Gülçin Bayramoğlu

Breakthrough Trichosporon asahii Fungemia in Neutropenic Patient with Acute Leukemia while Receiving Caspofungin

A 47-year-old man with newly diagnosed acute myeloblastic leukemia and non-insulin-dependent diabetes mellitus developed Trichosporon asahii fungemia while receiving caspofungin as empirical antifungal therapy. The diagnosis was based on repeated isolation of T. asahii in culture of blood for three times. Despite treatment with amphotericin B and voriconazole, the patient died. The in vitro antifungal susceptibilities of the T. asahii isolates were only available after the patient died. In vitro antifungal susceptibility tests showed high caspofungin and amphotericin B minimal inhibitory concentrations (MICs) value for this Trichosporon strain (MICs, 16 μg/ml, and > 32 μg/ml, respectively). Fluconazole, itraconazole, and voriconazole exhibited low MICs in vitro (MICs, 4 μg/ml, 0.5 μg/ml, and ≤ 0.015 μg/ml, respectively). Our experience strongly suggest that identification and antifungal susceptibility testing for T. asahii in neutropenic patients who may develop signs of infection in the presence of caspofungin as well as broadspectrum antibiotics treatment should not be overlooked.

Distribution, virulence attributes and antifungal susceptibility patterns of Candida parapsilosis complex strains isolated from clinical samples

It was recently proposed that Candida parapsilosis represents a complex composed of three closely related species, i.e., C. parapsilosis sensu stricto, C. orthopsilosis, and C. metapsilosis. The aim of this study was to describe the distribution of C. parapsilosis complex isolates among clinical samples. We also evaluated antifungal susceptibility profiles, in vitro presence of lipase and secreted aspartyl proteinase, as well as their ability to grow in total parenteral nutrition (TPN) solution, and biofilm production. A total of 413 non-C. albicans Candida isolates were obtained from various clinical samples between 2010 and 2011 in a Turkish Tertiary Care Hospital. Of them, 42 were identified as members of the C. parapsilosis complex. Among these, 38 (90.5%) were C. parapsilosis sensu stricto, 3 (7.1%) C. metapsilosis, and 1 (2.4%) C. orthopsilosis. All isolates recovered from blood were found to be C. parapsilosis sensu stricto and C. metapsilosis. In phenotypic tests, all 42 isolates grew in TPN solution and, although 26.2% of C. parapsilosis sensu stricto-isolates were capable of forming biofilms in vitro, neither C. orthopsilosis nor C. metapsilosis isolates were able to do so. Acid proteinase activity was detected in 31% of isolates and lipase activity in 33%. All isolates were sensitive to voriconazole, caspofungin, and anidulafungin, with only a single C. parapsilosis sensu stricto isolate showing dose-dependent susceptible to fluconazole. While the number of C. metapsilosis and C. orthopsilosis isolates remained low, there were no significant differences in antifungal MIC as compared to C. parapsilosis sensu stricto.

Risk factors and clinical characteristics of Stenotrophomonas maltophilia infections in neonates

BACKGROUND The aim of this study was to review the risk factors and clinical, bacteriological, and epidemiological characteristics of Stenotrophomonas maltophilia infections in our neonatal intensive care unit. METHODS A retrospective matched case-control study was performed by comparing 23 cases of S maltophilia with 45 controls to identify the potential risk factors. To identify the case patients, the admission and medical records of patients in the neonatal intensive care unit and records from the Microbiology Department were reviewed between 2003 and 2008. RESULTS Sepsis in two neonates (9%), conjunctivitis in two neonates (9%), and ventilator-associated pneumonia in 19 (82%) neonates were determined. Invasive-procedures, exposure to aminoglycoside and carbapenem, total parenteral nutrition, histamine 2 blockers, exposure to steroids, cholestasis, and duration of hospitalization were significantly associated with S maltophilia infections (p<0.05). On multivariate analysis, invasive procedures (odds ratio, 18.81) and duration of hospitalization (odds ratio, 1.06) were determined to be the risk factors for S maltophilia infection. The most active antimicrobial agent was trimethoprim/sulfamethoxazole (87%) for S maltophilia infection, and the mortality rate was 17%. CONCLUSIONS Neonatologists should avoid from unnecessary invasive procedures and broad-spectrum antibiotics to reduce S maltophilia infections. Invasive procedures should be finished in the shortest time possible. Agent/factor-specific antibacterial treatment should be administered. Patients being discharged as early as possible will also reduce infection frequency. Stenotrophomonas maltophilia should be considered in patients with high Stenotrophomonas infection risk factors.

Raoultella ornithinolytica causing fatal sepsis

Raoultella ornithinolytica, an encapsulated Gram-negative bacterium, is a member of the Enterobacteriaceae family. It rarely causes invasive infections.1,2 There are underlying conditions such as pathology of biliary system and malignancy in most cases. Although the majority can recover with adequate antibiotic therapy, some cases have a fatal outcome.2–4 A patient from our country with diabetic foot with ensuing bacteremia had been reported.5 That case was successfully treated by tigecycline. A 37-year old male patient with relapsing acute lymphocytic leukemia (ALL) was admitted to the hematology department for chemotherapy. He had been diagnosed 1.5 year before and had a history of bone marrow transplantation in the previous year. At first day of FLAG (Fludarabine 30 mg/m2, cytosine arabinoside (Ara-C) 2 g/m2, granulocyte colony stimulating factor (G-CSF) 5 g/kg/day) chemotherapy, febrile neutropenia developed and piperacillin–tazobactam 4.5 g intravenously (iv) every 6 h was started. Fever was under control in third day, but recurred after 12 days of treatment. Amphotericin-B 3 mg/kg/day was started with monitoring of galactomannan levels; based on the findings of high resolution computed tomography (HRCT) antibiotic therapy was switched to imipenem 500 mg iv every 6 h. Tigecycline 150 mg iv every 12 h was also added because of Gram-negative bacilli growth in subsequent three blood cultures. Despite that antibiotic modification, there was persistence of fever. Blood cultures grew Gram-negative bacilli, which were identified as “Raoultella ornithinolytica” by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) (Bruker Biotyper) and confirmed by conventional biochemical tests. MICs of antibiotics were determined by BD Phoenix automated microbiological system (Becton Dickinson, Sparks, MD, USA). Amoxicillin–clavulanic acid 1 g PO every 8 h was then added to the regimen. Clinical response did not ensue and it was switched to ciprofloxacin 400 mg iv every 12 h according to the results of antibiotic sensitivity testing (Table 1). The patient Table 1 – Susceptibility profile of Raoultella ornithinolytica.

Bloodstream yeast infections in a university hospital in Northeast Turkey: a 4-year survey

This study presents data on species distribution and antifungal susceptibility profiles of Candida bloodstream isolates obtained from a Turkish Tertiary Care Hospital during a 4-year period. All hospitalized patients who had ≥ 1 blood culture positive for yeast during their hospital stay from January 2005 through 2009 were included in this study. All isolates were identified to species level using CHROMagar and ID 32 C. Fluconazole and voriconazole antifungal susceptibility testing was performed using the disk diffusion method according to CLSI M44-A. In vitro activity of amphotericin B was determined by the Etest. Of all 166 yeast isolates, C. albicans was the dominant species (34.3%), followed by Candida parapsilosis (28.9%) and C. tropicalis (8.4%). All of the 48 C. parapsilosis strains were identified as C. parapsilosis sensu stricto. Resistance to fluconazole was more common among C. krusei isolates. Voriconazole resistance was absent. One C. lusitaniae strain showed a high amphotericin MIC (4 μg/ml). Our survey indicated an increase of some non-C. albicans Candida species in our hospital while antifungal resistance was uncommon.

Comparison of the sealing of different dentin bonding adhesives in root-end cavities: a bacterial leakage study.

