Derya Aysev

Fungal colonization and infection in children with acute leukemia and lymphoma during induction therapy

BACKGROUND Fungal infection represents a growing problem in children with hematologic malignancies. During chemotherapy induced neutropenia, colonization with fungi is considered a major risk factor for subsequent fungal infection. The rates and risk factors for mycotic infections in pediatric oncology patients is undetermined, particularly for centers in developing countries. The aim of this study was to evaluate the rates and risk factors of fungal colonization in children with acute leukemia and lymphoma at one of the major pediatric hematology/oncology centers in Turkey. PROCEDURE Fifty-two consecutive children newly diagnosed with acute leukemia and lymphoma during intensive remission induction therapy were evaluated for the occurrence of fungal colonization (defined as at least one positive surveillance culture) and infection. RESULTS Thirty-six of the 52 patients (69.2%) were colonized by Candida albicans which was the only fungus isolated from surveillance cultures. There were three (5.8%) proven systemic fungal infections: two cases of candidemia and one case of brain abscess with Aspergillus spp. isolated from tissue. All patients with fungal colonization were receiving prophylactic or curative antibiotics. No significant association was found between type of disease and fungal colonization, but there was a significant association with neutropenia. CONCLUSIONS Our findings suggest that there is a high rate of fungal colonization in children receiving remission induction therapy for acute leukemia and lymphoma. Limiting the use of antibiotics and instituting antifungal chemoprophylaxis may decrease the rate, while the early initiation of empiric antifungal therapy in patients with fever and suspected mycotic colonization may increase survival in these patients.

The value of the levels of acute phase reactants for the prediction of familial Mediterranean fever associated amyloidosis: a case control study

In order to determine the role of levels of acute phase proteins (APPs) for the development of amyloidosis in familial Mediterranean fever (FMF) patients, the levels of serum amyloid A (SAA), C reactive protein (CRP), fibrinogen and erythrocyte sedimentation rate were measured in paired sera of 36 FMF patients during and in between acute attacks, 39 of their healthy parents (obligate heterozgotes), and 15 patients with FMF associated amyloidosis. To compare the levels of APPs, 39 patients with chronic infections or inflammatory diseases who may develop secondary amyloidosis, 20 patients with acute infections who are known to have elevated acute phase response but will never develop amyloidosis and 19 healthy controls were included. The median levels of all APPs are increased in the patients with FMF during attacks and a significant decrease was observed after the attack was over. The level of SAA was above reference range in all FMF patients during the attack free period and the level of at least one other APP was also above normal in 64% of the patients. Both CRP and SAA levels were found to be higher in obligate heterozygotes compared to controls. The levels of SAA in patients with FMF during the attack-free period, obligate heterozygotes and patients with FMF-amyloidosis were found to be similar. The levels in each group were found to be higher than SAA levels found in healthy controls yet lower than the levels measured in the patients with acute infections and patients with chronic inflammation or chronic infections. In conclusion, our results show that SAA level reflects subclinical inflammation with high sensitivity but its value for the prediction of amyloid formation process seems to be low.

Alternative Treatment Protocols in Giardiasis: A Pilot Study

The aim of the study was to test new treatment protocols for giardiasis, which are less toxic, cheaper, and easier to use than the conventional treatment. 48 children who had been diagnosed as having giardiasis in a health-screening program involving 2 schools, were randomized to receive four different treatment protocols. The children were split into 4 treatment groups: I, mebendazole 100 mg t.i.d. for 1 day; II, mebendazole 100 mg t.i.d. for 7 days; III, metronidazole 15 mg/kg as one dose for 7 days; and IV, ornidazole 40 mg/kg as a single dose. The results were evaluated by microscopic examination of stools. The responses to the treatments revealed that the effectiveness of ornidazole was 100%, metronidazole 92.9%, mebendazole for 7 days 58.3%, and mebendazole for 1 day 41.7%. Minor side-effects were seen in only 3 children receiving ornidazole: 1 had urticaria, while the other 2 suffered from vertigo and nausea. The results of this study show that ornidazole as a single dose can be used as an alternative protocol for treating giardiasis. Further studies should be done to determine the safest effective total single dose.

