Gul Ruhsar Yilmaz

Colistin alone or combined with sulbactam or carbapenem against A. baumannii in ventilator-associated pneumonia

INTRODUCTION Colistin use has increased over the last ten years because of multidrug-resistant microorganisms. The aim of this study was to compare the clinical and microbiological efficacy of colistin alone or in combination with sulbactam or carbapenem in the treatment of ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) and extremely drug-resistant (XDR) A. baumannii. METHODOLOGY Cases treated for VAP because of MDR and XDR A. baumannii between January 2011 and January 2013 were included in the study. The primary and secondary outcome for colistin alone, colistin with sulbactam, and colistin with carbapenems were evaluated. The primary outcomes were clinical efficacy and microbiological efficacy; the secondary outcomes were nephrotoxicity, length of hospitalization, and mortality. RESULTS A total of 70 VAP patients were evaluated. A total of 17 patients (24.3%) were administered colistin alone, 20 patients (28.6%) were administered colistin and sulbactam, and 33 patients (47.1%) were administered colistin and carbapenem. Clinical and microbiological response rates were higher in the carbapenem combination group (63.6% and 63.6% in both) than in the sulbactam combination group, which registered 55.0% and 60.0%, respectively. However, this did not represent a significant difference statistically (p > 0.05). There was also no significant difference between colistin alone and the combination groups regarding clinical and microbiological efficacy and mortality. CONCLUSIONS Neither the administration of colistin alone nor colistin combined with either sulbactam or carbapenem had any noticeable advantage in the treatment of VAP in terms of clinical response, microbiological response, nephrotoxicity, length of hospitalization, and mortality.

Crucial parameter of the outcome in Crimean Congo hemorrhagic fever: Viral load.

BACKGROUND Crimean Congo hemorrhagic fever (CCHF) is a fatal disease with a mortality rate of 5-30%. CCHF can be asymptomatic or it may progress with bleeding and cause mortality. OBJECTIVES To evaluate relation of viral load with mortality, clinical and laboratory findings in CCHF. STUDY DESIGN A total of 126 CCHF patients were included. Serum samples obtained from all patients on admission for measurement of viral load. RESULTS In our study, mortality rate was 11.1%. The most important prognostic factor was viral load. Mean viral load was 8.3×10(7)copy/ml and 4.6×10(9)copy/ml in survived and dead patients, respectively (p<0.005). Probability of survival is found to be significantly reduced where AST >1130U/l, ALT >490U/l, CPK >505U/l, LDH >980U/l, platelet count <23×10(3)/l, creatinine >1.4mg/dl, INR >1.3, d-dimer >7100ng/dl, and viral load >1.03×10(8)copy/ml. Patients with 10(8)copy/ml or higher viral load had diarrhea, headache, unconsciousness, bleeding, and seizure significantly more frequently (p<0.05). WBC, hemoglobin, platelet counts were significantly lower whereas AST, ALT, CPK, LDH, creatinine levels, PT and aPTT time, d-dimer levels, and INR were found to be significantly higher in these group. CONCLUSIONS There are several severity criteria for prognosis of CCHF. In addition to these parameters, we introduce creatinine as a predictive factor for prognosis. Our study, which has the largest number of patients among studies that evaluate viral load on CCHF shows that viral load is the most effective parameter on mortality.

A retrospective controlled study of thiol disulfide homeostasis as a novel marker in Crimean Congo hemorrhagic fever

Objectives: Crimean Congo hemorrhagic fever (CCHF) is the second most common hemorrhagic fever worldwide. This study aimed to evaluate the oxidant–antioxidant balance of patients with CCHF by detecting dynamic thiol disulfide homeostasis (TDH), which is a novel oxidative stress marker, and other molecules, including paraoxonase (PON), arylesterase (ARES), ceruloplasmin (CLP), myeloperoxidase (MPO), and catalase. Methods: This retrospective, cross-sectional, controlled study, which involved patients with CCHF and healthy volunteers, measured dynamic TDH using a novel automated method developed by Erel. Results: We recruited 69 adult patients with CCHF (31 females, 38 males, median age 46 years). The case fatality rate was 1.49% (1/69). Increased disulfide/native thiol and disulfide/total thiol ratios, decreased total antioxidant status (TAS), and increased total oxidant status (TOS) were found in patients with CCHF. TAS, PON, and ARES values were found to be positively correlated with both native and total thiol levels, whereas TOS and CLP were negatively correlated with both, at a significant level. MPO activity was similar in both groups. Discussion: This is the first study in the literature to evaluate dynamic TDH in CCHF. TDH shifts to the oxidative side in patients with CCHF, leading to an increase in TOS.

