Bilge Aldemir Kocabaş

The use of colistin in critically ill children in a pediatric intensive care unit.

Background: Colistin is active against most multidrug-resistant, aerobic Gram-negative bacteria. Because of the reported nephrotoxicity during the first years of use of colistin, there were concerns of its use in pediatrics where there was limited experience The aim of this study is to document the clinical characteristics and outcomes of use of colistin in pediatric patients at a pediatric intensive care unit in Turkey. Methods: We reviewed the medical and laboratory records of 29 critically ill children who were treated with colistin for 38 courses between January 2011 and December 2011 at the Department of Pediatric Intensive Care Unit in Ankara University Medical School, Turkey. Results: The median age was 17 months (range 3–217 months). Male-to-female ratio was 1:1.37. Ventilator-associated pneumonia (21 courses) was the leading diagnosis followed by catheter-related blood stream infection (6 courses), bacteremia (4 courses), ventriculoperitoneal shunt infection, peritonitis and pneumonia (1 course). The most commonly isolated microorganisms were Acinetobacter baumanni, Pseudomonas aeruginosa, Klebsiella pneumoniae, Serratia marcescens, Stenotrophomonas maltophilia, and Enterobacter cloacae. Two colistin formulations were used. Colimycin (Kocak Farma) was used in 21 colistin treatment episodes. The median dosage of colistin in this group was 5.0 mg/kg/d (2.3–5.6 mg/kg/d). Colomycin (Forest Laboratories) was used in 17 colistin treatment episodes. The median dosage of colistin in the second group was 75,000 International Unit/kg/d (50,000–80,000 International Unit/kg/d). Thirty colistin treatment episodes (79%) had a good or partial clinical response and 8 (21%) had a poor clinical response. Of the 8 colistin treatment episodes with poor clinical response, 3 were in the Colimycin group and 5 were in the Colomycin group. Ten patients died. There was no evidence of neurotoxicity in this study. Nephrotoxicity was observed in 1 patient but was not attributed to colistin because the patient had multiorgan failure at the same time. Conclusions: This study in a small cohort of patients suggests that the use of colistin in severe nosocomial infections caused by multidrug-resistant Gram-negative bacteria is well-tolerated and efficacious.

Anti-N-methyl-D-aspartate receptor encephalitis that developed after herpes encephalitis: a case report and literature review.

Herpes encephalitis (HE) is among the most common forms of viral encephalitis. Earlier publications indicate the development of acyclovir-refractory choreoathetosis in patients with HE. These reports suggest the development of secondary autoimmunity in the pathogenesis of HE. Combined methylprednisolone and acyclovir treatment reduced the appearance of brain abnormalities relative to treatment with acyclovir alone in a mouse model of encephalitis. We describe a case of a 19-month-old previously healthy girl presenting with sudden onset seizures and loss of consciousness. Initial polymerase chain reaction (PCR) tests for the presence of herpes simplex virus (HSV) were negative as were the tests for the limbic encephalitis antibodies. Steroids were administered with acyclovir to treat suspected autoimmune encephalitis as a result of the patient history of varicella vaccination. HSV PCR testing was positive on the 5th day; however, steroid treatment was continued due to the positive response seen in the patient. Steroid therapy was reduced on the 25th day of treatment due to the development of upper respiratory tract infection and the patient developed orofacial dyskinesia and choreoathetoid movements on the 28th day. Antibodies against N-methyl-d-aspartate receptor were detected in the in the serum and cerebrospinal fluid (CSF) on the 28th day. This case is an example of the emergence of autoimmune symptoms in the pathogenesis of HE.

Underlying Diseases and Causative Microorganisms of Recurrent Pneumonia in Children: A 13-Year Study in a University Hospital

Abstract Pneumonia is a significant cause of death for children, particularly those in developing countries. The records of children who were hospitalized because of pneumonia between January 2003 and December 2015 were retrospectively reviewed, and patients who met the recurrent pneumonia criteria were included in this study. During this 13-year period, 1395 patients were hospitalized with pneumonia; of these, 129 (9.2%) met the criteria for recurrent pneumonia. Underlying diseases were detected in 95 (73.6%) patients, with aspiration syndrome (21.7%) being the most common. Rhinovirus (30.5%), adenovirus (17.2%) and respiratory syncytial virus (13.9%) were the most frequent infectious agents. These results demonstrate that underlying diseases can cause recurrent pneumonia in children. Viruses are also commonly seen in recurrent pneumonia. Appropriate treatments should be chosen based on an analysis of the underlying disease, the patient’s clinical condition and the laboratory and radiological data.

