Dilek Arman

Surveillance of microbial resistance in European Intensive Care Units: a first report from the Care-ICU programme for improved infection control

PurposeTo report initial results from a European ICU surveillance programme focussing on antibiotic consumption, microbial resistance and infection control.MethodsThirty-five ICUs participated during 2005. Microbial resistance, antibiotic consumption and infection control stewardship measures were entered locally into a web-application. Results were validated locally, aggregated by project leaders and fed back to support local audit and benchmarking.ResultsMedian (range) antibiotic consumption was 1,254 (range 348–4,992) DDD per 1,000 occupied bed days. The proportion of MRSA was median 11.6% (range 0–100), for ESBL phenotype of E. coli and K. pneumoniae 3.9% (0–80) and 14.3% (0–77.8) respectively, and for carbapenem-resistant P. aeruginosa 22.5% (0–100). Screening on admission for alert pathogens was commonly omitted, and there was a lack of single rooms for isolation.ConclusionsThe surveillance programme demonstrated wide variation in antibiotic consumption, microbial resistance and infection control measures. The programme may, by providing rapid access to aggregated results, promote local and regional audit and benchmarking of antibiotic use and infection control practices.

Colistin and tigecycline susceptibility among multidrug-resistant Acinetobacter baumannii isolated from ventilator-associated pneumonia

Multidrug-resistant (MDR) Acinetobacter baumannii is one of the most important pathogens in intensive care units related to morbidity and mortality, especially in ventilator-associated pneumonia (VAP). In this study, 80.5% of isolates were MDR. The antimicrobial susceptibilities for 12 different antibiotics of MDR A. baumannii isolated from VAP were tested. Among the MDR A. baumannii isolates, resistance rates were found to be 95.5%, 72.7%, 80.3%, 71.2% and 68.2% for ciprofloxacin, cefepime, imipenem, meropenem and cefoperazone/sulbactam, respectively. Netilmicin resistance was detected in 30.3% of the isolates. Resistance rates for colistin and tigecycline were 0% and 25.8%, respectively. It is obvious that new alternative drugs are needed for the treatment of MDR A. baumannii-related VAP owing to high resistance to carbapenems, quinolones, aminoglycosides and cefoperazone/sulbactam. Although colistin appears to be a good choice, adverse reactions and unavailability of colistin limit its wide usage in Turkey. Tigecycline, which will shortly be introduced commercially in Turkey, is very effective against MDR A. baumannii isolates and shows promising results to solve the problem, however resistance rates should be monitored closely.

Hematologic manifestations of brucellosis in children: 5 years experience of an Anatolian center.

Background Brucellosis continues to be an important cause of fever in underdeveloped countries and in the rural areas of developed world. It is a multisystemic disease, associated with a wide variety of symptoms. A wide variety of symptoms, including hematologic abnormalities, such as anemia, thrombocytopenia, pancytopenia, dissemine intravascular coagulation, and leucopenia could be seen. The aim of the study is to review the hematologic findings of brucellosis in childhood. Procedure In this short study, the records of 146 children with brucellosis were evaluated for hematologic manifestation retrospectively. Among them, 9 patients had pancytopenia and 5 had brucella-induced immune thrombocytopenia and were identified in a 5-year period between June 2004 and July 2009. Results Eight of the 9 patients with pancytopenia had Brucella melitensis isolated from blood cultures and/or bone marrow cultures, and all 9 patients had Brucella agglutination titers of at least 1:320. All patients with immune thrombocytopenia blood cultures were positive for Brucella. Except 1 patient the pancytopenia in these patients regressed completely and their peripheral blood counts returned to normal after treatment of Brucella infection. One patient was not responding to the brucella treatment and underwent allogeneic hematopoietic stem cell transplantation. All patients with brucella-induced immune thrombocytic purpura were symptomatic and had severe thrombocytopenia, they were placed on intravenous γ globulin for 2 days. Between day 3 and day 5 platelet counts increased in these patients. Conclusion Brucellosis should be considered as a possible diagnosis among patients with pancytopenia and immune thrombocytopenic purpura in endemic regions.

