Deniz Akduman

Colistin vs. the combination of colistin and rifampicin for the treatment of carbapenem-resistant Acinetobacter baumannii ventilator-associated pneumonia.

The aim of this study was to compare the responses of colistin treatment alone vs. a combination of colistin and rifampicin in the treatment of ventilator-associated pneumonia (VAP) caused by a carbapenem-resistant A. baumannii strain. Forty-three patients were randomly assigned to one of two treatment groups. Although clinical (P = 0·654), laboratory (P = 0·645), radiological (P = 0·290) and microbiological (P = 0·597) response rates were better in the combination group, these differences were not significant. However, time to microbiological clearance (3·1 ± 0·5 days, P = 0·029) was significantly shorter in the combination group. The VAP-related mortality rates were 63·6% (14/22) and 38·1% (8/21) for the colistin and the combination groups (P = 0·171), respectively. Our results suggest that the combination of colistin with rifampicin may improve clinical and microbiological outcomes of VAP patients infected with A. baumannii.

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

BackgroundInitial 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).MethodsWe 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.ResultsSixty 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.ConclusionOur 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.

Platelet and mean platelet volume kinetics in adult patients with sepsis

Abstract The aims of this study were to evaluate the kinetics of platelet counts and mean platelet volume (MPV) in adults with sepsis and to determine whether the responses are infection-specific. This retrospective cohort study included patients admitted to a tertiary-care teaching hospital with microbiologically proven nosocomial sepsis between January 2006 and January 2011. Platelet counts and MPV measurements were examined daily for 5 days after the onset of sepsis. During the study period, 151 of the 214 sepsis episodes were associated with thrombocytopenia. Gram-positive microorganisms were the most frequently isolated. The decrease in platelet counts was statistically significant for the first 3 days of sepsis in Gram-positive septic patients, for 4 days in Gram-negative septic patients and for all 5 days in fungal septic patients (p < 0.001). The increase in MPV values was statistically significant for the first 3 days of sepsis in Gram-positive septic patients and for all 5 days in the other groups (p < 0.001). We conclude that fungal sepsis has a stronger association with thrombocytopenia and increased MPV.

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.

Fourteen-Year Trend of Tuberculosis Dynamics in the Northwest of Turkey

Background: The incidence of tuberculosis (TB) in different countries as estimated by the World Health Organization (WHO) vary from 23/100,000 and less in industrialized countries, 191/100,000 in Africa and 237/100,000 in South East Asia. Objectives: The aim of this study was to analyze the dynamics of TB in the northwest of Turkey, between 1988 and 2001. Methods: All pulmonary TB cases reported to the National Tuberculosis Center by local TB dispensaries during 1988–2001 were analyzed. The number of new and relapsed TB cases were documented and classified according to age and type of TB (standard classification of TB patients according to disease type: pulmonary, new, smear positive; pulmonary, smear negative; relapse, and extrapulmonary). We recorded information about the prevalence of TB in different patient groups (patients with a contact history, patients who were detected in active community screening or passive case finding), TB trends in different age groups, type of TB, patients who had relapses, percentage of patients who were lost to follow-up. Results: A total number of 288,996 patients were examined at Zonguldak Tuberculosis Dispensary between 1988 and 2001. Case notification rates of TB decreased over the study period. Respiratory TB was the most commonly encountered form of disease (>90%). The percentage of TB decreased in the 0- to 14-, 15- to 24-year-olds and increased in the 25- to 44- and 45- to 64-year-olds. Conclusion: Properly designed disease surveillance systems are critical for monitoring the TB trends so that each country can identify its own high-risk groups and target interventions to prevent, diagnose, and treat the disease.

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

Abstract 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.

Health-care associated bacteremia in geriatric cancer patients with febrile neutropenia.

