Ali Acar

Nosocomial infection characteristics in a burn intensive care unit: Analysis of an eleven-year active surveillance

AIMS The objective of this study was to describe nosocomial infection (NI) rates, risk factors, etiologic agents, antibiotic susceptibility, invasive device utilization and invasive device associated infection rates in a burn intensive care unit (ICU) in Turkey. METHODS Prospective surveillance of nosocomial infections was performed according to Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) criteria between 2001 and 2012. The data was analyzed retrospectively. RESULTS During the study period 658 burn patients were admitted to our burn ICU. 469 cases acquired 602 NI for an overall NI rate of 23.1 per 1000 patient days. 109 of all the cases (16.5%) died. Pseudomonas aeruginosa (241), Acinetobacter baumannii (186) and Staphylococcus aureus (69) were the most common identified bacteria in 547 strains. CONCLUSION Total burn surface area, full thickness burn, older age, presence of inhalation injury were determined to be the significant risk factors for acquisition of NI. Determining the NI profile at a certain burn ICU can lead the medical staff apply the appropriate treatment regimen and limit the drug resistance. Eleven years surveillance report presented here provides a recent data about the risk factors of NI in a Turkish burn ICU.

Effects of three different topical antibacterial dressings on Acinetobacter baumannii-contaminated full-thickness burns in rats.

In this animal study, three topical antibacterial dressings, Acticoat, chlorhexidine acetate 0.5% and silver sulfadiazine 1%, were compared in the treatment of Acinetobacter baumannii contamination of burns. All treatments were effective and prevented the organism invading the muscle and causing systemic infection, so there were significant differences between the results of the treatment groups and the control group. Mean eschar concentrations did not differ significantly between the silver sulfadiazine and chlorhexidine acetate groups, but there were significant differences between these and the Acticoat group, indicating that Acticoat eliminated A. baumannii from the tissues more effectively.

HBV, HCV and HIV seroprevalence among blood donors in Istanbul, Turkey: how effective are the changes in the national blood transfusion policies?

The national blood transfusion policies have been changed significantly in recent years in Turkey. The purpose of this study was to determine the prevalence of HBV, HCV, and HIV in blood donors at the Red Crescent Center in Istanbul and to evaluate the effect of changes in the national blood transfusion policies on the prevalence of these infections. The screening results of 72695 blood donations at the Red Crescent Center in Istanbul between January and December 2007 were evaluated retrospectively. HBsAg, anti-HCV, and anti-HIV-1/2 were screened by microparticle enzyme immunoassay (MEIA) method. Samples found to be positive for anti-HIV 1/2 and anti-HCV were confirmed by Inno-Lia HCV Ab III and Inno-Lia HIV I/II Score, respectively. The seropositivity rates for HBsAg, anti-HCV, and anti-HIV-1/2 were determined as 1.76%, 0.07%, and 0.008%, respectively. Compared to the previously published data from Red Crescent Centers in Turkey, it was found that HBV and HCV seroprevalances decreased and HIV seroprevalance increased in recent years. In conclusion, we believe that the drop in HBV and HCV prevalence rates are likely multifactorial and may have resulted from more diligent donor questioning upon screening, a higher level of public awareness on viral hepatitis as well as the expansion of HBV vaccination coverage in Turkey. Another factor to contribute to the decreased prevalence of HCV stems from the use of more sensitive confirmation testing on all reactive results, thereby eliminating a fair amount of false positive cases. Despite similar transmission routes, the increase in HIV prevalence in contrast to HBV and HCV may be linked to the increase in AIDS cases in Turkey in recent years.