In vitro synergistic activity of tigecycline and colistin against XDR-Acinetobacter baumannii

The emergence of extensive drug-resistant (XDR) Acinetobacter baumannii limits the therapeutic options and leads to high mortality in intensive care units. Combined antibiotic therapy is frequently recommended for the treatment of these infections. Colistin (CO) and tigecycline (TIG), alone or in combination with other antimicrobials, are the most commonly used antibiotics in the treatment of these resistant infections. In this study, the in vitro synergistic activity of TIG and CO were tested for 25 XDR-A. baumannii strains isolated from ventilator-associated pneumonia by the Etest method. Resistance to CO was not detected, whereas 8% of the strains were resistant to TIG. The TIG–CO combination was more synergistic than TIG–rifampin and CO–rifampin according to the fractional inhibitory concentration index. No antagonism was detected between the drugs in the study. There was no strong correlation between the activity of the combinations with reference to strains or genotypes. Our results suggest that the combined use of TIG and CO may be useful for the treatment of XDR-A. baumannii infections.

High incidence of Candida parapsilosis candidaemia in non-neutropenic critically ill patients: epidemiology and antifungal susceptibility.

Abstract The epidemiological and antifungal susceptibility data for 35 episodes of candidemia in intensive care units (ICU) in 2007 were evaluated by prospective active surveillance. The incidence of fungaemia was 39.1 cases per 1000 ICU admissions and 2.85 cases per 1000 patient-days. The crude mortality was 65.7%; 70.8% of the fatalities occurred within 7 days of admission to the ICU. Only 2 species were isolated, Candida parapsilosis (77.1%) and Candida albicans (22.9%). There was no association between mortality and patient characteristics, prior antifungal usage, Candida subspecies or antifungal resistance (p > 0.05). Of the isolates, 5.7% were resistant to fluconazole and caspofungin, and 3.4% to voriconazole and amphotericin B. In molecular analysis of the isolates, 2 clusters of C. parapsilosis in the neurology and anaesthesiology ICUs were detected by randomly amplified polymorphic DNA (RAPD), suggesting a nosocomial transmission. In conclusion, a high incidence and high mortality rate of C. parapsilosis candidaemia were found in the ICUs. An excessive use of invasive procedures, total parenteral nutrition and broad-spectrum antibiotics in the ICUs, combined with a lack of proper infection control measures, may possibly explain the high incidence of C. parapsilosis candidaemia in our hospital.

Tigecycline: Its potential for treatment of brucellosis

The in vitro efficacy and synergistic activity of tigecycline in comparison with other antimicrobials used in brucellosis, were tested for 16 Brucella melitensis strains by the E-test method. Tigecycline had the lowest minimal inhibitory concentration levels, and rifampin the highest, in the study. Tigecycline also provided the better synergistic activity compared to doxycycline according to the fractional inhibitory concentration index. The results of this in vitro study suggest tigecycline as a therapeutic alternative for brucellosis. These observations need to be supported with clinical studies.

Age and duration of disease as factors affecting clinical findings and sacroiliitis in brucellosis.

Objective:Brucellosis may be seen in any age group, but it still involves young and middle aged adults more frequently. Our aim was to investigate the relationship between age and the duration of disease on clinical findings of brucellosis in adults in this study.Patients and Method:One hundred and sixty-three patients with brucellosis, treated in our hospital, between 1997 and 2003, were evaluated retrospectively.Results:Fever was found in 60.7% of the patients, and it was significantly higher when the duration of disease was less than one month (p = 0.03). Fever was significantly lower in the ≥ 65 age group (p = 0.01). Sacroiliitis was detected in 44.1% of patients. Sacroiliitis was significantly higher in the 15–35 age group (p = 0.03). There were no differences between age groups and other clinical and laboratory findings.Conclusions:Sacroiliac involvement was noted particularly in young adults who manifested lumbar pain and fever, but this might not be a major symptom of brucellosis in the elderly, or in patients showing symptoms for more than a month.

International Nosocomial Infection Control Consortium (INICC) national report on device-associated infection rates in 19 cities of Turkey, data summary for 2003–2012

BackgroundDevice-associated healthcare-acquired infections (DA-HAI) pose a threat to patient safety, particularly in the intensive care unit (ICU). We report the results of the International Infection Control Consortium (INICC) study conducted in Turkey from August 2003 through October 2012.MethodsA DA-HAI surveillance study in 63 adult, paediatric ICUs and neonatal ICUs (NICUs) from 29 hospitals, in 19 cities using the methods and definitions of the U.S. NHSN and INICC methods.ResultsWe collected prospective data from 94,498 ICU patients for 647,316 bed days. Pooled DA-HAI rates for adult and paediatric ICUs were 11.1 central line-associated bloodstream infections (CLABSIs) per 1000 central line (CL)-days, 21.4 ventilator-associated pneumonias (VAPs) per 1000 mechanical ventilator (MV)-days and 7.5 catheter-associated urinary tract infections (CAUTIs) per 1000 urinary catheter-days. Pooled DA-HAI rates for NICUs were 30 CLABSIs per 1000 CL-days, and 15.8 VAPs per 1000 MV-days. Extra length of stay (LOS) in adult and paediatric ICUs was 19.4 for CLABSI, 8.7 for VAP and 10.1 for CAUTI. Extra LOS in NICUs was 13.1 for patients with CLABSI and 16.2 for patients with VAP. Extra crude mortality was 12% for CLABSI, 19.4% for VAP and 10.5% for CAUTI in ICUs, and 15.4% for CLABSI and 10.5% for VAP in NICUs. Pooled device use (DU) ratios for adult and paediatric ICUs were 0.54 for MV, 0.65 for CL and 0.88 for UC, and 0.12 for MV, and 0.09 for CL in NICUs. The CLABSI rate was 8.5 per 1,000 CL days in the Medical Surgical ICUs included in this study, which is higher than the INICC report rate of 4.9, and more than eight times higher than the NHSN rate of 0.9. Similarly, the VAP and CAUTI rates were higher compared with U.S. NHSN (22.3 vs. 1.1 for VAP; 7.9 vs. 1.2 for CAUTI) and with the INICC report (22.3 vs. 16.5 in VAP; 7.9 vs. 5.3 in CAUTI).ConclusionsDA-HAI rates and DU ratios in our ICUs were higher than those reported in the INICC global report and in the US NHSN report.

Disseminated cryptococcosis in a human immunodeficiency virus-negative patient: a case report.

Cryptococcus neoformans is a widely distributed saprophytic fungus that may cause opportunistic infections in normal and immunocompromised individuals particularly in patients with HIV infection. Disseminated infection in HIV‐negative individuals is occasionally seen: a 57‐year‐old HIV‐negative Turkish female initially presented with enlarged mediastinal lymph nodes and a large pulmonary parenchymal nodule, eventually diagnosed with disseminated cryptococcosis and tuberculosis.

Bacterial spectrum and antimicrobial susceptibility pattern of bloodstream infections in children with febrile neutropenia: experience of single center in southeast of Turkey.

Empirical antimicrobial therapy is usually started in febrile neutropenic patients without having culture results. The aim of this study was to help determine the policies of empirical antibiotic usage in febrile neutropenic children by detecting the antimicrobial susceptibility profile in this group of patients. In this study 811 blood cultures taken from neutropenic children hospitalized at the Department of Oncology of Gaziantep Children Hospital November 2007 and February 2010 were retrospectively evaluated. Blood cultures were routinely collected in aerobic and anaerobic media and incubated using the BACTEC system. Identification and antimicrobial susceptibility testing of the isolates to antimicrobial agents was performed using the Vitek2® system according to the recommendations of the Clinical and Laboratory Standards Institute. Of 811 isolates analyzed, 128 (56.4%) were gram positive cocci, 43 (18.9%) were gram negative bacilli and fungi accounted for 56 (24.7%). The main isolated Gram-positive bacteria from blood were coagulase-negative staphylococcus (56.7%), followed by methicillin-resistant Staphylococcus aureus (14.1%). S. aureus and Streptococcus spp. were all susceptible to linezolid, vancomycin and teicoplanin. S aureus was still susceptible to few other antimicrobial agents such as tetracycline (82.4%), chloramphenicol (55.6%). Seven E. faecium, 7 E. fecalis and 1 E. hirae was isolated from blood cultures. Vancomycin resistance was detected in 6 out of 15 (40%) Enterococcus spp. isolates. Among gram-negative bacteria E. coli (30.2%) was followed by Klebsiella pneumoniae (20.9%) and Proteus spp. (18.6%). Imipenem (89.2%), meropenem (86.6%), chloramphenicol (88.9%), amicasin (82.4%) and fosfomycin (81.3%) showed highest susceptibility in vitro activity against all Gram-negative isolates. To know the antimicrobial susceptibility profile of the pathogens frequently isolated from febrile neutropenic children and to consider this profile before starting an empirical antibiotic therapy would help the clinics which have any role in the treatment of these patients to determine the empirical antibiotic usage policies.