OBJECTIVE The aim of this study was to determine the epidemiology, clinical manifestations, and outcome of health-care associated bacteremia in geriatric cancer patients with febrile neutropenia. MATERIALS AND METHODS We retrospectively evaluated cancer patients with febrile neutropenia aged ≥60years with culture proven health-care associated bacteremia between January 2005 and December 2011. The date of the first positive blood culture was regarded as the date of bacteremia onset. Primary outcome was the infection related mortality, defined as the death within 14days of bacteremia onset. RESULTS The two most common pathogens responsible for bacteremia were Staphylococcus epidermidis (36.1%) and Escherichia coli (31.5%), with high rates of methicillin resistance and extended-spectrum β-lactamase (ESBL) production, respectively. There were no statistically significant differences in infection related mortality rate according to the type of malignancy (p=0.776). By the univariate analysis, factors associated with 14day mortality among febrile neutropenic episodes were prolonged neutropenia (p=0.024), persistent fever (p=0.001), hospitalization in ICU (p<0.001) and the initial clinical presentations including respiratory failure (p<0.001), hepatic failure (p=0.013), hematological failure (p<0.001), neurological failure (p<0.001), severe sepsis (p<0.001), and septic shock (p=0.036). Multivariate analysis showed that persistent fever was an independent factor associated with infection related mortality (odds ratio, 18.0; 95% confidence interval, 5.2-62.6; p<0.001). CONCLUSIONS The only independent risk factor for mortality was persistent fever. Although the most frequently isolated pathogens were S. epidermidis and E. coli, high rates of methicillin resistance and ESBL production were found respectively.

Thrombocyte and Erythrocyte Indices in Sepsis and Disseminated Intravascular Coagulation

Thrombocyte and Erythrocyte Indices in Sepsis and Disseminated Intravascular Coagulation Sepsis is the inflammatory response against infection. The existence of DIC during sepsis indicates a poor prognosis and coagulation abnormalities and thrombocytopenia may exist. The aim of this study was to investigate platelet and erythrocyte indices in sepsis patients with DIC and without DIC. In both groups coagulation tests, platelet count and indices, erythrocyte count and indices were retrospectively analysed. In the sepsis plus DIC patients the prothrombin time and D-dimer values were found significantly higher and fibrinogen, platelet and plateletcrit were found significantly lower than in the sepsis without DIC group. The analysis of mean platelet volume, platelet distribution width, erythrocyte count and indices revealed no significant differences between the two groups. These results showed us that the depression of bone marrow in septic patients with DIC and without DIC did not differ. The activation of the coagulation system might probably be the cause of thrombocyte depletion in DIC. Trombocitni i Eritrocitni Indeksi u Sepsi i Diseminovanoj intravaskularnoj Koagulaciji Sepsa predstavlja inflamatorni odgovor na infekciju. Prisustvo diseminovane intravaskularne koagulacije (DIK) tokom sepse ukazuje na lošu prognozu, a mogu se javiti i poremećaji u koagulaciji i trombocitopenija. Cilj ove studije bio je da se ispitaju trombocitni i eritrocitni indeksi kod pacijenata sa sepsom i DIK, odnosno sepsom bez DIK. U obe grupe retrospektivno su analizirani testovi koagulacije, broj i indeks trombocita i broj i indeks eritrocita. Kod pacijenata sa sepsom i DIK, protrombinsko vreme i vrednosti D-dimera bili su značajno povišeni, dok su fibrinogen, trombociti i trombocitokrit bili značajno niži nego u grupi sa sepsom bez DIK. Prilikom analize srednje zapremine trombocita, širine distribucije trombocita i broja i indeksa eritrocita nisu otkrivene značajne razlike između dve grupe. Ovakvi rezultati ukazuju na to da kod pacijenata sa sepsom i DIK i pacijenata sa sepsom bez DIK nema razlika u depresiji koštane srži. Aktivacija koagulacijskog sistema predstavlja mogući uzrok manjka trombocita u DIK.