Increasing incidence of Gram-negative organisms in bacterial agents isolated from diabetic foot ulcers

INTRODUCTION In the present study, we sought to identify the bacterial organisms associated with diabetic foot infections (DFIs) and their antibiotic sensitivity profiles. METHODOLOGY We retrospectively reviewed the records of wound cultures collected from diabetic patients with foot infections between May 2005 and July 2010. RESULTS We identified a total of 298 culture specimens (165 [55%] wound swab, 108 [36%] tissue samples, and 25 [9%] bone samples) from 107 patients (74 [69%] males and 33 [31%] females, mean age 62 ± 13 yr) with a DFI. Among all cultures 83.5% (223/267) were monomicrobial and 16.4% (44/267) were polymicrobial. Gram-negative bacterial isolates (n = 191; 61.3%) significantly outnumbered Gram-positive isolates (n = 121; 38.7%). The most frequently isolated bacteria were Pseudomonas species (29.8%), Staphylococcus aureus (16.7%), Enterococcus species (11.5%), Escherichia coli (7.1%), and Enterobacter species (7.1%), respectively. While 13.2% of the Gram-negative isolates were inducible beta-lactamase positive, 44.2% of Staphylococcus aureus isolates were methicillin resistant. CONCLUSIONS Our results support the recent view that Gram-negative organisms, depending on the geographical location, may predominate in DFIs.

Hantavirus Infection in Istanbul, Turkey

To the Editor: More than 20 serotypes of hantavirus have been identified, and 11 infect humans. Puumala virus (PUUV), Dobrava virus (DOBV), and Seoul virus cause different forms of hemorrhagic renal syndrome (1,2). DOBV is endemic to Turkey and countries in the Balkan region. Approximately 10,000–12,000 cases of infection with PUUV and DOBV occur in European Russia each year (3). Initial case reports identified a hantavirus epidemic (laboratory confirmed) in February 2009 that involved 12 persons in Bartin and Zonguldak in western Turkey near the Black Sea. The hantavirus responsible for this epidemic was a PUUV subtype (4). We report a man infected with DOBV in Turkey who died 2 days after admission to an intensive care unit (ICU). The patient was a 22-year-old man who lived near Istanbul, Turkey. He was admitted to the Silivri State Hospital in March 2010 because of fatigue, diffuse pain, nausea, and vomiting. Approximately 2 hours after admission, ecchymotic rashes developed on his upper extremities and spread to other areas. His general condition worsened, and 15 hours later, he was transferred to the ICU of the Emergency Service of Gulhane Military Medical Academy Haydarpasa Training Hospital. His medical history did not include exposure to rodents or any travel. At admission to the ICU, his general condition was poor, and his speech was garbled and incoherent. He had a body temperature of 37.2°C, a pulse of 140 beats/min, an arterial blood pressure of 90/60 mm Hg, diffuse hemorrhagic foci, and a disseminated ecchymotic rash. Laboratory test results showed the following: 13,200 leukocytes/mm3, 92% polymorphonuclear leukocytes, hemoglobin 11.6 mg/dL, 385,000 platelets/mm3, alanine aminotransferase 62 IU/mL, aspartate aminotransferase 170 IU/mL, creatine phosphokinase 2,115 IU/L, lactate dehydrogenase 1,109 IU/L, urea 65 mg/dL, creatinine 3.78 mg/dL, prothrobin time 24.8 s, activated partial thromboplastin time 116.3 s, potassium 2.9 mEq/L, C-reactive protein 326 mg/dL, and erythrocyte sedimentation rate 132 mm/h. Subsequently, urinary output decreased and respiratory functions worsened. He then lost consciousness and was subjected to mechanic ventilation. Lumbar puncture was not performed because of risk for bleeding (high international normalized ratio values for blood coagulation and thrombocytopenia). Cranial computed tomographic scan did not show any pathologic changes. Treatment with ceftriaxone, 4 g/day intravenously, was initiated, and the dose was adjusted according to creatinine clearance because of suspected meningococcemia. A single dose of prednisolone, 80 mg intravenously, was given concomitantly. Bacterial growth was not observed in cultures of urine and blood samples. The Hanta Profile 1 EUROLINE Test (Euroimmun, Luebeck, Germany) was used to detect immunoglobulin (Ig) G and IgM against 3 hantavirus serotypes (PUUV, DOBV, and Hantaan virus). Results of a hantavirus IgM immunoblot test were positive for DOBV. The QIAamp viral RNA Mini Extraction Kit (QIAGEN, Hilden, Germany) was used for extraction of viral RNA. PUUV and DOBV RNA in serum and urine samples were investigated by using an in-house real-time PCR (Rotorgene; QIAGEN). DOBV RNA was detected in urine samples by PCR (Table). Table Detection of Dobrava virus in 22-year-old patient, Turkey* Meningococcemia, acute hemorrhagic fever, and Crimean-Congo hemorrhagic fever were considered in the differential diagnosis for the patient. Other diseases were excluded by biochemical, serologic, and microbiologic test results. Hantavirus infection was diagnosed in this patient on the basis of criteria recommended by the European Network for Diagnostics of Imported Viral Diseases (5). On the second day of treatment, the patient died of cardiopulmonary arrest. The patient had worked as a security guard in a new prison located in an area that had contained oak and hornbeam forests. DOBV is carried by rodents (Apodemus flavicollis), and the habitat of this rodent in Europe is open oak or beech forest. In a field study performed in rural areas of Turkey near the Black Sea and Aegean Sea, hantavirus was detected in Microtus spp. voles (6). In another study performed in regions near the Aegean Sea, DOBV was detected in 7 (3.5%) of 200 patients with acute or chronic renal failure (7). However, information about specific regions in Turkey in which hantavirus is endemic is limited. Hantavirus infections, which were first identified in northwestern Turkey in 2009 and subsequently in Istanbul, should be considered in the diagnosis of patients who have fever and bleeding. Because of recent emergence of hantavirus in Turkey, areas to which this virus is endemic and where risk for infection is highest have not been identified. Therefore, all inhabitants at high risk for infection (forest workers, military personnel, farmers, persons living in or near a forest, persons handling wood) should be informed about this risk.