Successful treatment of central venous catheter infection due to Candida lipolytica by caspofungin-lock therapy.

Fungal infections, mainly represented by bloodstream infections (BSI) due to Candida spp., have maintained a constant incidence rate over the past 10 years, representing around 10% of catheter-related BSI (Kojic EM et al., Clin Microbial Rev 2004; 17: 255–67). The Infectious Diseases Society of America (IDSA) guidelines on Candida catheter-related BSI recommend the systemic antifungal therapy and catheter removal (Pappas PG et al., Clin Infect Dis 2009; 48: 503–35). This is warranted both by the ability of Candida spp. to form biofilms that greatly reduce antifungal activity and by the extremely high risk of metastatic infections, particularly endocarditis and retinitis (Viale P et al., J Chemother 2006; 18: 235–49). In clinical practice, catheter removal is not always easily performed, depending both on type of device (for tunnelled or totally implanted catheters, a surgical procedure is needed) and on the patient s condition (e.g. patients with severe platelet or coagulation factor deficit). For these reasons, antifungal-lock technique (ALT) alternative to the device removal is proposed (Mermel LA et al., Clin Infect Dis 2001; 32: 1249–72). ALT consists of catheter lumen replenishment by a selected antimicrobial agent and then locking it for a time to eradicate the microbes embedded in endoluminal biofilms (Angel-Moreno A et al., J Infect 2005; 51: e85–87). Treatment of catheter-related BSI due to Candida spp. with ALT has been tried in few cases (Mermel LA et al., Clin Infect Dis 2001; 32: 1249–72; Buckler BS et al., Pediatr Infect Dis J 2008; 27: 762–4; Arnow P et al., Am J Med 1991; 90: 128–30; Viale P et al., Clin Infect Dis 2001; 33: 1947–8; Benoit JL et al., Clin Infect Dis 1995; 21: 1286–8). Herein, to our knowledge, we report the first case of non-complicated Candida lipolytica fungaemia related to a Hickman catheter cured with intraluminal caspofungin in addition to systemic caspofungin therapy.

Nasopharyngeal colonization with penicillin-resistant Streptococcus pneumoniae in Turkish children.

Abstract Background: Streptococcus pneumoniae is one of the major infectious agents observed in children. In spite of the fact that penicillin is preferred in the treatment of infections caused by S. pneumoniae, there has been a world‐wide increase in the frequency of penicillin‐resistant S. pneumoniae.

Antistreptococcal Response is Exaggerated in Children with Familial Mediterranean Fever

Abstract: Familial Mediterranean fever (FMF) is an autosomal recessive disorder. Although the pathogenesis of the disease is not yet completely understood, enhanced acute-phase responsiveness is considered to be one of the most important mechanisms. The presence of high levels of antistreptolysin O (ASO) antibodies and streptococcus-associated diseases, such as acute poststreptococcal glomerulonephritis (AGN) and acute rheumatic fever (ARF), has been reported in patients with FMF. In order to better understand the effect of FMF on antistreptococcal antibody response, we measured ASO and antideoxyribonuclease B (anti-DNAse B) levels in patients with FMF and compared them with those in healthy controls. The study consisted of two parts. In the first step, antistreptococcal antibody levels were analysed in 44 patients with FMF and 165 healthy children who had no history or clinical evidence of upper respiratory tract infection (URTI) for the last 4 months. In the second step, antistreptococcal antibody levels were measured in 15 patients with FMF and 22 healthy controls in response to documented group A β-haemolytic streptococcal pharyngitis. In the first part of the study, ASO and anti-DNAse B levels in patients with FMF were found to be significantly higher than those in healthy controls (P<0.001). In the second part, ASO and anti-DNAse B titres were found to be significantly higher in patients with FMF than in controls (P<0.001 and <0.05, respectively) 4 weeks after a positive throat culture. We concluded that patients with FMF have an exaggerated response to streptococcal antigens and might be prone to poststreptococcal non-suppurative complications, such as ARF.

