Güven Çelebi

Colistin vs. the combination of colistin and rifampicin for the treatment of carbapenem-resistant Acinetobacter baumannii ventilator-associated pneumonia.

The aim of this study was to compare the responses of colistin treatment alone vs. a combination of colistin and rifampicin in the treatment of ventilator-associated pneumonia (VAP) caused by a carbapenem-resistant A. baumannii strain. Forty-three patients were randomly assigned to one of two treatment groups. Although clinical (P = 0·654), laboratory (P = 0·645), radiological (P = 0·290) and microbiological (P = 0·597) response rates were better in the combination group, these differences were not significant. However, time to microbiological clearance (3·1 ± 0·5 days, P = 0·029) was significantly shorter in the combination group. The VAP-related mortality rates were 63·6% (14/22) and 38·1% (8/21) for the colistin and the combination groups (P = 0·171), respectively. Our results suggest that the combination of colistin with rifampicin may improve clinical and microbiological outcomes of VAP patients infected with A. baumannii.

Characterisation of carbapenem-resistant Acinetobacter baumannii outbreak strains producing OXA-58 in Turkey

The aim of this study was to characterise the molecular epidemiology and mechanisms of carbapenem resistance of nosocomial Acinetobacter baumannii isolates in a new university hospital in Turkey. A total of 145 carbapenem-resistant A. baumannii (CRAB) isolates were collected during the period 2003-2006. All isolates were typed by amplified fragment length polymorphism (AFLP) analysis. AFLP analysis showed three predominant clusters consisting of 72, 20 and 12 clinical strains as well as some smaller clusters and 23 unique strains. The three main clonal AFLP types corresponded to three major antibiotic susceptibility patterns. One environmental isolate was found related to the major outbreak clone. The reference type strains of European clones I, II and III were also typed by AFLP and analysed for clonal similarity. Polymerase chain reaction (PCR) analysis of different carbapenem resistance genes showed that strains from each of the three main clusters as well as 79% of the remaining strains harboured the bla(OXA-58) gene. No genes encoding the metallo-beta-lactamases GIM-1, SIM-1, SPM-1, IMP-like and VIM-like or the oxacillinases OXA-24-like and OXA-23-like were detected. In conclusion, multiple clones of CRAB strains producing OXA-58-type oxacillinase were responsible for a sustained CRAB outbreak occurring in a hospital in Turkey. These isolates were not associated with A. baumannii strains of the major European clones I, II or III.

Inadequate treatment of ventilator-associated and hospital-acquired pneumonia: Risk factors and impact on outcomes

BackgroundInitial antimicrobial therapy (AB) is an important determinant of clinical outcome in patients with severe infections as pneumonia, however well-conducted studies regarding prognostic impact of inadequate initial AB in patients who are not undergoing mechanical ventilation (MV) are lacking. In this study we aimed to identify the risk factors for inadequate initial AB and to determine its subsequent impact on outcomes in both ventilator associated pneumonia (VAP) and hospital acquired pneumonia (HAP).MethodsWe retrospectively studied the accuracy of initial AB in patients with pneumonia in a university hospital in Turkey. A total of 218 patients with HAP and 130 patients with VAP were included. For each patient clinical, radiological and microbiological data were collected. Stepwise multivariate logistic regression analysis was used for risk factor analysis. Survival analysis was performed by using Kaplan-Meier method with Log-rank test.ResultsSixty six percent of patients in VAP group and 41.3% of patients in HAP group received inadequate initial AB. Multiple logistic regression analysis revealed that the risk factors for inadequate initial AB in HAP patients were; late-onset HAP (OR = 2.35 (95% CI, 1.05-5.22; p = 0.037) and APACHE II score at onset of HAP (OR = 1.06 (95% CI, 1.01-1.12); p = 0.018). In VAP patients; antibiotic usage in the previous three months (OR = 3.16 (95% CI, 1.27-7.81); p = 0.013) and admission to a surgical unit (OR = 2.9 (95% CI, 1.17-7.19); p = 0.022) were found to be independent risk factors for inadequate initial AB. No statistically significant difference in crude hospital mortality and 28-day mortality was observed between the treatment groups in both VAP and HAP. However we showed a significant increase in length of hospital stay, duration of mechanical ventilation and a prolonged clinical resolution in the inadequate AB group in both VAP and HAP.ConclusionOur data suggests that the risk factors for inadequate initial AB are indirectly associated with the acquisition of resistant bacteria for both VAP and HAP. Although we could not find a positive correlation between adequate initial AB and survival; empirical AB with a broad spectrum should be initiated promptly to improve secondary outcomes.