Comparison of silver-coated dressing (Acticoat®), chlorhexidine acetate 0.5% (Bactigrass®) and nystatin for topical antifungal effect in Candida albicans-contaminated, full-skin-thickness rat burn wounds

BACKGROUND In this experimental animal study, the effects of three different topical antimicrobial dressings on Candida albicans contaminated full-thickness burn in rats were analyzed. METHODS In total 32 adult Wistar rats (body weight 200-220 g) were used. Silver-coated dressing (Acticoat™®), chlorhexidine acetate 0.5% (Bactigrass®) and Mycostatine (Nystatin®) were compared to assess the antifungal effect of a once-daily application on experimental rat 15% full-skin thickness burn wound seeded 24h earlier with a 10(8) CFU/mL standard strain of C. albicans ATCC 90028. All the animals were sacrificed at post burn day 7. The quantitative counts of seeded organism in burn eschar and subjacent muscle were determined, in addition to the cultures of left ventricle blood and lung biopsies. RESULTS While there were significant differences between Acticoat™® group (4 ± 10 × 10(4)) and control group (5 ± 6 × 10(6)), and between Nystatin group (4 ± 4 × 10(4)) and control group (P=0.01, P=0.01), there were no significant differences between chlorhexidine acetate 0.5% group (2 ± 3 × 10(4)) and control group (P=0.7) respectively. Acticoat™® and Nystatin were sufficient to prevent to C. albicans from invading to the muscle and from causing systemic infection. CONCLUSIONS The animal data suggest that nystatin is the most effective agents in the treatment of C. albicans-contaminated burn wounds, and Acticoat™® is a choice of treatment on fungal burn wound infection with antibacterial effect and the particular advantage of limiting the frequency of replacement of the dressing.

The significance of repeat testing in Turkish blood donors screened with HBV, HCV and HIV immunoassays and the importance of S/CO ratios in the interpretation of HCV/HIV screening test results and as a determinant for further confirmatory testing

