Carbapenem and Colistin Resistance, Integrons and Plasmid Replicon Types in Multi-Drug Resistant Klebsiella Strains Isolated in Turkey.

BACKGROUND: Multidrug-resistant (MDR) Klebsiella is a globally important nosocomial pathogen. In the present study, 101 multidrug-resistant Klebsiella strains isolated from various clinical specimens obtained from two different Medical Faculties' hospitals were involved. We aimed to find out the prevalence of carbapenemase, mobile colistin resistance genes, and integrons in MDR Klebsiella strains. METHODS: The antibiotic susceptibilities of strains were determined by Kirby Bauer disc-diffusion method and resistance to colistin was confirmed by detection of minimum inhibitory concentrations. The prevalence of carba-penemase genes (blaOXA-48, blaNDM, blaIMP, blaVIM, blaKPC), mobile colistin-resistance genes (mcr-1 and mcr-2), and integrons (class I, II and III) were examined in Klebsiella strains by polymerase chain reaction. RESULTS: All strains were resistant to ß-lactam antibiotics, carbapenems, and quinolones. On the other hand, only nine (8.9%) strains were resistant to colistin. The most common carbapenemase genes were blaNDM (64.3%) and blaOXA-48 (53.5%). Besides, 28 (27.7%) strains were found to harbor both blaNDM and blaOXA-48. These 28 strains be-longed to the IncA/C (18.7%), IncL/M (7.7%), and IncFIIs (1.1%) plasmid replicon types. No strain was positive for blaIMP, mcr-1, and mcr-2. Class I and Class II integrons were shown to be harbored in 83.2% and 63.3% of strains, respectively. In total, 63 (63.6%) of strains harbored both classes I and II integrons. Class III integron was not detected. There was a statistically significant relationship between the presence of integrons and antibiotic resistance for cefotaxime (p = 0.024), ciprofloxacin (p < 0.001) trimethoprim/sulfamethoxazole (p < 0.001) and levofloxacin (p = 0.002). To our knowledge, this study represents the first report of a human isolate for the co-presence of blaNDM, blaOXA-48 and both Class I and Class II integrons, from Turkey. CONCLUSIONS: Our findings also highlight the dissemination of integrons and carbapenemases and the importance of surveillance on emerging antibiotic resistance.

The Prevalence of Protein S Variant in Patients Diagnosed with COVID-19.

BACKGROUND: The rapid spread of the new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) which causes the coronavirus disease 2019 (COVID-19) facilitated the emergence of numerous variants. The present study aimed to investigate the prevalence and change of important "S" protein variants such as N501Y, DelH69/ 70, and E484K in SARS CoV-2 PCR positive patients diagnosed with COVID-19 who have referred to a private hospital within the period that mutations were detected during COVID-19 pandemic. METHODS: One hundred and eighty-seven patients who have been referred due to the suspicion of COVID-19 between December 2020 and April 2021 and in whom SARS-CoV-2 was detected positive in the PCR test were enrolled into the study. These patients were randomly selected among 285 patients detected in these months, among those with the most accurate graphics and data. The RNA material extracted from the nasopharyngeal swab samples taken from the patients was analyzed and specifically N501Y, del69-70, and E484K mutations were investigated through the Real-Time PCR method. RESULTS: The mean age of the patients was 37.5 ± 14.1 years. Mutations were detected in 84 (44.9%) samples in total (N501Y + DelH69/70 by 81%, DelH69/70 by 7.1%, E484K by 7.1% and N501Y + E484K by 4.8%). There was no sample detected with the N501Y mutation. The mutation rate between December - February was detected between 1% and 8%, and the mutation rate increased to 39% to 44% in April and March. While DelH69/70 mutation was detected in December 2020 only, it was observed that N501Y + DelH69/70 variants became dominant as of February 2021, and E484K and N501Y + E484K variants started to appear in March and April. It was observed that the variant rates included DelH69/70 (p < 0.001), N501Y (p < 0.001), N501Y + DelH69/70 (p < 0.001), and N501Y + E484K (p = 0.01) mutations increased significantly according to the months. The E484K mu-tation was significantly higher in males (p = 0.037). There was no differences between mutation rates between the age groups. CONCLUSIONS: Our findings indicate that the appearance of important SARS-CoV-2 variants gradually increases, that rates of mutation increase up to 40% within several months, that the N501Y + DelH69/70 variant gradually becomes to be dominant, and that different variations appear along with mutations.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

The treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.

