Firdevs Aksoy

Risk Factors of Catheter-Related Bloodstream Infections in Parenteral Nutrition Catheterization

BACKGROUND Intravascular catheters are integral to the practice of modern medicine. Potential risk factors for catheter-related bloodstream infection (CRBSI) include underlying disease, method of catheter insertion, and duration and purpose of catheterization. The administration of parenteral nutrition (PN) through intravascular catheters increases CRBSI risks. The purpose of this study was to evaluate the risk factors of CRBSI in patients with PN administration. METHODS This study was conducted at the Karadeniz Technical University Hospital between October 2003 and November 2004. All the patients to whom PN was administered through intravascular catheters were prospectively monitored for the presence of CRBSI and risk factors. RESULTS During the study period, 111 intravascular catheters through which PN was administered were monitored for a total of 1646 catheter-days. CRBSI was determined in 31 cases, a CRBSI rate of 18.8 per 1,000 catheter-days. When risk factors affecting CRBSI were investigated using logistic regression, an increase in APACHE II score (OR, 1.10; 95% CI, 1.01-1.21; p = .012), prolongation of catheterization (OR, 1.08; 95% CI, 1.02-1.14; p = .004), catheterization in emergent conditions (OR, 5.45; 95% CI, 1.20-24.82; p = .016), and poor patient hygiene (OR, 4.38; 95% CI, 1.39-13.78; p = .019) were all determined to be independent risk factors. Proper implementation of hand hygiene and maximal barrier precautions during the insertion of catheters reduced CRBSI levels (OR, 0.28; 95% CI, 0.09-0.88; p = .003 and OR, 0.26; 95% CI, 0.08-0.93; p = .017, respectively). CONCLUSIONS It was concluded that the duration of catheterization should be shortened; that the intravascular catheter, which is inserted in urgent situations, should be removed as soon as possible; and that maximal sterile barrier precautions should be taken and due attention should be paid to hand hygiene.

The efficacy of ribavirin in the treatment of Crimean-Congo hemorrhagic fever in Eastern Black Sea region in Turkey

BACKGROUND The efficiency of ribavirin for treatment of Crimean-Congo hemorrhagic fever (CCHF) is unknown. In the literature, prospective randomized studies investigating the efficacy of ribavirin are not found. OBJECTIVES To investigate the efficacy of ribavirin in treatment of patients with CCHF. STUDY DESIGN In this prospective randomized cohort study 136 cases were included between June 2004 and August 2007. The diagnosis was confirmed in the CCHF reference laboratory of Refik Saydam National Hygiene Central Institute of the Turkish Ministry of Health. Patients either received ribavirin plus supportive treatment (Group A) (n=64) or only supportive treatment (Group B) (n=72). For the evaluation of efficacy of ribavirin, various parameters were compared between Group A and Group B. RESULTS As well as the similarity of demographic features between the two groups, there were no statistical differences in incubation time; hospitalization time; patients requiring platelet replacement therapy; the time taken for platelet levels to return to normal levels and mortality. In Group B, the rate of tick contact was higher (p=0.03). In Group A, leukocyte levels took longer to return to the normal levels (p=0.02). CONCLUSION In our study, there was no positive effect determined on clinical or laboratory parameters in CCHF patients treated with ribavirin, also it was observed that leukocyte levels took longer to return to normal (p=0.02) and, while not statistically significant, the longer period of hospitalization (p=0.09) needed was observed as a negative effect. Because of these reasons, it is thought that the use of ribavirin makes no significant contribution to the prognosis of the CCHF disease.

The effectiveness of routine laboratory findings in determining disease severity in patients with Crimean-Congo hemorrhagic fever: Severity prediction criteria

BACKGROUND Crimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease caused by a tick-borne virus from the Bunyaviridae family. OBJECTIVES To determine the predictive criteria for severity among patients with CCHF based on clinical and laboratory findings. STUDY DESIGN This retrospective study was conducted on patients with CCHF and hospitalized between June 2004 and August 2008 at Karadeniz Technical University, Turkey. Demographic characteristics, clinical findings and laboratory tests on admission of all patients with CCHF were investigated. RESULTS A total of 152 patients with confirmed CCHF were investigated. Sixty-three (41.4%) of these patients were in the severe group. Laboratory findings using the ROC curve method and optimum diagnostic cut-off points for specific laboratory parameters in the severe group were; PLT: 90,000, Hb: 13.5 g/dL, PT: 13.1s, aPTT: 34 s, INR: 1, AST: 117U/L, ALT: 71U/L, AST/ALT: 1.62, LDH: 508 U/L, CK: 267 U/L and CRP: 0.59 mg/dL. At multivariable analysis, the risk for a severe clinical course in CCHF patients increased 2.59 and 3.93 times in the presence of platelet count and Hb below cut-off values, whereas the same risk increased 2.95, 2.92 and 3.47 times when the results for INR, AST and CRP, respectively, were above the predetermined cut-off values. CONCLUSIONS A number of laboratory findings that can easily be measured at routine examination of patients hospitalized with a suspicion of CCHF are valuable and sensitive predictors. These parameters will contribute considerably to the design, practice and management of supportive treatment, blood and blood products replacement and intensive care services.

Crimean-Congo haemorrhagic fever presenting as epididymo-orchitis

BACKGROUND Crimean-Congo haemorrhagic fever (CCHF) is a potentially fatal disease caused by a tick-borne virus. OBJECTIVES A 53-year-old man presented with fever and acute painful scrotal swelling simulating acute epididymo-orchitis. STUDY DESIGN Based on the clinical and epidemiological findings, CCHF virus infection and epididymo-orchitis were suspected. This symptom, rarely reported in viral haemorrhagic fevers, was observed in this case. RESULTS The diagnosis was confirmed by detection of the IgM antibody to CCHF virus and positive RT-PCR. CONCLUSION We report the first case of imported CCHF presenting as epididymo-orchitis. This symptom is a rare complication of CCHF, and the clinician should consider this entity in the differential diagnosis of adults with epididymo-orchitis.

Voriconazole-Induced Neuropathy

Background: Fungal infections are common and life threatening among immunosupressive patients. Rare side effects may occur related to the use of voriconazole, which is the drug of choice in invasive aspergillosis. Patients and Methods: Neuropathy was determined through clinical and electromyographic findings during the course of voriconazole therapy in 2 patients developing invasive aspergillosis. Results: Since examinations revealed no neuropathy capable of ascription to any other cause and improvement followed the cessation of the drug, this suggested that neuropathy may be linked to voriconazole use. Conclusion: Neuropathy may be seen as a side effect during voriconazole treatment. Voriconazole-induced side effects should be borne in mind and patients carefully monitored during its use.

The seroprevalance of Crimean-Congo haemorrhagic fever in people living in the same environment with Crimean-Congo haemorrhagic fever patients in an endemic region in Turkey

Crimean-Congo haemorrhagic fever (CCHF) is endemic in Turkey, and since 2004 many cases have been reported from different regions of Turkey. There are limited data about the seroprevalence of the disease in household members of patients or persons sharing the same environment. We evaluated seroprevalence of CCHF in the immediate neighbourhood and in household members of patients living in the same environment as confirmed cases of CCHF in an endemic area of Turkey. A total of 625 healthy subjects [mean (s.d.) age: 42·3 (18·4) years, 58·7% females] without a past history of CCHF infection included in this case-control, retrospective study were evaluated in terms of sociodemographic characteristics, risk factors for CCHF via a study questionnaire, while serum analysis for CCHF virus (CCHFV) IgG antibodies was performed by ELISA. Anti-CCHFV IgG antibodies were positive in 85 (13·6%) participants. None of the seropositive individuals had a history of symptomatic infection. Regression analysis revealed that animal husbandry [odds ratio (OR) 1·84, 95% confidence interval (CI) 1·09-3·11], contact with animals (OR 2·31, 95% CI 1·08-5·10), contact with ticks (OR 3·45, 95% CI 1·87-6·46), removing ticks from animals by hand (OR 2·48, 95% CI 1·48-4·18) and living in a rural area (OR 4·05, 95% CI 1·65-10·56) were associated with increased odds of having IgG seropositivity, while being a household member of a patient with prior CCHF infection had no influence on seropositivity rates. This result also supports the idea that CCHF is not transmitted person-to-person by the airborne route.

The First Crimean-Congo Hemorrhagic Fever Case in the Winter Season from Turkey

Turkey is one of the countries in which Crimean-Congo hemorrhagic fever is frequently seen and most of the cases are reported between April and August. We describe the first case of Crimean-Congo hemorrhagic fever in the winter season, when Hyalomma tick activity is absent, from Turkey.

Tetanus in adults: results of the multicenter ID-IRI study

Tetanus is an acute, severe infection caused by a neurotoxin secreting bacterium. Various prognostic factors affecting mortality in tetanus patients have been described in the literature. In this study, we aimed to analyze the factors affecting mortality in hospitalized tetanus patients in a large case series. This retrospective multicenter study pooled data of tetanus patients from 25 medical centers. The hospitals participating in this study were the collaborating centers of the Infectious Diseases International Research Initiative (ID-IRI). Only adult patients over the age of 15 years with tetanus were included. The diagnosis of tetanus was made by the clinicians at the participant centers. Izmir Bozyaka Education and Research Hospital’s Review Board approved the study. Prognostic factors were analyzed by using the multivariate regression analysis method. In this study, 117 adult patients with tetanus were included. Of these, 79 (67.5%) patients survived and 38 (32.5%) patients died. Most of the deaths were observed in patients >60 years of age (60.5%). Generalized type of tetanus, presence of pain at the wound area, presence of generalized spasms, leukocytosis, high alanine aminotransferase (ALT) and C-reactive protein (CRP) values on admission, and the use of equine immunoglobulins in the treatment were found to be statistically associated with mortality (p < 0.05 for all). Here, we describe the prognostic factors for mortality in tetanus. Immunization seems to be the most critical point, considering the advanced age of our patients. A combination of laboratory and clinical parameters indicates mortality. Moreover, human immunoglobulins should be preferred over equine sera to increase survival.

Development and validation of a modified quick SOFA scale for risk assessment in sepsis syndrome

Sepsis is a severe clinical syndrome owing to its high mortality. Quick Sequential Organ Failure Assessment (qSOFA) score has been proposed for the prediction of fatal outcomes in sepsis syndrome in emergency departments. Due to the low predictive performance of the qSOFA score, we propose a modification to the score by adding age. We conducted a multicenter, retrospective cohort study among regional referral centers from various regions of the country. Participants recruited data of patients admitted to emergency departments and obtained a diagnosis of sepsis syndrome. Crude in-hospital mortality was the primary endpoint. A generalized mixed-effects model with random intercepts produced estimates for adverse outcomes. Model-based recursive partitioning demonstrated the effects and thresholds of significant covariates. Scores were internally validated. The H measure compared performances of scores. A total of 580 patients from 22 centers were included for further analysis. Stages of sepsis, age, time to antibiotics, and administration of carbapenem for empirical treatment were entered the final model. Among these, severe sepsis (OR, 4.40; CIs, 2.35–8.21), septic shock (OR, 8.78; CIs, 4.37–17.66), age (OR, 1.03; CIs, 1.02–1.05) and time to antibiotics (OR, 1.05; CIs, 1.01–1.10) were significantly associated with fatal outcomes. A decision tree demonstrated the thresholds for age. We modified the quick Sequential Organ Failure Assessment (mod-qSOFA) score by adding age (> 50 years old = one point) and compared this to the conventional score. H-measures for qSOFA and mod-qSOFA were found to be 0.11 and 0.14, respectively, whereas AUCs of both scores were 0.64. We propose the use of the modified qSOFA score for early risk assessment among sepsis patients for improved triage and management of this fatal syndrome.

The prognostic importance of platelet indices in patients with Crimean-Congo Hemorrhagic Fever

Abstract Background Platelet count is an important tool for the diagnosis and prognosis of Crimean-Congo Hemorrhagic Fever (CCHF). The platelet indices plateletcrit, mean platelet volume (MPV) and platelet distribution width (PDW) are parameters obtained as part of the automated complete blood count. These parameters are of prognostic importance in several diseases. The aim of this study was to evaluate the platelet count and its relations with platelet indices in CCHF patients. Methods One hundred and forty-nine patients with confirmed CCHF were included in the study. Patients were divided into two groups (severe cases, patients who exhibited hemorrhage during their hospital stay, and mild/moderate cases with no hemorrhage during hospital stay). The demographic characteristics and laboratory test results of all patients were compared. P < 0.05 was regarded as statistically significant. Results Hemorrhaging was observed in 38.3% of patients during hospitalization. Platelet count, PCT and PDW values (respectively) on the first day of hospitalization were 43.3 ± 29.3, 0.06 ± 0.07%, and 17.4 ± 1.5% in the severe cases and 64.5 ± 35.4, 0.08 ± 0.03%, and 16.8 ± 1.5% in the mild/moderate cases, respectively (P < 0.05). The difference between MPV values was not statistically significant. At cutoff values at ROC analysis, platelet count (≤53000) and PCT(≤0.06) exhibited 73.7% and 71.9% sensitivity, respectively, and predicted a hemorrhagic disease course with a 80.9% negative predictive value. Seven of the severe patients died (P = 0.001). At cutoff values, platelet count (>31000) and PCT (>0.03) predicted patient survival with 100% specificity and 100% positive predictive value. Table 1: Demographic and laboratory characteristics of patients with severe and mild/moderate CCHF Severe cases n = 57 Mild/moderate cases n = 92 p-value Age 45.8 ± 15.6 51.8 ± 17.1 0.034 Female, n (%) 35 (61.4) 38 (41.3) 0.017 Blood/blood product transfusion 39 42 0.007 IVIG 14 5 0.002 Mortality 7 0 0.001 PLT 43.3 ± 29.3 64.5 ± 35.4 <0.0001 PCT 0.06 ± 0.07 0.08 ± 0.03 0.001 PDW 17.4 ± 1.5 16.8 ± 1.5 0.040 MPV 8.6 ± 1.3 8.6 ± 1.2 0.782 Conclusion Our study shows that platelet count, PCT and PDW are parameters that may be used to determine disease severity. The platelet index, and particularly PCT, may be at least as useful as platelet count in helping clinicians identify severe cases. Disclosures All authors: No reported disclosures.