The purpose of this study was to investigate the intra‐assay correlations amongst initial reactive and repeat screening results used in enzyme immunoassays (EIAs) for hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV in blood donors. This study evaluated the value of using the power of the signal to cut‐off (S/CO) ratio index for confirming anti‐HCV/HIV reactive screening results, thereby touching upon the utility of S/CO indices in determining whether further confirmatory testing was necessary. Screening test results of the 72 695 blood donors were evaluated over a 1‐year period. Correlation analysis among each initial test and retests was done by Pearson r test. Appropriate S/CO values to determine the need of the confirmation testing was investigated by ROC analyses. EIA intra‐assay correlations were of statistical significance and were determined as follows: 0·948 for anti‐HCV, 0·827 for anti‐HIV and 0·948 for HBsAg. The threshold S/CO ratio values which predicted more than 95% of the confirmation test result were 3·8 for HCV and 5·6 for HIV. We were able to demonstrate a strong level of intra‐assay correlation amongst EIAs, thereby eliminating the need for repetition of the screening test. Hence, we suggest that repeat screening should only be limited to HBV and HIV tests with low EIA S/CO ratios. Thus, using the power of the S/CO ratio in determining the need for HCV confirmation testing can be a cost‐effective measure, especially if the S/CO value is ≥3·8.

Surgical site infection rates in 16 cities in Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

BACKGROUND Surgical site infections (SSIs) are a threat to patient safety; however, there were no available data on SSI rates stratified by surgical procedure (SP) in Turkey. METHODS Between January 2005 and December 2011, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in 20 hospitals in 16 Turkish cities. Data from hospitalized patients were registered using the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) methods and definitions for SSIs. Surgical procedures (SPs) were classified into 22 types according to International Classification of Diseases, Ninth Revision criteria. RESULTS We recorded 1879 SSIs, associated with 41,563 SPs (4.3%; 95% confidence interval, 4.3-4.7). Among the results, the SSI rate per type of SP compared with rates reported by the INICC and CDC NHSN were 11.9% for ventricular shunt (vs 12.9% vs 5.6%); 5.3% for craniotomy (vs 4.4% vs 2.6%); 4.9% for coronary bypass with chest and donor incision (vs 4.5 vs 2.9); 3.5% for hip prosthesis (vs 2.6% vs 1.3%), and 3.0% for cesarean section (vs 0.7% vs 1.8%). CONCLUSIONS In most of the 22 types of SP analyzed, our SSI rates were higher than the CDC NHSN rates and similar to the INICC rates. This study advances the knowledge of SSI epidemiology in Turkey, allowing the implementation of targeted interventions.

Hepatitis B virus reactivation in a Juvenile Rheumatoid arthritis patient under treatment and its successful management: a complicated case

Juvenile rheumatoid arthritis is a common chronic inflammatory disease in the childhood and it can differentiate rarely into spondiloarthropaties. It is one of the important causes of chronic pain and disability. Some of the drugs used for the treatment have immunosupressive activity. One of the serious side-effects of immunosupressive treatment is activation of opportunistic pathogens. Hepatitis B virus (HBV) is one of these pathogens, and the rate of carriers in the population is considerably high. It can cause liver damage and death if reactivated. Thus, the management of oppotunistic pathogens becomes a complex issue when treating rheumatic diseases with immunosupressive drugs. In this case report, we present a juvenile rheumatoid arthritis patient whose liver enzymes raised while he was under treatment and afterwards HBV reactivation was determined as the cause. When reactivation was detected, we started controlled antiviral therapy. We achieved successful clinical and laboratory results after adding biological agents to the treatment. Careful evaluation of the patients who have indication for immunosuppressive agents and regular follow-up in case of infection may be protective from severe morbidity and/or mortality.

Burn caused by pressure cookers.

Dietary and food service employees use pressure cookers to cook food. Despite widespread use of pressure cookers, a few burn cases have been reported in the literature. We report a case of 44-year-old man who suffered secondand third-degree burn of his arms, shoulders, neck, chin, and face as the result of contact steam. The patient was cooking in the kitchen and used a pressure cooker to make pea soup from split peas. When he removed the lid from the pressure cooker, boiling hot peas escaped. Burn areas were dressed every day, and antibiotic therapy was begun. The burn area was treated conservatively within 5 weeks. Pressure cooking is a method of cooking in a sealed vessel that does not permit air or liquids to escape below a preset pressure. It is typical for the pressure of venting to be about 15 psi above atmospheric pressure. That raises the boiling point to about 121°C or 257°F. This steam may cause serious burns. These burns have a tendency to affect a relatively small BSA but cause a deep localized burn because of the high boiling point. The following quick and cheap preventive measures should be taken: