Gökhan Aygün

Blood stream infections due to OXA-48-like carbapenemase-producing Enterobacteriaceae: treatment and survival

BACKGROUND Blood stream infections (BSIs) due to carbapenem-resistant Enterobacteriaceae (CRE) are associated with high hospital mortality rates and present a tremendous challenge to clinicians. The optimal treatment remains undefined. We aimed to investigate the risk factors for mortality and the correlation between different treatment modalities and outcomes. METHODS The clinical characteristics and treatment outcomes of a cohort of 36 patients with BSIs due to CRE were investigated and a retrospective nested case-control study of surviving and non-surviving patients was conducted. RESULTS Fifty percent of the cases were male and the mean patient age was 54.9 ± 15.8 years. Klebsiella pneumoniae was the etiological agent in 26 cases (72.2%), Escherichia coli in eight (22.2%), and Enterobacter aerogenes in two (5.5%). All strains were phenotypically positive for carbapenemase activity and all except two (one E. coli and one K. pneumoniae) yielded both blaOXA-48 carbapenemases and blaCTX-M-type extended-spectrum beta-lactamases (ESBLs) in PCR products. The 14-day, 28-day, and all-cause in-hospital mortality rates were 41.6%, 50%, and 58.3%, respectively. The median time to death was 8 days (range 2-52 days). No significant differences were observed between survivors and non-survivors in terms of baseline characteristics, comorbid conditions, etiologies, or sources of bacteremia, however hematological malignancies (p=0.015) and prolonged neutropenia (p=0.044) were more common in non-survivors. Microbiological eradication and clinical response within 7 days were two major determinants of 28-day attributable mortality (p=0.001 and p=0.001, adjusted r(2)=0.845). Colistin-based dual combinations, and preferably triple combinations, were associated with significantly better outcomes when compared to non-colistin-based regimens (p<0.001). Time to active treatment had a significant effect on the course of infection (p=0.014). CONCLUSION Earlier active treatment with colistin based regimens and microbiological and clinical response within 7 days are major predictors of survival in cases of BSIs due to CRE. Rectal screening offers the advantage of earlier recognition and prompt empirical treatment.

Impact of a multidimensional infection control approach on central line-associated bloodstream infections rates in adult intensive care units of 8 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

BackgroundCentral line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey.MethodsWe conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention.ResultsDuring baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 – 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB.ConclusionsThe implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Novel Influenza a (H1N1) Infection in a Pediatric Hematology Oncology Clinic During the 2009–2010 Pandemia

Pandemic influenza A infection (2009 H1N1) was associated with a worldwide outbreak of febrile respiratory infection. Although usually it results in a mild illness, certain patient groups are at increased risk for complications. The authors reviewed their experience in a pediatric hematology-oncology unit to determine the outcome of this disease in children with hematological conditions and solid tumors. During the second outbreak (1 November 2009 to 14 January 2010), a total of 187 children from pediatric clinic were tested for H1N1 influenza A by multiplex polymerase chain reaction (PCR), 63 of them were positive. Patients’ signs and symptoms were recorded prospectively. Ten (35.7%) (5 children with solid tumors, 4 with leukemia, 1 with hereditary spherocytosis) of 28 tested children with hematological conditions were diagnosed with 2009 H1N1 influenza infection. Fever (100%) and cough (90%) were the most common symptoms. Five were neutropenic (neutrophil count <1000/mm3), 4 had severe neutropenia (neutrophil count <500/mm3). Systemic antibiotics were given in 5 patients with the diagnosis of febrile neutropenia. Four were inpatients, others were hospitalized after the diagnosis. One patient required mechanical ventilation; however, he had concomitant invasive fungal infection. Eight patients were treated by oseltamivir, all tolerated the drug well. A total of 4 cases from 9 cancer patients had a delay in their planned chemotherapy for 7 to 15 days. Pandemic H1N1 influenza caused mild symptoms in children with cancer and/or hematological conditions but resulted in delay in anticancer therapy and increase in hospitalization and antibiotic usage.