Spontaneous Cervical Epidural Abscess Caused by Serratia Marcescens.

Serratia marcescens infections are very rare and usually occur in the form of nosocomial and opportunistic infections. The subjects usually have severe medical comorbidities such as immunosuppression, diabetes mellitus, and renal failure. Spontaneous Serratia marcescens infection is very rare. In this case, we demonstrate that it can be seen in the spontaneous cervical epidural abscess. A 54-year female patient presented with a complaint of weakness in the left arm. Cervical magnetic resonance imaging revealed a spinal epidural abscess at the C5-6 level. Surgery was planned for this lesion. The abscess that created a cervical mass effect was totally removed and treatment with oral antibiotics was continued due to S. marcescens growth in the culture. This is the first case where S. marcescens has caused the development of a cervical epidural abscess in a patient without any medical comorbidity. Key Words: Serratia marcescens, Spinal epidural abscess, Vertebral osteomyelitis, Cervical discitis.

Actions of N-acetylcysteine, daptomycin, vancomycin, and linezolid on methicillin-resistant Staphylococcus aureus biofilms in the ventriculoperitoneal shunt infections: an experimental study.

BACKGROUND: Shunt systems are used to provide cerebrospinal fluid drainage in the treatment of hydrocephalus. Recently, antibiotic-impregnated shunt systems are used to prevent colonization in the ventriculoperitoneal catheters. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common causative microorganism of shunt infections. The aim of the study is to investigate effects of several substances on MRSA biofilms in the ventriculoperitoneal catheters. METHODS: The present study consists of mainly eight groups (each has two subgroups as antibiotic-impregnated and nonantibiotic-impregnated catheters). In addition, each group contains six molds using MRSA strains. In this study, daptomycin (DAPT) (2 mg/ml), vancomycin (VAN) (10 mg/ml), linezolid (LIN) (2 mg/ml), N-acetylcysteine (NAC) (6 mg/ml), and various combinations of these substances were used to evaluate the treatment against MRSA using scanning electron microscope (SEM) images and microbiological enumeration. RESULTS: The colony count in the antibiotic-impregnated samples significantly decreased compared to nonantibiotic-impregnated samples in the MRSA, MRSA + DAPT, and MRSA + LIN groups (p < 0.01), respectively. Conversely, the colony count in antibiotic-impregnated samples significantly increased compared to nonantibiotic-impregnated samples in NAC + DAPT and NAC + VAN groups (p < 0.01), respectively. CONCLUSIONS: The results showed that the use of antibiotic-impregnated catheters has a significant impact on the prevention of infection whereas the combination of NAC and DAPT showed better antibiofilm and antibacterial effects than other combinations on the prevention and treatment of nonantibiotic-impregnated catheter infections.

The effect of favipiravir versus hydroxychloroquine on clinical and laboratory findings in COVID-19 in healthcare workers.

OBJECTIVES: Comparative data on hydroxychloroquine and favipiravir, commonly used agents in the treatment of Coronavirus Disease-2019 (COVID-19), are still limited. In this study, it was aimed to compare treatment outcomes in healthcare workers with COVID-19 who were prospectively followed by the occupational health and safety unit. METHODS: A total of 237 healthcare-workers, diagnosed as mild or moderate COVID-19 between March 11, 2020 and January 1, 2021, were given hydroxychloroquine (n = 114) or favipiravir (n = 123). Clinical and laboratory findings were evaluated. RESULTS: The mean age of the patients was 33.4±11.5 years. The mean time to negative PCR was found to be significantly shorter in patients receiving favipiravir compared to the hydroxychloroquine group (10.9 vs. 13.9 days; p < 0.001). The rate of hospitalization in the hydroxychloroquine group was significantly higher than favipiravir group (15.8% vs. 3.3%). In terms of side effects; the frequency of diarrhea in patients receiving hydroxychloroquine was significantly higher than that in the favipiravir group (31.6% vs. 6.5%; p < 0.001). CONCLUSIONS: Favipiravir and hydroxychloroquine were similar in terms of improvement of clinical symptoms of healthcare workers with mild or moderate COVID-19 infection, but favipiravir was significantly more effective in reducing viral load and hospitalization rates. Furthermore, favipiravir caused significantly less side-effects than hydroxychloroquine.