Urinary tract infections owing to ESBL‐producing bacteria: microorganisms change – clinical pattern does not

Aim:  Urinary tract infections (UTIs) caused by extended‐spectrum beta lactamase (ESBL)‐producing bacteria have become a growing problem worldwide. The aim of this study was to investigate the clinical and radiological findings in patients with community‐acquired UTIs owing to ESBL‐producing bacteria.

A rapid lateral flow stool antigen immunoassay and 14C-urea breath test for the diagnosis and eradication of Helicobacter pylori infection in children

Our aim was to evaluate diagnostic accuracy of rapid immunochromatographic stool antigen test (Rapid HpSA; LINEAR Chemical, Barcelona, Spain) and a practical low-dose (14)C urea breath test (UBT) (Heliprobetrade mark) test before and after eradication therapy. One hundred nine children with abdominal symptoms (age range, 5-17 years; mean, 12.1) underwent endoscopy, (14)C-UBT, and Rapid HpSA. Patients were defined as Hp infected when histology was positive for Hp. Forty children (36.6%) were Hp infected. The sensitivity of Rapid HpSA and (14)C-UBT was 65% and 92.5% (P = 0.0003), respectively; the specificity of Rapid HpSA and (14)C-UBT was 92.3% and 85.5% (P = 0.180), respectively. After eradication therapy endoscopy, (14)C-UBT and Rapid HpSA were repeated. The eradication rate was 70.5%. After eradication, the sensitivity of Rapid HpSA and (14)C-UBT was 60% and 100%, respectively; the specificity of Rapid HpSA and (14)C-UBT was 100%. (14)C-UBT was more reliable than the Rapid HpSA test for the diagnosis and for confirming eradication of Hp infection.

RIGHT ATRIAL CATHETER-RELATED COMPLICATIONS IN PEDIATRIC ONCOLOGY PATIENTS: The Situation in a Developing Country

The complications of right atrial catheters (RACs) in pediatric oncology patients are unknown for centers in developing countries. This study examined the complications of RACs at Ankara University Medical School, Turkey. A total of 90 RACs were placed in 61 children for long-term chemotherapy with a total experience of 15,536 catheter days. The rate of catheter-related sepsis was 4.9 episodes per 1000 catheter days. Coagulase-negative staphylococci and Candida species were the most common organisms, accounting for 25.0 and 13.1% of all organisms, respectively. The most common reasons for the removal of the RACs were infection (42.4%) and dislodgement (32.2%). The rates of complications were significantly higher in this study than in western studies. This increase could be explained by the differences in catheter care practices in the Turkish center. In conclusion, the use of RACs in a developing country necessitates an appraisal of the benefits and risks for each patient and improvement of catheter care procedures.

The validity of diagnostic criteria for streptococcal pharyngitis in Integrated Management of Childhood Illness (IMCI) guidelines.

The WHOs Integrated Management of Childhood Illness (IMCI) programme is being implemented in Turkey with an additional section relating to throat problems for our countrys adaptation. The aim of this study is to evaluate the validity of this additional part and suggest new combinations for the diagnosis of streptococcal pharyngitis to improve the guidelines. Throat swabs were obtained from 245 children between 0 and 17 years of age with signs and symptoms of upper respiratory tract infections. Considering the throat culture based diagnosis as the gold standard, the validity of the symptoms alone and in combinations were calculated. The combination in Turkeys IMCI guideline was found to be 36.9 per cent sensitive and 68.3 per cent specific. Sensitivities of combinations including at least two of the following three symptoms, namely sore throat, pharyngeal erythema, and pharyngeal exudates or sore throat, pharyngeal erythema, and fever, were 76.9 and 87.7 per cent, respectively. Specificities of the same combinations were 49.4 and 30.6 per cent. We concluded that new combinations with a higher sensitivity may be considered as a criterion for antibiotic treatment.