Results from the Survey of Antibiotic Resistance (SOAR) 2002-09 in Turkey.

OBJECTIVES: To investigate changes in antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae from the Survey of Antibiotic Resistance (SOAR) in community-acquired respiratory tract infections (CA-RTIs) between 2002 and 2009 in Turkey. METHODS: Previously published SOAR data were used for this analysis. MICs were determined using Etest(®) gradient strips or disc diffusion. Susceptibility against a range of antimicrobial agents was assessed using CLSI breakpoints. RESULTS: A total of 900 S. pneumoniae isolates were analysed: 2002-03 (n = 75), 2004-05 (n = 301) and 2007-09 (n = 524). Four antibiotics were tested consistently throughout and three showed a statistically significant decrease in susceptibility (P < 0.0001): penicillin (74.7% susceptible in 2002-03; 67.8% in 2004-05; and 47.2% in 2007-09); cefaclor (85.3% in 2002-03; 78.7% in 2004-05; and 53.5% in 2007-09) and clarithromycin (85.3% in 2002-03; 82.7% in 2004-05; and 61.9% in 2007-09). Susceptibility to amoxicillin/clavulanic acid did not significantly change (100% in 2002-03; 98.7% in 2004-05; and 97.7% in 2007-09). A total of 930 H. influenzae isolates were analysed: 2002-03 (n = 133), 2004-05 (n = 379) and 2007-09 (n = 418). Four antibiotics were also consistently tested: ampicillin, amoxicillin/clavulanic acid, clarithromycin and cefaclor. All showed >90% susceptibility, but only cefaclor susceptibility significantly reduced (P < 0.0001) over time (99.2% in 2002-03; 96.3% in 2004-05; and 90.4% in 2007-09). CONCLUSIONS: In S. pneumoniae from Turkey, there has been a clear statistically significant reduction in susceptibility to key antibiotics since 2002, but not to amoxicillin/clavulanic acid (or amoxicillin). However, susceptibility in H. influenzae remained stable. Continued surveillance is required to monitor future changes in antibiotic susceptibility for CA-RTI bacteria.

Validation of a severity grading score (SGS) system for predicting the course of disease and mortality in patients with Crimean-Congo hemorrhagic fever (CCHF).

We aimed to validate a severity grading score (SGS) system for predicting the course of disease and fatality in Crimean-Congo hemorrhagic fever (CCHF). This SGS was established using several variables that were assumed to be associated with mortality and had clinical importance. We included patients diagnosed with CCHF from different centers. Patients who had symptoms of CCHF for <5 days were included. The patients were grouped into three categories according to mortality risk. An SGS ≤4 showed no association with mortality [n = 323 (79.9 % of the total study population), and all survived]. An SGS between 5 and 8 points was classified into the intermediate risk group (20 %), and 14 of 70 patients in this group died. An SGS ≥9 was classified as the high risk of mortality group and 11 of 11 patients in this group died (p = 0.001). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for an SGS >9 points at admission were 96, 100, 97, 100, and 44 %, respectively. This SGS system may help appropriate the triage of patients, decrease the cost of treatment, and improve the functionality of healthcare staff. The present study is the first investigation about the validation of an SGS system in patients with CCHF.

The seroprevalance of Crimean-Congo haemorrhagic fever in people living in the same environment with Crimean-Congo haemorrhagic fever patients in an endemic region in Turkey.

Crimean-Congo haemorrhagic fever (CCHF) is endemic in Turkey, and since 2004 many cases have been reported from different regions of Turkey. There are limited data about the seroprevalence of the disease in household members of patients or persons sharing the same environment. We evaluated seroprevalence of CCHF in the immediate neighbourhood and in household members of patients living in the same environment as confirmed cases of CCHF in an endemic area of Turkey. A total of 625 healthy subjects [mean (s.d.) age: 42·3 (18·4) years, 58·7% females] without a past history of CCHF infection included in this case-control, retrospective study were evaluated in terms of sociodemographic characteristics, risk factors for CCHF via a study questionnaire, while serum analysis for CCHF virus (CCHFV) IgG antibodies was performed by ELISA. Anti-CCHFV IgG antibodies were positive in 85 (13·6%) participants. None of the seropositive individuals had a history of symptomatic infection. Regression analysis revealed that animal husbandry [odds ratio (OR) 1·84, 95% confidence interval (CI) 1·09-3·11], contact with animals (OR 2·31, 95% CI 1·08-5·10), contact with ticks (OR 3·45, 95% CI 1·87-6·46), removing ticks from animals by hand (OR 2·48, 95% CI 1·48-4·18) and living in a rural area (OR 4·05, 95% CI 1·65-10·56) were associated with increased odds of having IgG seropositivity, while being a household member of a patient with prior CCHF infection had no influence on seropositivity rates. This result also supports the idea that CCHF is not transmitted person-to-person by the airborne route.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey. METHODS: A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach. RESULTS: In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.) CONCLUSIONS: The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Molecular epidemiology and the clinical significance of Acinetobacter baumannii complex isolated from cerebrospinal fluid in neurosurgical intensive care unit patients.

OBJECTIVE: This study was intended to investigate the clinical significance and molecular epidemiology of Acinetobacter baumannii complex (ABC) isolated from cerebrospinal fluid (CSF) in neurosurgical intensive care unit (NSICU) patients, particularly comparing isolates from healthcare workers' (HCW) hands. METHODS: We retrospectively reviewed the medical records of 30 patients with CSF cultures positive for ABC seen at our NSICU from the date it first opened, January 2007, to September 2010. Pulsed-field gel electrophoresis (PFGE) typing was performed on 68 strains isolated from 32 patients' CSF and 36 HCWs' hands. RESULTS: ABC isolates were considered to be clinically significant in 21 (70.0%) patients but insignificant in the other nine (30.0%) patients. The prolonged (>7 days) use of cephalosporins was more common in patients with clinically significant ABC isolates (p = 0.049). Multiple drug resistance (MDR) was observed in 12 (57.1%) clinically significant isolates. Empirical antimicrobial therapies were not appropriate for nine of these 21 patients (42.8%). Mortality was significantly higher in the clinically significant group than in the clinically insignificant group (18/21 vs. 3/9; p = 0.008). Fifty-three isolates (77.9%) were grouped into 15 clusters, three of which contained possibly related isolates from patients' CSF and staff members' hands. CONCLUSIONS: The fact that ABC isolates grown from CSF cultures do not always exhibit infection and have high multiple antibiotic resistance, including to carbapenems, should be borne in mind when planning treatment for these patients. In addition, HCWs' hands may play a significant role in transmission to patients, and compliance with infection control procedures, especially hand washing, must be enhanced in order to avoid ABC infections.

Serum carbohydrate antigen 19-9 levels in patients with unilateral hydronephrosis due to urinary lithiasis.

AIM: We aimed to investigate that the association between serum carbohydrate antigen 19-9 (CA 19-9) levels and unilateral hydronephrosis due to urinary lithiasis in homogeneous groups who had no urinary tract infection and renal impairment. METHODS: A total of 50 patients with ureteral stone enrolled in this study prospectively. The patients were divided into two groups according to degree of hydronephrosis. Patients without hydronephrosis were taken into Group I and who had hydronephrosis were taken into Group II. All patients were underwent treatment of shock wave lithotripsy (SWL). Serum CA 19-9 was measured using immunassay method pre-treatment of SWL. After complete stone clearence and recovery of hydronephrosis in all patients, patiens were re-evaluated and CA 19-9 levels were measured. RESULTS: There were no significant differences for age, gender, body mass index, stone volume, shock wave number, number of SWL seasons, and serum creatinin between the groups (P>0.05). Pre-SWL serum mean Ca 19-9 levels were 14.82±14.64 U/mL. in Group I and 13.89±13.03 U/mL. in Group II (P=0.8686). After complete stone clearance and recovery of hydronephosis with SWL, the mean CA 19-9 values were measured as 14.14±10.67 U/mL. in Group II and there were not found significant change as compared pre-SWL values for Group II (P=0.7334). CONCLUSION: The relationship between CA 19-9 values and hydronephrosis was not found to be statistically meaningful on the contrary to previous reports and it does not appear as a useful parameter to predict of urinary obstruction non-invasively.