Asymptomatic Brucella bacteraemia and isolation of Brucella melitensis biovar 3 from human breast milk

Brucellosis is a zoonotic disease and virtually all infections derived from exposure to animals or ingestion of unpasteurized dairy products. Brucellosis among family members has been reported. However, screening household members of an index case of acute brucellosis is not a routine procedure. A 10-y-old boy was diagnosed with acute brucellosis. Unpasteurized goat cheese commonly consumed within the family was thought to be the possible source of the bacteria. The family (parents, sister and brother) was screened with physical examination, serum tube agglutination test, blood cultures and routine laboratory tests. Three additional cases (parents and sister) of serological and culture proven brucellosis were detected. Two of them (mother and sister) were asymptomatic and had no clinical findings. Brucella melitensis biovar 3 was isolated from breast milk culture and from all blood cultures of 4 brucellosis cases. In conclusion, brucellosis, even with bacteraemia, can be completely asymptomatic. Consumption of raw milk products by household members is a common risk factor for brucellosis outbreak among family members. Thus, screening household members of an index case of brucellosis can expose new brucellosis cases.

Piperacillin–tazobactam Versus Carbapenem Therapy With and Without Amikacin as Empirical Treatment of Febrile Neutropenia in Cancer Patients: Results of an Open Randomized Trial at a University Hospital

OBJECTIVE Empirical beta-lactam monotherapy has become the standard therapy in febrile neutropenia. The aim of this study was to compare the efficacy and safety of piperacillin-tazobactam versus carbapenem therapy with or without amikacin in adult patients with febrile neutropenia. METHODS In this prospective, open, single-center study, 127 episodes were randomized to receive either piperacillin-tazobactam (4 x 4.5 g IV/day) or carbapenem [meropenem (3 x 1 g IV/day) or imipenem (4 x 500 mg IV/day)] with or without amikacin (1 g IV/day). Doses were adjusted according to renal function. Clinical response was determined during and at completion of therapy. RESULTS One hundred and twenty episodes were assessable for efficacy (59 piperacillin-tazobactam, 61 carbapenem). Mean duration of treatment was 14.8 +/- 9.6 days in the piperacillin-tazobactam group and 14.7 +/- 8.8 days in the carbapenem group (P > 0.05). Mean days of fever resolution were 5.97 and 4.48 days for piperacillin-tazobactam and carbapenem groups, respectively (P > 0.05). Similar rates of success without modification were found in the piperacillin-tazobactam (87.9%) and in the carbapenem groups (75.4%; P > 0.05). Fungal infection occurrence rates were 30.5 and 18% in piperacillin-tazobactam and carbapenem groups, respectively (P = 0.05). Antibiotic modification rates were 30.5 and 13.1% (P = 0.02) and the addition of glycopeptides to empirical antibiotic regimens rates were 15.3 and 44.3% for piperacillin-tazobactam and carbapenem groups, respectively (P = 0.001). The rude mortality rates were 14% (6/43) and 29.3% (12/41) in piperacillin-tazobactam and carbapenem groups, respectively (P = 0.08). CONCLUSIONS The effect of empirical regimen of piperacillin-tazobactam regimen is equivalent to carbapenem in adult febrile neutropenic patients.