A case with atypical hand-mouth-foot disease accompanying with onicomadesis and a small-scale outbreak

Hand-mouth-foot disease is generally caused by Coxsackievirus A16 and Enterovirus 71, which are subtypes of enteroviruses, and it can lead to outbreaks in the people. Recently, an atypical form of disease has been described which consists of different characteristics from classical form. It differs from the classical form of disease with widespread distribution of vesiculobullous skin lesions on the trunk and neck, high rate of ulcerate and bullous formation, crusted and scabbed lesions and onychomadesis. Herein, we reported a 17-month-old child with atypical hand-foot-mouth disease. He was firstly diagnosed with eczema herpeticum, lead to a small outbreak, and healed with onicomadesis. We pointed out atypical enteroviral diseases in infants especially presented with eczema herpeticum and negative tests for herpesviruses. Unnecessary use of acyclovir could be avoided if atypical manifestations of disease are well known. Also, hospital and community outbreaks can be prevented by taking protective measures.

P271 Underlying disease and causative microorganisms of recurrent pneumonia in children: 13-year study in a university hospital

Background and aims Pneumonia is the most important cause of death in children in many countries. The use of inappropriate antibiotics in the treatment of pneumonia is associated with multi drug resistant microorganisms that lead to increased morbidity and mortality. Therefore, the causative microorganism should be detected for avoidence of unnecessary antibiotic usage. Underlying diseases are predisposing factors for recurrent pneumonia. The choice of pneumonia treatment should be based on causative microorganisms and underlying diseases. In this study we aimed to evaluate the frequency of recurrent pneumonia and underlying disease in hospitalised children, to identify the distribution of causative microorganisms and to compare our data with previous studies. Methods Between January 2003 and December 2015 children hospitalised due to pneumonia were retrospectively owerviewed. The patients who met criteria for recurrent pneumonia were included in this study. Demographic, clinical, laboratory and imaging results were collacted from the data system. Results During 13 years, 129 (9.2%) hospitalised children met criteria of recurrent pneumonia. Underlying diseases were detected in 95 (73.6%) patients. Rhinovirus, adenovirus and respiratory synstial virus were the most frequent causative agents. Conclusion The majority of patients who were hospitalised due to recurrent pneumonia had an underlying disease. The most common cause was aspiration syndrome and viruses were leading causative agents for recurrent pneumonia. As a result; It should kept in mind that viruses can be commonly seen in recurrent pneumonia. Appropriate treatment choice should be made according to the underlying disease, clinical condition, laboratory and radiological data of the patient.

P270 Clinical characteristics of childhood hydatid disease: a single tertiary centre experience from turkey

Background and aims Hydatid disease is a parasitic infection and it is a major health problem in some areas. We aimed to evaluate the demographic and clinical findings of patients with hydatid disease in our hospital and to compare our results with previous studies. Methods Between January 2009 and December 2015, patients who were diagnosed as hydatid disease in our hospital, were included retrospectively in this study. Demographic characteristics, clinical findings, laboratory and imaging results, treatment modalities and complications were collected. Results Twenty-eight patients were involved in our study. Patients often admitted to hospital with chest pain, cough, fever, abdominal pain, nausea and vomiting. The median age of patients’ was 134 (55-197) months. Twenty (71.4%) patients were male. The most common physical finding was decreased breath sounds. Most frequently affected organs were liver (71.4%) and lungs (57.1%). In addition cysts were detected atypical locations such as heart (n=2), brain (n=2), spleen (n=2), pancreas (n=1), kidney (n=1) and pelvis (n=1). Medical treatment was given in all patients with hydatid disease. Treatment modalities were as follows: 60.7% (17/28) surgical treatment, 14.3% (4/28) interventional radiologic drainage, 21.4% (6/28) only medical treatment and 3.6% (1/28) interventional radiology drainage and surgery treatment together. Post operative complications were bile leakage, cholangitis, pneumothorax and fistula. No mortality occurred, but recurrence was seen in 1 (3.6%) patient. Conclusions Hydatid disease is an important problem in our country. In patients with hydatid disease, there might be multiple organ involvement at the same time. Therefore, advanced imaging methods such as abdominal ultrasonography, echocardiography, and brain magnetic resonance should be used for the detection of localised atypical cysts for all patients. Clinical findings and location of the cysts may help deciding the choice of treatment. Long term outcomes are satisfactory with adequate treatment.