Comparison of methods for prediction of prostate cancer in Turkish men with PSA levels of 0-10 ng/mL.

PURPOSE: Several concepts to improve the diagnostic accuracy of prostate specific antigen (PSA) for prediction of prostate cancer have been studied. The aim of this study was to examine and compare the methods used for improving the diagnostic accuracy of PSA in a country with low incidence of prostate cancer. METHODS: 997 patients with prostate biopsy were included into study. Predictive models using PSA, PSA density (PSAD), free PSA/total PSA (f/tPSA), binary logistic regression (LR) analysis, artificial neural networks (ANNs), and decision trees (DTs) have been developed. For LR, ANNs and DTs, a validation group consisting of 241 cases was reserved. RESULTS: 193 (19%) biopsies out of 997 showed prostatic cancer. Median PSAD in patients with malignant and benign lesions were 0.21 and 0.16, respectively (p<0.001). According to 25% f/tPSA cut-off level, 18.4% of the patients with PSA<25% and 16.0% of the patients with PSA>25% had prostate cancer (p=0.423). Receiver operating characteristics (ROC) area under the curve (AUC) values for PSA, PSA density, f/tPSA, LR, ANNs, and DTs were 0.587, 0.625, 0.560, 0.678, 0.644, and 0.698, respectively. ROC AUCs in the validation group for LR, ANNs and DTs were 0.717, 0.516 and 0.629 respectively. CONCLUSIONS: For cases with f/tPSA<25%, no increased probability for prostatic carcinoma was observed. Multivariate models have higher AUCs than PSA, PSAD or f/tPSA. LR, DTs and ANNs showed similar results, however application of ANNs to the validation group produced a significantly lower AUC, limiting the value of ANNs in this situation.

Effect of education on the rate of and the understanding of risk factors for intravascular catheter-related infections.

OBJECTIVE: Intravascular catheters are indispensable tools in modern medical therapy. In spite of their great benefits, however, the widespread use of catheters leads to several complications, including infections that cause significant morbidity, mortality, and economic losses for hospitalized patients. DESIGN: This study was conducted at Farabi Hospital, a 495-bed facility at Karadeniz Technical University Medical School in Trabzon, Turkey, and involved 3 separate periods: preeducation, education, and posteducation. Patients with intravascular catheters were monitored daily, as were the results of their physical examinations. The information acquired was recorded in a questionnaire. RESULTS: During the preeducation period (October 2003 through March 2004), 405 intravascular catheters inserted into 241 patients were observed for 5,445 catheter-days. Seventy-one cases of intravascular catheter-related infection (CRI) were identified, giving a CRI rate of 13.04 infections per 1,000 catheter-days. The catheter-related bloodstream infection (CRBSI) rate was 8.3 infections per 1,000 catheter-days, and the exit-site infection (ESI) rate was 3.5 infections per 1,000 catheter-days. During the posteducation period (June through November 2004), 365 intravascular catheters inserted into 193 patients were observed for 5,940 catheter-days. Forty-five cases of CRI were identified, giving a rate of 7.6 infections per 1,000 catheter-days. The CRBSI rate was 4.7 infections per 1,000 catheter-days, and the ESI rate was 2.2 infections per 1,000 catheter-days. When findings from the 2 periods were compared, it was determined that education reduced CRI incidence by 41.7%. CONCLUSION: CRI can be prevented when hospital personnel are well informed about these infections. We compared the knowledge levels of the relevant personnel in our hospital before and after theoretical and practical training and identified a significant increase in knowledge after training (P<.0001). Parallel to this, although still below ideal levels, we identified a significant improvement in the incidence of CRI during the posteducation period (P=.004). The rate was low for the first 3 months of this period but increased 2.08 times after the third month. In conclusion, regular training for the residents in charge of inserting intravascular catheters and the nurses and interns who maintain the catheters is highly effective in reducing the rate of CRI in large teaching hospitals.