First isolation of vancomycin-resistant enteroccoci and spread of a single clone in a university hospital in northwestern Turkey

Reported here is the first isolation of vancomycin-resistant Enterococcus (VRE) at a hospital in northwestern Turkey and a description of the ensuing outbreak investigation. The first isolate was obtained from a wound culture of a patient in an intensive care unit. Thereafter, a total of 205 rectal swabs, 67 skin swabs and 123 environmental samples were screened, revealing five more VRE isolates. All isolates showed similar antibiotic resistance patterns, except for two that differed regarding gentamicin resistance. The vanA gene was present in all isolates. Pulsed-field gel electrophoresis demonstrated that all isolates belonged to a single clone, with the gentamicin-resistant isolates demonstrating two-band differences. This is the first outbreak to be caused by spread of a single VRE clone in Turkey; it was successfully controlled by strict adherence to appropriate infection control practices.

Activity of a dry mist-generated hydrogen peroxide disinfection system against methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii

BACKGROUND The aim of this study was to evaluate the activity of a dry mist-generated hydrogen peroxide (DMHP) system (Sterinis; Gloster Sante Europe, Labege cedex, France) against methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii. METHODS McFarland 0.5 suspensions of 2 test bacteria, either pure or containing 5% sterile serum, were prepared and inoculated onto sterile stainless steel disks. Each disk in a Petri dish-with the Petri dish cover either closed or open-was placed in different locations in an intensive care unit room. Quantitative cultures were performed after the cycle. RESULTS No growth occurred on the disks in the absence of a barrier, except 1 disk containing serum. Existence of a barrier, as a drawer or a covered Petri dish, caused failure in the disinfection activity. The mean reduction in initial log(10) bacterial count was lower for both of the test bacteria in presence of a barrier: 4.44- to 4.70-log(10) colony-forming units (cfu) decrease was observed in absence of a barrier, whereas 1.49- to 3.79-log(10) cfu decrease was observed in presence of a barrier. When the culture results were compared according to organic load content, the mean (±standard deviation) reduction of initial contamination in pure and in serum containing MRSA suspensions was 4.25 ± 1.20- and 3.34 ± 1.89-log(10) cfu, respectively. The mean (±standard deviation) reduction in pure and in serum containing A baumannii suspensions was 4.34 ± 0.89- and 3.87 ± 1.26-log(10) cfu, respectively. The differences were statistically significant (P < .001). CONCLUSION Sterinis was capable of killing MRSA and A baumannii on open surfaces; however, it was not effective in closed or semiclosed areas. Presence of serum also caused failure in the disinfection activity of the system.

Factors associated with catheter-associated urinary tract infections and the effects of other concomitant nosocomial infections in intensive care units

Abstract Background: Catheter-associated urinary tract infections (CAUTIs) are the most common nosocomial infections in intensive care units (ICUs). The objectives of this study were to describe the incidence, aetiology, and risk factors of CAUTIs in ICUs and to determine whether concomitant nosocomial infections alter risk factors. Methods: Between April and October 2008, all adult catheterized patients admitted to the ICUs of Zonguldak Karaelmas University Hospital were screened daily, and clinical and microbiological data were collected for each patient. Results: Two hundred and four patients were included and 85 developed a nosocomial infection. Among these patients, 22 developed a CAUTI alone, 38 developed a CAUTI with an additional nosocomial infection, either concomitantly or prior to the onset of the CAUTI, and 25 developed nosocomial infections at other sites. The CAUTI rate was 19.02 per 1000 catheter-days. A Cox proportional hazard model showed that in the presence of other site nosocomial infections, immune suppression (hazard ratio (HR) 3.73, 95% CI 1.47–9.46; p = 0.006), previous antibiotic usage (HR 2.06, 95% CI 1.11–3.83; p = 0.023), and the presence of a nosocomial infection at another site (HR 1.82, 95% CI 1.04–3.20; p = 0.037) were the factors associated with the acquisition of CAUTIs with or without a nosocomial infection at another site. When we excluded the other site nosocomial infections to determine if the risk factors differed depending on the presence of other nosocomial infections, female gender (HR 2.67, 95% CI 1.03–6.91; p = 0.043) and duration of urinary catheterization (HR 1.07 (per day), 95% CI 1.01–1.13; p = 0.019) were found to be the risk factors for the acquisition of CAUTIs alone. Conclusions: Our results showed that the presence of nosocomial infections at another site was an independent risk factor for the acquisition of a CAUTI and that their presence alters risk factors.