OBJECTIVE To compare the root-end sealing of the different dentin-bonding adhesives (DBAs) in root-end cavities using a bacterial leakage system. STUDY DESIGN One hundred extracted single-rooted teeth were instrumented, and root-ends were resected and ultrasonically prepared. All teeth were then randomly assigned to 6 experimental groups (n = 15) and 2 control groups (positive and negative control; n = 5) for root-end filling with iBond (Heraeus Kulzer, Hanau, Germany), G-bond (GC Co., Tokyo, Japan), Xeno III Bond (Dentsply/Caulk, Milford, DE), AdheSe Bond (Ivoclar Vivadent, Schaa, Liechenstein), Clearfil Protect Bond (Kuraray, Osaka, Japan), or Clearfil Tri-S Bond (Kuraray). All preparations were further restored with a hybrid resin composite (Renew; Bisco, Schaumburg, IL). Nail varnish was applied to all external root surfaces to the level of the resected root-ends to prevent lateral microleakage. Samples were sterilized in an ethylene oxide sterilizer for 12 h. The apical 3-4 mm of the roots were immersed in brain-heart infusion culture medium with phenol red indicator within culture chambers. The coronal access of each specimen was inoculated every 48 h with a suspension of Enterococcus faecalis. Bacterial leakage was monitored every 24 h for 4 weeks. The data obtained were analyzed using a chi-squared test, with alpha = .05 as the level for statistical significance. RESULTS All positive controls leaked within 24 h; none of the negative controls leaked. Under the conditions of the study, despite some variations, there were no statistically significant differences in rate of bacterial leakage among the experimental test materials at 1-4 weeks (P > .05). CONCLUSIONS The type of DBA had no influence in the bacterial leakage of the root-end fillings.

Antimicrobial susceptibility and resistance mechanisms of methicillin resistant Staphylococcus aureus isolated from 12 Hospitals in Turkey

IntroductionMethicillin-resistant Staphylococcus aureus (MRSA) is one of the most important nosocomial pathogens and is also emerging in Turkish hospitals. The aim of this study was to determine the antimicrobial susceptibility profiles of MRSA isolated from Turkish hospitals.Materials and methodsA total of 397 MRSA strains isolated from 12 hospitals in Turkey were included to present study. Antimicrobial susceptibilities were tested using agar dilution method. Presence of ermA, ermB, ermC, msrA, tetM, tetK, linA and aac-aph genes were studied by PCR.ResultsAll strains were susceptible to vancomycin and linezolid. The susceptibility rates for fusidic acid, lincomycin, erythromycin, tetracyclin, gentamycin, kanamycin, and, ciprofloxacin were 91.9%, 41.1%, 27.2%, 11.8%, 8.5%, 8.3% and 6.8%, respectively. Lincomycin inactivation was positive for 3 isolates. Of 225 erythromycin resistant isolates 48 had ermA, 20 had ermC, and 128 had ermA-C. PCR was negative for 15 strains. Of 3 isolates with lincomycin inactivation one had linA and msrA. Of 358 gentamycin resistant isolates 334 had aac-aph and 24 were negatives. Among 350 tetracyclin resistant isolates 314 had tetM. Of 36 tetM negative isolates 10 had tetK.ConclusionMRSA isolates from Turkish hospitals were multiresistant to antimicrobials. Quinolone and gentamycin resistance levels were high and macrolide and lincosamide resistance were relatively low. Susceptibility rates for fusidic asid were high. Linezolide and vancomycin resistance are not emerged. The most common resistance genes were ermA, tetM and aac-aph. Evolution of antimicrobial susceptibilities and resistance genes profiles of MRSA isolates should be surveyed at regional and national level for accurate treatment of patients and to control dissemination of resistance genes.

Serotype distribution of Streptococcus pneumoniae in children with invasive diseases in Turkey: 2008–2014

Successful vaccination policies for protection from invasive pneumococcal diseases (IPD) dependent on determination of the exact serotype distribution in each country. We aimed to identify serotypes of pneumococcal strains causing IPD in children in Turkey and emphasize the change in the serotypes before and after vaccination with 7-valent pneumococcal conjugate vaccine (PCV-7) was included and PCV-13 was newly changed in Turkish National Immunization Program. Streptococcus pneumoniae strains were isolated at 22 different hospitals of Turkey, which provide healthcare services to approximately 65% of the Turkish population. Of the 335 diagnosed cases with S. pneumoniae over the whole period of 2008–2014, the most common vaccine serotypes were 19F (15.8%), 6B (5.9%), 14 (5.9%), and 3 (5.9%). During the first 5 y of age, which is the target population for vaccination, the potential serotype coverage ranged from 57.5 % to 36.8%, from 65.0% to 44.7%, and from 77.4% to 60.5% for PCV-7, PCV-10, and PCV-13 in 2008–2014, respectively. The ratio of non-vaccine serotypes was 27.2% in 2008–2010 whereas was 37.6% in 2011–2014 (p=0.045). S. penumoniae serotypes was less non-susceptible to penicillin as compared to our previous results (33.7 vs 16.5 %, p=0.001). The reduction of those serotype coverage in years may be attributed to increasing vaccinated children in Turkey and the increasing non-vaccine serotype may be explained by serotype replacement. Our ongoing IPD surveillance is a significant source of information for the decision-making processes on pneumococcal vaccination.