Device-associated hospital-acquired infection rates in Turkish intensive care units. Findings of the International Nosocomial Infection Control Consortium (INICC).

We conducted a prospective study of targeted surveillance of healthcare-associated infections (HAIs) in 13 intensive care units (ICUs) from 12 Turkish hospitals, all members of the International Nosocomial Infection Control Consortium (INICC). The definitions of the US Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (NNISS) were applied. During the three-year study, 3288 patients for accumulated duration of 37 631 days acquired 1277 device-associated infections (DAI), an overall rate of 38.3% or 33.9 DAIs per 1000 ICU-days. Ventilator-associated pneumonia (VAP) (47.4% of all DAI, 26.5 cases per 1000 ventilator-days) gave the highest risk, followed by central venous catheter (CVC)-related bloodstream infections (30.4% of all DAI, 17.6 cases per 1000 catheter-days) and catheter-associated urinary tract infections (22.1% of all DAI, 8.3 cases per 1000 catheter-days). Overall 89.2% of all Staphylococcus aureus infections were caused by methicillin-resistant strains, 48.2% of the Enterobacteriaceae isolates were resistant to ceftriaxone, 52.0% to ceftazidime, and 33.2% to piperacilin-tazobactam; 51.1% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.7% to ceftazidime, 38.7% to imipenem, and 30.0% to piperacilin-tazobactam; 1.9% of Enterococcus sp. isolates were resistant to vancomycin. This is the first multi-centre study showing DAI in Turkish ICUs. DAI rates in the ICUs of Turkey are higher than reports from industrialized countries.

Adenovirus-mediated IKKbetaKA expression sensitizes prostate carcinoma cells to TRAIL-induced apoptosis.

Despite the fact that tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) can selectively induce apoptosis in cancer cells, TRAIL resistance in cancer cells has challenged the use of TRAIL as a therapeutic agent. First, prostate carcinoma cell lines (DU145, LNCaP and PC3) were screened for sensitivity to adenovirus delivery of TRAIL (Ad5hTRAIL). As amplified Ikappa B kinase (IKK) activity is responsible for the constitutive nuclear factor-kappaB (NF-kappaB) activation leading to uncontrolled cell growth and metastasis, a dual vector approach using both an adenovirus vector (Ad) expressing the dominant-negative mutant of IKKbeta (AdIKKbetaKA) and Ad5hTRAIL was employed to determine if prostate cancer cells were sensitized to TRAIL in the setting of IKK inhibition. Inhibition of the NF-kappaB pathway through IKK blockade sensitized all three prostate cancer cell lines to TRAIL, regardless of NF-kappaB activation or decoy receptor gene expression. Moreover, a novel quantitative real-time RT-PCR assay and conventional flow cytometry analysis indicated that TRAIL-resistant DU145 and LNCaP cells, but not TRAIL-sensitive PC3 cells, expressed substantial amounts of TRAIL Decoy Receptor 4. In conclusion, TRAIL decoy receptor expression appeared to be the chief determinant of TRAIL resistance encountered in prostate carcinoma cell lines.

Idiopathic prostatic giant calculi in a young male patient.

We report a case of 41-year-old man with idiopathic prostatic giant calculi presenting with voiding difficulty. To our knowledge this is the youngest case with idiopathic prostatic giant calculi reported in the literature. The etiopathogenesis of prostatic calculi are also discussed.

[Nosocomial Stenotrophomonas maltophilia infections in a university hospital]. / Bir universite hastanesinde nozokomiyal stenotrophomonas maltophilia enfeksiyonlari.

Stenotrophomonas maltophilia is a nosocomial pathogen of increasing importance. In our study, 190 S. maltophilia strains isolated from 153 hospitalized patients between January 2000-April 2004, at Farabi Hospital at Medical School of Karadeniz Technical University, were prospectively evaluated. Of these patients 67.9% were clinically compatible with nosocomial infection, and 32% were considered as colonization. It was observed that rate of infection had a tendency to increase one year of age and above 50 years of age. Nosocomial infection and/ or colonization with S. maltophilia was detected in 19.7 +/- 15.2 (1-89) days after hospitalization. The clinical manifestations were bacteremia (36.5%), pneumoniae (28.8%), urinary system infection (12.5%), surgical site infection (11.5%) and peritonitis (6.7%). The bacteremia episodes were associated with central venous catheter in 37.3% (19/51), ventilator associated pneumonia in 11.7% (6/51), urinary system infection in 7.8% (4/51), peritonitis in 3.9% (2/51), and surgical site infection in 1.9% (1/51) of cases. Nineteen patients (37.3%) had no apparent primary source of infection. Higher APACHE II score, longer duration of hospitalization and prior extended-spectrum antibiotic therapy were observed in most of the patients. Antibiotic susceptibility testing revealed that, the most effective antibiotics against the isolates were trimethoprim-sulfamethoxazole (94%), ticarcillin/clavulanate (79%) and ciprofloxacin (53.5%). Crude mortality rate in the patients with S. maltophilia infections was found to be 25%. In addition, it was observed that proper antibiotic treatment had protective role against mortality (14.6% vs 63.6%; OR = 0.1, Cl95 0.12-0.42, P = 0.000). It can be concluded that to prevent infections due to S. maltophilia , effective infection control programmes and rational antibiotic use policies should be established promptly.

Potential role of reactive oxygen species on testicular pathology associated with infertility.

AIM: To investigate the level of malondialdehyde (MDA), a direct indicator of lipid peroxidation-induced injury by reactive oxygen species (ROS), in testicular biopsy specimens from infertile patients. METHODS: Levels of MDA were measured in testicular biopsy specimens from 29 consequent-randomized infertile men, aged 29.58+/-4.76 (21 to approximately 45) years. All patients were evaluated by a complete medical and reproductive history, physical examination, semen analysis (at least two), serum follicle-stimulating hormone and free testosterone levels, testicular biopsy and contact imprint. Scrotal colour Doppler ultrasonography was used to confirm suspected varicocele. The testicular MDA level was measured using the thiobarbituric acid test and the results were expressed per unit tissue weight. RESULTS: As a causal factor in infertility, varicocele was identified in 17 (58.6 %) patients, and idiopathic infertility, testicular failure and obstruction in 4 (13.8 %) patients each. The testicular MDA level was 13.56 (6.01), 49.56 (24.04), 58.53 (48.07), and 32.64 (21.51), 32.72 (13.61), 23.07 (7.82), 42,12 (34.76) pmol/mg tissue in the normal spermatogenesis (control), late maturation arrest, Sertoli cell only (SCO) and hypospermatogenesis (mild, moderate, severe) groups, respectively. The elevation of MDA levels was significant in the testicular tissue from SCO and maturation arrest groups compared with the controls (P<0.05). In addition, the elevation in testicular MDA levels between the SCO and the moderate hypospermatogenesis, and the moderate hypospermatogenesis and the maturation arrest groups was significant (P<0.05). CONCLUSION: Severe pathologic changes in the testicular tissue are associated with a high level of lipid peroxidation. These findings suggest that overproduction of ROS may play a role in the mechanism of testicular degeneration associated with infertility.

Comparison of the effects of surgical and autologous fascial suture materials on testicular histology in rats subjected to orchiopexy.

In this study orchiopexy was performed in 30 Sprague-Dawley rats in order to compare traumatic effects of surgical and autologous fascial suture materials on testicular histology. Abscess formation was observed in 72.7% of the chromic, in 36.3% of the nylon, and in 18.1% of the vicryl fixed groups. There were no abscess formations in the dartos and autologous fascial fixed group. Examination of the testes revealed complete absence of spermatogenesis in the chromic fixed group. Spermatogenesis was normal, 72% in the vicryl, 18.1% in the nylon, 90.9% in the dartos and autologous fascial suture fixed groups. Antisperm antibody was not observed in any rat sera. We consider that it is preferred to use dartos pouch fixation. If necessary, it is advisable to use autologous fascial suture materials.

[Detection of seropositivity against rubella virus in women in the reproductive age and comparison of the rubella hemagglutination inhibition test and the ELISA-IgG test]. / Dogurganlik yasindaki kadinlarda kizamikçik seropozitiflik oraninin hemaglütinasyon önlenim ve ELISA IgG yöntemleri ile saptanmasi ve kiyaslanmasi.

In this study Hemagglutination Inhibition (HI) and ELISA-IgG tests used for Rubella serology were compared in terms of specificity and sensitivity In addition, 100 sera samples taken from women in pregnancy age were tested for Rubella antibodies. The results indicated that the sensitivity of Rubella ELISA IgG test is 100% and the specificity is 97.4%. The seropositivity of women in pregnancy age was found to be 93% by Rubella ELISA-IgG test.

[Sporadic kala-azar in the Black Sea region]. / Karadeniz'de sporadik Kala-azar yöresi.

Visceral leishmaniasis is a disease, also called kala-azar, caused by species of Leishmania, which is known as intracellular parasite. Disease show a broad spectrum on the clinical symptoms. This infection is seen classically in Mediterranean countries, in same Asian countries between 30th-48th north parallels and in South America. In Mediterranean countries the parasite causing the visceral Leishmaniasis is Leishmania donovani. Turkey is also a Mediterranean country taking place between 36th-42nd north parallels.

[Escherichia coli strains isolated from the urine of children with urinary tract infections and their antibiotic susceptibility. A comparative study from three centers]. / Uriner sistem infeksiyonu olan çocuklarin idrarlarindan izole edilen Escherichia coli suslarinin bazi antibiyotiklere duyarliliklari. Uç Merkezden Yapilan Karsilastirmali Calisma.

We searched the susceptibility of E. coli strains isolated from urine cultures of sick children with urinary tract infections to Nitrofurantoin, Co-trimoxazole, Gentamicin, Ampicillin and Amoxillin-Clavulonic acid. In our study, we compared the results of Farabi Hospital of Black Sea Technical University Medical Faculty, Hacettepe University Medical Faculty Children Hospital and Glasgow Royal Hospital for sick children and tried to show their regional and national differences for antibiotic susceptibility.

[Prevention of wound infection in elective colon surgery by the use of systemic ceftriaxone and ornidazole]. / Elektif kolon cerrahisinde sistemik seftriakson ve ornidazolun yara enfeksiyonunda profilaktik etkisi.

In this study prophylactic effects of ceftriaxone and ornidazole on the patients undergoing elective colon surgery was studied in the surgical clinics, Medical Faculty of Karadeniz Technical University. Colon cleaning with Nichol's method was performed in all cases. But kanamycin and metronidazole were given instead of erythromycin and metronidazole. One hour before the operation ceftriaxone 1 gr. and ornidazole 500 mg. (IV, IM) were administered. Those antibiotics were followed by ceftriaxone 2 gr. daily and ornidazole 1 gr. daily (IV, IM) three days after operation. The wound infection were observed in the postoperative period (5%). The average hospitalization time of the cases were 12 days. This period was 18 days and 21 days in the cases having infection. Side effects related the drugs were not observed and there were no significant laboratory changes.