In Vitro Activity of Linezolid, Daptomycin and N-acetylcysteine Agents on Staphylococcus Aureus Biofilms in the Ventriculoperitoneal Shunt Model.

AIM: To examine the effects of N-acetylcysteine (NAC) alone and in combination with linezolid (LIN) and daptomycin (DAPT) on methicillin-sensitive Staphylococcus aureus (MSSA) biofilm formation. MATERIAL AND METHODS: Twelve groups (each containing six molds) of standard ventriculoperitoneal shunts were infected with MSSA. By using microbiological and electron microscopic evaluation methods, NAC was evaluated, alone and in combination with DAPT and LIN, in terms of preventing and eliminating biofilm capacity. The effect of NAC alone and in combination with DAPT and LIN were shown by microbial counts and electron microscopic observation. RESULTS: There was no significant difference in biofilm formation in shunts after different antibiotic treatments. However, the combination of NAC and DAPT had the highest bactericidal effects of all the groups. CONCLUSION: The resistance of bacteria and the dose-dependent effects of antibiotics can be considered.

Outbreak of tularemia: a case-control study and environmental investigation in Turkey.

OBJECTIVE: The aim of this study was to identify the potential factors associated with infection sources and modes of transmission during a recent outbreak (October 2004) of tularemia in Suluova, Turkey. METHODS: Following the diagnosis of five patients with tularemia in October 2004, active surveillance was initiated to identify further cases. This was a matched case-control study with analysis based on the first 43 cases of tularemia (probable or suspected) and 43 matched controls. A probable case was defined as a patient, resident in Suluova, who had signs and symptoms (regional lymphadenopathy and fever) compatible with tularemia and a positive serology or PCR for Francisella tularensis during the period October 21 to November 31, 2004. A suspected case was defined as a patient with compatible signs and symptoms who did not meet the laboratory criteria for a probable case, who also had no laboratory evidence of infection by other microorganisms, and who was resident in Suluova between the same dates. The microagglutination test was used for serological diagnosis. A standardized questionnaire was used to collect information on general demographics, exposure to all known sources of tularemia infection, potential risk factors related to water and animals (i.e., fishing, farming, hunting, and other activities), and the environmental conditions of the house. PCR was used to screen for evidence of the tularemia agents in clinical samples from patients and water samples. RESULTS: The overall attack rate was 2.3 per 1000 population (86/38000). Twenty-eight suspected cases and 15 probable cases of tularemia were included in the study. The most common presenting symptom was lymphadenopathy present in 95.3%, followed by fever (83.7%) and sore throat (79.1%). Twenty-eight out of 43 were reported to have painful lymph nodes. F. tularensis was detected by PCR in samples obtained from the ulcerated lesions of two patients. In the multivariate logistic regression model, keeping a domestic animal in the garden was associated with an increased risk of contracting the disease (OR=10.87; 95% CI: 1.26-93.65; p=0.03). F. tularensis was detected by PCR in the water sample obtained from the rivulet that passes through Suluova. CONCLUSIONS: The results of this study show that case-control studies may be useful for analyzing epidemics and for identifying the source of infection. In order to prevent water-related zoonotic infections, water and sewerage systems should be improved.

Changes in acute viral hepatitis epidemiology in the Turkish adult population: A multicenter study.

BACKGROUND/AIMS: The present study aimed to determine the changes in the epidemiology of hepatitis in recent years in an adult Turkish population. MATERIALS AND METHODS: Overall, 852 patients with acute viral hepatitis from 17 centers were included in this study. Their sociodemographic characteristics, clinical courses, treatments, and laboratory findings were retrospectively analyzed. RESULTS: The most commonly found microorganisms were the hepatitis B virus (55.2%) and hepatitis A virus (37.6%), and the types of acute viral hepatitis differed significantly according to the age group (p≤0.001). The most frequently reported symptom was fatigue (73.7%), and the most common complications were cholecystitis (0.4%) and fulminant hepatitis (0.4%). The median hospital stay was 9 days (range 1-373). In total, 40.8% patients with acute hepatitis B virus developed immunity. CONCLUSION: In Turkey, there are significantly large adolescent and adult populations susceptible to acute viral hepatitis. Therefore, larger vaccination programs covering these age groups should be implemented.

The effect of favipiravir versus hydroxychloroquine on clinical and laboratory findings in COVID-19 in healthcare workers

Abstract Objectives Comparative data on hydroxychloroquine and favipiravir, commonly used agents in the treatment of Coronavirus Disease-2019 (COVID-19), are still limited. In this study, it was aimed to compare treatment outcomes in healthcare workers with COVID-19 who were prospectively followed by the occupational health and safety unit. Methods A total of 237 healthcare-workers, diagnosed as mild or moderate COVID-19 between March 11, 2020 and January 1, 2021, were given hydroxychloroquine (n = 114) or favipiravir (n = 123). Clinical and laboratory findings were evaluated. Results The mean age of the patients was 33.4±11.5 years. The mean time to negative PCR was found to be significantly shorter in patients receiving favipiravir compared to the hydroxychloroquine group (10.9 vs. 13.9 days; p < 0.001). The rate of hospitalization in the hydroxychloroquine group was significantly higher than favipiravir group (15.8% vs. 3.3%). In terms of side effects; the frequency of diarrhea in patients receiving hydroxychloroquine was significantly higher than that in the favipiravir group (31.6% vs. 6.5%; p < 0.001). Conclusions Favipiravir and hydroxychloroquine were similar in terms of improvement of clinical symptoms of healthcare workers with mild or moderate COVID-19 infection, but favipiravir was significantly more effective in reducing viral load and hospitalization rates. Furthermore, favipiravir caused significantly less side-effects than hydroxychloroquine.

A cluster of anthrax cases including meningitis.

We report a common-source outbreak of anthrax. The source of infection was the carcass of a cow. Three patients developed anthrax, which affects meninx, skin and larynx. The patient with meningitis died. In all, 20 people who contacted or ate the cooked meat of the dead cow were given prophylactic tetracycline and remained well. This small outbreak calls for the increased awareness of physicians to this clinical entity in locations in which anthrax is endemic and for health education.

Impact of clinical and laboratory findings on prognosis in leptospirosis.

OBJECTIVE: The aim of this study was to evaluate epidemiological, clinical and laboratory features, and risk factors for mortality in leptospirosis. METHODS: Seventy-two adult leptospirosis cases were reviewed. Categorical clinical and laboratory findings of survivors and non-survivors were assessed by Chi square analysis. Non-categorical findings were assessed by the student t test. Clinical findings and laboratory data with p <0.05 were assessed by stepwise logistic regression analysis for mortality. RESULTS: Of all patients, mean age was 47.3 +/- 15.7 years, 82% were men and, 51% were farmers. Icterus occurred in 75%, and high fever was seen in 61 of the patients. The most frequently detected serotype was Leptospira icterohaemorrhagiae (30%). Overall mortality rate was 17%. In those non-survivors, altered mental status (p = 0.002), hepatomegaly (p = 0.037), haemorrhage (p = 0.019), ALT level (p = 0.008), AST level (p = 0.02), prolonged prothrombin time (p = 0.02) and increased serum potassium levels (p = 0.004) were seen more frequently than in survivors. Altered mental status (p = 0.01, OR: 8.9, CI 95%: 1.6-50.7) and serum potassium levels at hospital admission (p = 0.01, OR: 4.2, CI 95%: 1.4-13.1) were detected as independent risk factors for mortality. CONCLUSIONS: Leptospirosis patients with altered mental status and hyperpotassaemia at hospital admission are at high risk for mortality and should be followed up more closely at the intensive care unit.

Transmission of human immunodeficiency virus and hepatitis B virus by blood brotherhood rituals.

Blood brother/sisterhood is a ritual that involves the exchange of a small amount of venous blood via the binding of excisions. Human immunodeficiency virus (HIV) and hepatitis B virus (HBV) could be transmitted by this ritual. Two cases infected with HIV and HBV by a blood brotherhood ritual are reported.