Risk factors for infection with colistin-resistant gram-negative microorganisms: a multicenter study.

BACKGROUND Knowing risk factors for colistin resistance is important since colistin is the only remaining choice for the treatment of infections caused by multi-drug resistant microorganisms. OBJECTIVE Evaluate risk factors associated with infection by colistin-resistant microorganisms. DESIGN Retrospective study. SETTINGS Tertiary healthcare centers. PATIENTS AND METHODS An e-mail including the title and purpose of the study was sent to 1500 infectious disease specialists via a scientific and social web portal named “Infeksiyon Dunyasi (Infection World)”. Demographic and clinical data was requested from respondents. MAIN OUTCOME MEASURE(S) Colistin-resistance. RESULTS Eighteen infectious disease specialists from twelve tertiary care centers responded to the invitation. Data was collected on 165 patients, 56 cases (39.9%) and 109 (66.0%) age- and sex-matched controls. The colistin-resistant microorganisms isolated from cases were 29 Acinetobacter baumannii (51.8%), 18 Pseudomonas aeruginosa (32.1%) and 9 Klebsiella spp. Colistin, carbapenem, and quinolone use in the last three months were risk factors for colistin resistance in the univariate analysis. Previous quinolone use in the last three months (P=.003; RR:3.2; 95% CI:1.5–6,7) and previous colistin use in the last three months (P=.001; RR: 3.6; 95% CI: 1.63–7.99) were significant risk factors in the multivariate analysis. CONCLUSION Clinicians should limit the use of quinolones and remain aware of the possibility of resistance developing during colistin use. LIMITATIONS The lack of a heteroresistance analysis on the isolates. No data on use of a loading dose or the use of colistin in combination.

Dynamics of Anidulafungin use in a Tertiary Care Hospital.

Dear Editor, Fungal agents have been reported to be more frequently responsible from health care associated infections in recent years [1]. New antifungal agents for invasive fungal infections are introduced to market and we wanted to evaluate our dynamics in use of one of them, the anidulafungin use in our patients with suspected invasive fungal infection. The study was designed as an observational retrospective single center study in a tertiary care hospital. The patients who were treated with anidulafungin, either empirically or culture based, even for one day were included. The pharmacy reports and infection control team consultation reports as well as hospital data base were used. A total of 27 patients included [Table/Fig-1]. Candida spp. was revealed from 14 (52%) patients: 4 (15%) C. albicans, 8 (30%) non-albicans Candida (NAC) and in 2 (7%) patients both C.albicans and NAC were revealed. From the culture positive 14 patients, only 9 (64%) had subsquent culture samples after initiating antifungal therapy, the remaining 5 patients either didn’t have a control blood culture because either they died (n=4) while they were under anidulafungin therapy or referred to another center and lost from follow-up (n=1). Culture negativity was achieved in a median of 3 days in all of the remaining 9 patients (100%) who have subsquent culture samples. Only one patient had another positive culture on the 12th day of therapy, after achieving negative blood culture on the 2nd therapy day. No source was found for persistence of candidemia and control blood culture was again turned to negative on the 19th day of therapy. Of total 27 patients, 22 (82%) patients had died because of underlying medical problems, 11 (44%) of the patients had died before they completed anidulafungin therapy and median anidulafungin therapy duration of these 11 patients were only 5 days (2-15days). As conclusion, anidulafungin was used in elder patients who have long hospitalization duration especially in ICUs; all the patients who have subsquent culture samples were achieved culture negativity under anidulafungin therapy; culture negativity was achieved in a median of 3 days. Attributable mortality cannot be calculated because of the study-design and controlled randomized studies are needed in these complicated patients of ICUs. [Table/Fig-1]: Demographic variables of the patients under anidulafungin therapy (n=27)

[P. falciparum malaria related with travel: four cases].

Malaria is still an important public health problem in the world. Although the number of malaria cases in Turkey has been declining in recent years, the febrile patients with a history of travel to the endemic regions should raise the suspicion of malaria. P. vivax is the most common cause of malaria in Turkey; and those caused by other Plasmodium spp. are imported cases. Since P. falciparum malaria may cause fatal complications, urgent therapy is necessary. We hereby report four falciparum malaria cases with a history of travel to Sudan and Uganda.