Bacterial colonization and associated factors in patients with bronchiectasis

Objectives: To evaluate the bacterial colonization and associated risk factors in patients with bronchiectasis. Methods: A total of 121 patients followed at the Bronchiectasis Unit, between 1996 and 2013 and diagnosed as having noncystic fibrosis bronchiectasis with high resolution computed tomography or multi-slice computed tomography were included in this retrospective study. The following definition of colonization was used for study purposes: Detection of at least two isolates of an organism separated by at least 3 months in a year. Results: Of these 121 patients, 65 (54%) were female and 56 (46%) were male. Mean age was 50.6 ± 16.1 years. Mean duration of illness was 20.3 ± 15.5 years. 43 (35.5%) cases had colonization. The major pathogens responsible for colonization were Pseudomonas aeruginosa (n = 25; 20.6%) and Haemophilus influenzae (n = 14, 11.5%). The stepwise logistic regression analysis showed a significant association between colonization and a low percentage of forced vital capacity (FVC%) and the presence of cystic bronchiectasis (P < 0.05). Conclusion: The following factors have been found to be associated with colonization in patients with bronchiectasis: Low FVC% and the presence of cystic bronchiectasis.

Prospective observational study on antibiotic-associated bloody diarrhea: report of 21 cases with a long-term follow-up from Turkey.

Objective Antibiotic-associated hemorrhagic colitis is a distinct form of antibiotic-associated bloody diarrhea (AABD) in which Clostridium difficile is absent. Although the cause is not exactly known, reports have suggested the role of Klebsiella oxytoca and/or C. difficile. Materials and Methods Between 2001 and 2006, stool samples of 21 consecutive patients with AABD were cultured for common enteric pathogens and K. oxytoca, and were tested for the presence of parasites and C. difficile toxin A+B within the first 24 h of their initial admission and a colonoscopy was performed when available. The patients were followed up prospectively by telephone interviews. Results The occurrence of symptoms ranged between 6 h and 14 days following the first dose of the antibiotic responsible and the duration of the AABD ranged between 6 h and 21 days. The antibiotic responsible was oral ampicillin/sulbactam in 18 (85%) cases. C. difficile toxin A+B production by enzyme-linked immunosorbent assay and K. oxytoca growth in stool cultures were detected in six (29%) and 11 (51%) of 21 patients, respectively. Endoscopic morphology and histology in a limited number of patients revealed no more than a nonspecific inflammation and acute colitis, respectively. Conclusion This study confirms that antibiotic-associated hemorrhagic colitis, as a distinct entity in relation to K. oxytoca, is seen in half of the patients with AABD. Most of the cases are seen within a week following the antibiotic use. Almost all of the patients did not develop any flares during the long-term antibiotic-free follow-up. In some of the patients with AABD, there was coexistence of K. oxytoca with C. difficile toxin A+B.

Determination of clinical significance of coagulase-negative staphylococci in blood cultures

The aim of this study was to investigate the criteria used to distinguish coagulase-negative staphylococci (CoNS) bacteremia from contamination. We evaluated 162 adult patients with CoNS-positive blood cultures (BCs). Of the 162 patients, 35 (21.6%) had at least 2 positive BCs and 127 (78.4%) had a single positive BC. According to the Laboratory-Confirmed Bloodstream Infection (LCBI) criteria, 24 (14.8%) patients with the same species of CoNS had true bacteremia, and 138 (85.2%) patients had contaminants. Despite the detection of the same CoNS species, 9 of the 24 patients had different CoNS genotypes. Using clinical assessments, only 20 patients were diagnosed with true bacteremia, 8 of them had a single positive BC. We concluded that only using the LCBI criteria or clinical evaluations of a patient were not sufficient to distinguish CoNS bacteremia from contamination. Molecular identification should also be performed as a diagnostic laboratory parameter for CoNS bacteremia.