P268 Bloodstream infections in paediatric immunocompromised patients, responsible pathogens, antibiotic susceptibility patterns and treatment outcomes: experience of single centre in turkey

Background and aims Bloodstream infections are the major cause of morbidity, increased cost, prolonged hospitalisation and mortality in paediatric haematology and oncology patients. We aimed to identify causative microorganisms and their antimicrobial susceptibilities in paediatric immunocompromised patients. Methods Patients with haematological and/or oncological diseases who admitted to our hospital with fever between January 2010 and November 2015 were included in this study. Patients’ demografic and clinical findings were collected from hospital information systems and microbiology laboratory records retrospectively. Results Totally 71 paediatric patients who had 111 bloodstream infection episodes were included in this study. The median age of patients was 90 (3-247) months. The most underlying disease was acute lymphoblastic leukaemia. While 31 patients had only peripheral blood culture positivity, 80 patients had catheter related blood stream infections. Of 80.2% blood stream infections occurred in neutropenic period. Responsible pathogens were detected as follows: 35.1% gram-positive microorganisms, 60.5% gram-negative bacteria and 4.4% fungi. The most causative gram negative pathogen was Escherichia coli and the most isolated gram positive microorganism was meticillin resistant coagulase negative Staphylococci. Extended spectrum beta lactamase was produced by 60% of Klebsiella spp. and 42.1% of E. coli. In addition carbapenemase producing E. coli and Klebsiella spp. were 15.8% and 26.7% respectively. Enterococcus spp. had 88.9% ampicillin resistance and%33.3 vancomycin resistance. Bloodstream infection related mortality rate was 2.7%. Conclusion Gram negative microorganisms were predominant pathogens in bloodstream infections. Extended spectrum beta lactamase and carbapenem resistance were increasingly important and they limited treatment options. The choice of empiric antimicrobial drug in immunosuppressed patients is life-saving. For all these reasons, the choice of empirical antibiotics should be made according to the clinical condition of the patient and the prevalent microorganisms in the current clinic, as favourable antimicrobial therapy will be able to achieve positive clinical outcomes.

P272 The importance of directly observed therapy in perinatal tuberculosis

9.5 month-old boy presented with a one-month history of cough and lymphadenopathy. The mother was diagnosed with pulmonary tuberculosis when the baby was 1,5 months old. Thus, the breastfeeding was stopped and isoniazid prophylactic therapy was recommended to baby. However, the treatment was only applied between 6–9 months old by the family. He was evaluated for pneumonia at first and nonspecific antibiotic therapies were started. After ten-day treatment, the symptoms didn’t get better. He was again evaluated and three serial samples of gastric aspirates that sent for ARB and Tbc PCRes were positive. Chest CT revealed that concerning the whole middle and lower lobes in the right lung at the widespread consolidation area, necrotic areas where the largest reached over 23 × 13 mm was monitored. He was administered a four-drug anti-tuberculous treatment of INH (11.5 mg/kg), rifampicin (15 mg/kg), pyrazinamide (25 mg/kg), etambuthol (18.75 mg/kg). At the first month of treatment all acid fast stains and PCR were negative. Even though ChestCT were the same, findings showed remarkable improvement After 2 months the child was discharged to his home with two-drug- maintence therapy. As well as early diagnosis and treatment, directly observed therapy is crucial in tuberculosis.