Evaluation of cervical computed tomography findings in oropharyngeal tularaemia

Cervical contrast-enhanced computed tomography (CECT) was performed in 16 cases (5M, 11F) of oropharyngeal tularaemia, diagnosed at Zonguldak Karaelmas University, Turkey, between January 2004 and March 2006. All patients showed lymphadenopathy with contrast enhancement, 12 of them with peripheral contrast enhancement. Lymph node necrosis was found in 13 of the patients, abscess formation in 9 and cyst formation in 13. This appears to be the largest series of cervical CECT in oropharyngeal tularaemia reported to date. Tularaemia is a differential diagnosis of massive adenotonsillar enlargement and extensive necrotic cervical lymphadenopathy.

Herpes simplex virus encephalitis in pregnancy

Herpes simplex encephalitis (HSE), which is an uncommon condition, is a significant cause of neurological impairment in pregnant women. Assessment of fetal contamination remains a problem. Up to now only a few pregnant HSE cases have been reported in the literature [1]. We report a case of HSE in the third trimester of pregnancy who was treated with acyclovir and recovered completely to deliver a healthy child at term. A 26-year-old woman, gravida 1 para 0, at 25 weeks of gestation was admitted to our hospital with a five-day history of fever, headache, and nausea and a 12-hour history of mental status changes. Her symptoms were initially attributed to acute sinusitis, and cefuroxime axetil p.o. had been started four days previously. The day before admission she had begun to display personality changes and abnormal behaviors. On admission, her blood pressure was 140/90 mmHg and her temperature was 398C. Physical and neurological examinations were unremarkable and signs of meningeal irritation were absent. Her laboratory test results were as follows: leukocyte count 156 10/mm, hemoglobin 10.2 g/dL, C-reactive protein þ, erythrocyte sedimentation rate 31 mm/h; platelet count, blood biochemistry tests, and urinalysis were normal. Lumber puncture (LP) was performed, which showed normal cerebrospinal fluid (CSF) pressure, with 70 white cells (90% polymorphonuclear cells) and 40 red cells per mm. CSF protein was 51.66 mg/dL, CSF glucose was 64.36 mg/dL, and blood glucose was 134 mg/dL. Acid-fast and Gram stains revealed no positive results. An initial diagnosis of poorly treated bacterial meningitis and encephalitis was made and ceftriaxone 26 2 g i.v. and acyclovir 36 750 mg i.v. was started. On the second day of admission she suffered a generalized tonic-clonic epileptic seizure and phenytoin therapy was added. CSF culture was negative. On follow-up she remained febrile and her conscious state deteriorated, hence on day 3, ceftriaxone was ceased and meropenem 36 2 g i.v. was started in addition to acyclovir. An electroencephalogram (EEG) showed diffuse slowing with an epileptic activity in the right frontal region. On the same day, a cerebral magnetic resonance imaging (MRI) was performed showing increased signal and edema in the right temporal region. Dexamethasone therapy was started. On day 5 she became afebrile but remained drowsy over the following two days. On day 7 her conscious state improved and the results of the herpes simplex virus (HSV) type I polymerase chain reaction (PCR) on the initial CSF sample was positive confirming the diagnosis of HSE. She had no evidence of genital or disseminated HSV infection. HSV type I and type II IgM and HSV type II IgG were negative, and HSV type I IgG was positive in serum. Meropenem was ceased and the patient received a 21-day course of acyclovir with a rapid improvement in her condition. During the course of the disease, fetal ultrasound monitoring was normal. Dexamethasone was continued in a reducing regimen until day 28. One week after discharge, a control EEG showed normal