Herpes simplex virus encephalitis in pregnancy

Herpes simplex encephalitis (HSE), which is an uncommon condition, is a significant cause of neurological impairment in pregnant women. Assessment of fetal contamination remains a problem. Up to now only a few pregnant HSE cases have been reported in the literature [1]. We report a case of HSE in the third trimester of pregnancy who was treated with acyclovir and recovered completely to deliver a healthy child at term. A 26-year-old woman, gravida 1 para 0, at 25 weeks of gestation was admitted to our hospital with a five-day history of fever, headache, and nausea and a 12-hour history of mental status changes. Her symptoms were initially attributed to acute sinusitis, and cefuroxime axetil p.o. had been started four days previously. The day before admission she had begun to display personality changes and abnormal behaviors. On admission, her blood pressure was 140/90 mmHg and her temperature was 398C. Physical and neurological examinations were unremarkable and signs of meningeal irritation were absent. Her laboratory test results were as follows: leukocyte count 156 10/mm, hemoglobin 10.2 g/dL, C-reactive protein þ, erythrocyte sedimentation rate 31 mm/h; platelet count, blood biochemistry tests, and urinalysis were normal. Lumber puncture (LP) was performed, which showed normal cerebrospinal fluid (CSF) pressure, with 70 white cells (90% polymorphonuclear cells) and 40 red cells per mm. CSF protein was 51.66 mg/dL, CSF glucose was 64.36 mg/dL, and blood glucose was 134 mg/dL. Acid-fast and Gram stains revealed no positive results. An initial diagnosis of poorly treated bacterial meningitis and encephalitis was made and ceftriaxone 26 2 g i.v. and acyclovir 36 750 mg i.v. was started. On the second day of admission she suffered a generalized tonic-clonic epileptic seizure and phenytoin therapy was added. CSF culture was negative. On follow-up she remained febrile and her conscious state deteriorated, hence on day 3, ceftriaxone was ceased and meropenem 36 2 g i.v. was started in addition to acyclovir. An electroencephalogram (EEG) showed diffuse slowing with an epileptic activity in the right frontal region. On the same day, a cerebral magnetic resonance imaging (MRI) was performed showing increased signal and edema in the right temporal region. Dexamethasone therapy was started. On day 5 she became afebrile but remained drowsy over the following two days. On day 7 her conscious state improved and the results of the herpes simplex virus (HSV) type I polymerase chain reaction (PCR) on the initial CSF sample was positive confirming the diagnosis of HSE. She had no evidence of genital or disseminated HSV infection. HSV type I and type II IgM and HSV type II IgG were negative, and HSV type I IgG was positive in serum. Meropenem was ceased and the patient received a 21-day course of acyclovir with a rapid improvement in her condition. During the course of the disease, fetal ultrasound monitoring was normal. Dexamethasone was continued in a reducing regimen until day 28. One week after discharge, a control EEG showed normal

Tricuspid endocarditis causing massive pulmonary embolism in a non-addicted patient without any underlying cardiac disease.

Sir, A 75-y-old female presented at our hospital with a 2-month history of fever, fatigue and sweating. She was previously healthy and had no underlying diseases or percutaneous intervention history. Chest tomography revealed multiple lung abscesses and transthoracic echocardiogram revealed a 2 /4 cm multilobar mobile vegetation on the tricuspid valve (Fig. 1). All blood cultures grew Staphylococcus aureus and a definitive diagnosis of right-sided endocarditis with septic pulmonary abscesses was established. The patient was treated with vancomycin plus gentamicin. Early resection of the vegetation was planned but cardiovasculary surgery could not be performed because of the profound thrombocytopenia despite multiple transfusions of thrombocyte suspensions. Her blood cultures became sterile on the fifth d of antibiotic therapy but fever persisted. The whole vegetation embolized to the right pulmonary artery on the fifth d of admission. Her medical status deteriorated despite supportive care and she died on d 11. Right-sided infective endocarditis accounts for 10% of all cases of infective endocarditis and predominantly occurs in intravenous drug users, patients with pacemakers or central venous lines, and with congenital heart diseases (1). Vegatations can cause thromboembolic complications during the course of both rightsided and left-sided infective endocarditis. There is debate as to whether characteristics of the vegetation by echocardiography can predict complications such as embolization. Some authors have found no relation between embolic episodes with regard to vegetation size or mobility (2), whereas others have reported increased mortality and embolization with larger vegetations (3, 4). In a series reported recently by Deprele et al., mobile vegetations /1 cm in size were associated with an increased risk of embolic episodes in infective endocarditis (5). Durante et al. reported that patients with infective endocarditis with large vegetation are at increased risk of major embolic complications during the in-hospital course of the disease (6). Large size vegetations in right-sided endocarditis can cause massive pulmonary embolism (7). In selected patients with huge and mobile vegetations, early surgical intervention may improve survival. Indications for early surgical intervention in right-sided endocarditis are defined: persistent infection, presence of severe right-sided heart failure, multiple embolic episodes, infection with S. aureus, annulus involvement, prosthetic valve infection and large sized ( /1 cm) mobile vegetations (8). We report this case in order to emphasize the importance of early surgical intervention which can be life saving in right-sided endocarditis with large and mobile vegetations. We think that the case is interesting since the patient had no underlying conditions for tricuspid S. aureus endocarditis.