First imported coccidioidomycosis in Turkey: A potential health risk for laboratory workers outside endemic areas.

Coccidioidomycosis caused by Coccidioides immitis or Coccidioides posadasii is endemic in arid climate zones in America, travel-related cases have been reported. We report the first documented case of coccidioidomycosis in Turkey, overviewing reported cases in Europe and underlying difficulties of differential diagnosis outside endemic regions. The patient was an otherwise healthy 41-year-old man who travelled endemic areas. Laboratory diagnosis was based on direct microscopy of two subsequent subcutaneous biopsy specimens and culture and confirmed molecularly. Laboratory personnel should become aware that BioSafety Level-3 organisms may become more frequent and widespread.

Bronchial Hyperreactivity in Non-Cystic Fibrosis Bronchiectasis

1 Müsellim Benan1, Uzel Işıl1, Börekçi Şermin1, Tutluoğlu Bülent1, Aygün Gökhan2, Yaşar Hatice2, Halis Nigar1, Erk Müzeyyen1 1Göğüs Hastalıkları Anabilim Dalı, 2Mikrobiyoloji Anabilim Dalı, İstanbul Üniversitesi, Cerrahpaşa Tıp Fakültesi, İstanbul, Türkiye Bronşektazide Bronş Aşırı Duyarlılığı / Bronchial Hyperreactivity in Bronchiectasis Bronchial Hyperreactivity in Non-Cystic Fibrosis Bronchiectasis

A fatal case of urosepsis due to Corynebacterium riegelii

Corynebacterium species other than Corynebacterium diphtheriae rarely cause infections in human but rather reside in flora, however they have been reported to cause opportunistic infections in both immunocompromised and immunecompetent patients. Here we report for the first time a case of an elderly female patient presenting with a fatal urosepsis caused by a recently defined pathogen, Corynebacterium riegelii, identified on second day after patient hospitalization leading to a progressive worsening and death of the patient on 6th day.

Yenidoğan yoğun bakım ünitesinde izlenen hastalarda flora kazanımı ve enfeksiyon ilişkisinin araştırılması: Cerrahpaşa deneyimi Orijinal Araştırma

Yenidogan Yogun Bakim Unitesinde izlenen ve tedavi edilen hastalarin flora kazanimlarini ve bunlarin enfeksiyon gelisimindeki rollerini arastirmak amaciyla 8 aylik donem icinde 53 olguda kolonizasyon surveyansi calismasi yapilmistir Toplam 1210 ornek incelenmis 613’unde ureme tespit edilmiotir Ureme saptanan orneklerden 599 bakteri 14 maya kokeni izole edilmistir K pneumoniae 43 en sik koagulaz negatif stafilokoklar ise 26 ikinci siklikta tanimlanan bakteriler olmustur Gram negatif comaklarda 3 kusak sefalosporinlere ve aminoglikozidlere stafilokoklarda metisiline streptokoklarda penisiline yuksek duzeyde direnc saptanmistir Kolonize olan kokenler cevre yuzeyleri ve el kulturlerinden izole edilmis direncli yogun bakim florasinin hastalar arasi aktariminda saglik calisanlarinin ve tedavide kullanilan ekipmanlarin onemli rol oynadigi tespit edilmistir Ortalama kolonizasyon baslangici oral beslenmeye gecisle parelel sekilde 5 3±3 2 gun olarak belirlenmistir Orogastrik sonda ile beslenmenin ve yogun bakimda uzun sure kalmanin yogun bakim florasi ile kolonize olmayi kolaylastirdigi saptanmistir Olgularimizda 17 oraninda nozokomiyal pnomoni 6 oraninda “gec sepsis” gelismistir K pneumoniae 38 P aeruginosa 17 C albicans 8 oraninda nozokomiyal enfeksiyon etkeni olmustur Anahtar Kelimeler: Yenidogan epidemiyoloji kolonizasyon enfeksiyon