Urinary tract infections in neonates with unexplained pathological indirect hyperbilirubinemia: Prevalence and significance

BACKGROUND It is controversial to test for urinary tract infection (UTI) in patients with unexplained indirect hyperbilirubinemia in the first 2 weeks of life. We aimed to study the prevalence and significance of UTIs in such neonates who were requiring phototherapy. METHODS Subjects were 2- to 14-day-old neonates with indirect bilirubin levels above phototherapy limit with no other abnormality in their bilirubinaemia-related etiologic workup. UTI was diagnosed by 2 consecutive positive cultures obtained by catheterisation, documenting growth of >10,000 colonies of the same microorganism with consistent antibiograms. The UTI (+) patients were evaluated by renal ultrasonography (US), and some were followed up for possible recurrent UTI. RESULTS 262 neonates were included in the study. UTI prevalence was 12.2%, and bacteraemia was 6.2% among UTI (+) patients. The two most common pathogens (81.2%) were Escherichiacoli and Klebsiella. pneumonia. All UTI (+) patients had undergone US, revealing 12.5% pelvicaliectasis, other 12.5% increased renal parenchymal echogenicity, 3.1% concurrent pelvicaliectasis and increased renal parenchymal echogenicity. 53.1% of UTI (+) patients had undergone follow-up, after which 23.5% recurrent UTI were found at the end of a mean of 52 months. CONCLUSION We suggest that the neonates with unexplained pathological jaundice should be tested for possible UTI. Consequently, all newborns with UTI shall be evaluated by the urinary US and followed up for recurrent UTI.

Carbapenem-resistant Leuconostoc Septicemia in an Immunocompetent Infant.

To the Editor: Leuconostoc species are catalase (−), alpha or non-hemolytic gram (+) cocci, present commonly in nature, but are absent in human flora [1]. L. mesenteroides is the most frequently isolated type in human infections [2]. The first Leuconostoc infection in humans was reported in two immune deficient patients in the year 1985 [2, 3]. Immunosuppression, intravascular catheter or previous vancomycin use are risk factors for Leuconostoc infection [4]. We hereby present an immunocompetent infant who developed L. mesenteroides septicemia. A 17-mo-old boy was admitted with seizure. He had fever, tachycardia and tachypnea, and was confused without meningeal irritation. White blood cell was 14.400/mm, C-reactive protein 10.09 mg/dl (<0.5), procalcitonin 2.52 μg/l (N < 0.5) with toxic granulation in the peripheral blood smear. Ceftriaxone and amikasin were started. In blood culture, alpha hemolytic gram (+) cocci grown were detected and the strain was identified as L. mesenteroides (Fig. 1). Minimum inhibitor concentration (MIC) were ≥256 μg/ml for ceftriaxone, 0.25 for penicillin, 1 for amikacin, 4 for imipenem and 0.75 for linezolid. He had diarrhea on the second day of hospitalization. Stool analysis was negative for parasites, rotavirus and adenovirus. He had no fever and no growth on blood culture after 48 h of treatment. Immune system examination revealed normal serum immunoglobulins, positive antiHbs and Bacillus Calmette-Guerin (BCG) vaccination scar. We could not perform lumbar puncture because the family did not accept the procedure. Electroencephalography and cranial magnetic resonance imaging were normal. The patient was discharged in good health, without any additional problems. Gastrointestinal system can both be a colonization source and an entrance route for infections [2]. Gastrointestinal system was a possible entry route as the source of infection was diarrhea. Treatment of leuconostoc infections rely on antimicrobial sensitivity test results. Penicillin G and ampicillinMIC values are higher than those observed in other streptococci. Carbapanems, erythromycin, clindamycin, tetracyclin, minocycline, chloramphenicol, linezolid, gentamycin and daptomycin are amongst other possible antibiotic choices.