and minimal fibrotic alterations. Acid-fast staining of CSF, tuberculosis culture, tuberculosis PCR results and repeated HIV serology were found negative. Despite the lack of microbiological confirmation, empirical antituberculosis treatment was also started with the suspicion of miliary tuberculosis as the patient had a symptom of long-term dry cough, miliary infiltrations on chest CT, anergic tuberculin skin test and a history of pulmonary tuberculosis in childhood. After two weeks, amphotericin B was changed to oral fluconazole which was continued for an additional eight weeks. Antituberculosis therapy was given for nine months. Control chest CT taken after four months of antituberculosis therapy revealed improvement of the lesions. This presentation emphasizes the fact that cryptococcal infections may develop in HIV negative patients, even together with tuberculosis in certain cases and radiological findings of the two infections may be confusing when both of them invade the lungs.

[Mediterranean spotted fever due to contact with dog-tick]. / Köpek kenesi ile temas sonrasinda gelisen akdeniz benekli atesi.

Mediterranean spotted fever (MSF) is one of the tick-borne rickettsial infections caused by Rickettsia conorii. It is transmitted to humans by brown dog ticks (Rhipicephalus sanguineus). In this case report, a 16-years-old male patient who was diagnosed as MSF after an exposure to dog-tick in Bartin province (located at middle Black Sea region of Turkey) has been presented. His history revealed that, five days before admission to the hospital (on June, 2007) he had cleaned dog-ticks from his dog, and after 12 hours he found a stucked tick on his leg and he took it out right away with a tweezer. High fever, headache and generalized maculopapular rash including soles and palms and a black-colored lesion at the tick bite site developed three days later. In clinical examination, there was a black escar circled with a red-purple colored halo in front of the right tibia at the site of the tick bite showing high similarity to "tache noire" which was specific to MSF. Indirect immunofluorescence assay (IFA) for Rickettsia yielded negative result in the serum sample collected on admission day, however, it was found positive at 1/512 titer in the serum sample collected 10 days after admission. The patient has recovered completely without any complication after 10 days of doxycycline therapy. The aim of this presentation is to point out that MSF should be considered for the differential diagnosis of a patient with a history of tick bite, fever, maculopapular rash, headache, myalgia, arthralgia and especially with black escar during summer months in our country where the incidence of tick-borne infections has been increasing since recent years.