Mustafa Kemal Celen

Efficacy and safety of tenofovir disoproxil fumarate in pregnancy for the prevention of vertical transmission of HBV infection

AIM To evaluate the effects of tenofovir disoproxil fumarate (TDF) use during late pregnancy to reduce hepatitis B virus (HBV) transmission in highly viremic mothers. METHODS This retrospective study included 45 pregnant patients with hepatitis B e antigen (+) chronic hepatitis B and HBV DNA levels > 10⁷ copies/mL who received TDF 300 mg/d from week 18 to 27 of gestation (n = 21). Untreated pregnant patients served as controls (n = 24). All infants received 200 IU of hepatitis B immune globulin (HBIG) within 24 h postpartum and 20 μg of recombinant HBV vaccine at 4, 8, and 24 wk. Perinatal transmission rate was determined by hepatitis B surface antigen and HBV DNA results in infants at week 28. RESULTS At week 28, none of the infants of TDF-treated mothers had immunoprophylaxis failure, whereas 2 (8.3 %) of the infants of control mothers had immunoprophylaxis failure (P = 0.022). There were no differences between the groups in terms of adverse events in mothers or congenital deformities, gestational age, height, or weight in infants. At postpartum week 28, significantly more TDF-treated mothers had levels of HBV DNA < 250 copies/mL and normalized alanine aminotransferase compared with controls (62% vs none, P < 0.001; 82% vs 61%, P = 0.012, respectively). CONCLUSION TDF therapy during the second or third trimester reduced perinatal transmission rates of HBV and no adverse events were observed in mothers or infants.

Efficacy and Tolerability of Antibiotic Combinations in Neurobrucellosis: Results of the Istanbul Study

ABSTRACT No data on whether brucellar meningitis or meningoencephalitis can be treated with oral antibiotics or whether an intravenous extended-spectrum cephalosporin, namely, ceftriaxone, which does not accumulate in phagocytes, should be added to the regimen exist in the literature. The aim of a study conducted in Istanbul, Turkey, was to compare the efficacy and tolerability of ceftriaxone-based antibiotic treatment regimens with those of an oral treatment protocol in patients with these conditions. This retrospective study enrolled 215 adult patients in 28 health care institutions from four different countries. The first protocol (P1) comprised ceftriaxone, rifampin, and doxycycline. The second protocol (P2) consisted of trimethoprim-sulfamethoxazole, rifampin, and doxycycline. In the third protocol (P3), the patients started with P1 and transferred to P2 when ceftriaxone was stopped. The treatment period was shorter with the regimens which included ceftriaxone (4.40 ± 2.47 months in P1, 6.52 ± 4.15 months in P2, and 5.18 ± 2.27 months in P3) (P = 0.002). In seven patients, therapy was modified due to antibiotic side effects. When these cases were excluded, therapeutic failure did not differ significantly between ceftriaxone-based regimens (n = 5/166, 3.0%) and the oral therapy (n = 4/42, 9.5%) (P = 0.084). The efficacy of the ceftriaxone-based regimens was found to be better (n = 6/166 [3.6%] versus n = 6/42 [14.3%]; P = 0.017) when a composite negative outcome (CNO; relapse plus therapeutic failure) was considered. Accordingly, CNO was greatest in P2 (14.3%, n = 6/42) compared to P1 (2.6%, n = 3/117) and P3 (6.1%, n = 3/49) (P = 0.020). Seemingly, ceftriaxone-based regimens are more successful and require shorter therapy than the oral treatment protocol.

The evaluation of microbiology and Fournier's gangrene severity index in 27 patients

OBJECTIVES The objectives of this study were to identify the causative microorganisms and factors associated with survival in patients with Fourniers gangrene and to determine the accuracy of the Fourniers gangrene severity index. MATERIALS AND METHODS We retrospectively evaluated 27 patients with Fourniers gangrene who were treated and followed up at our hospital between January 2005 and December 2006. Biochemical, hematologic, and bacteriologic study results at admission and at the final evaluation, etiologic and predisposing factors at admission, physical examination findings, the timing and extent of surgical debridement, and antibiotic therapy used were all recorded. RESULTS The admission laboratory parameters that were significantly correlated with outcome included urea, creatinine, sodium, and potassium; at the final evaluation, in addition to these parameters, hematocrit, albumin, and bicarbonate levels were also significantly associated with outcome. The mean Fourniers gangrene severity index score (FGSIS) at admission for survivors was 5.04+/-2.49 compared with 13.6+/-4.61 for non-survivors. There was a strong correlation between the FGSIS and mortality (p<0.0001). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated microorganisms. CONCLUSIONS Patient metabolic status and predisposing factors are important in the prognosis of Fourniers gangrene. Hence, we believe that the FGSIS should be used clinically to evaluate therapeutic options and assess results.

Brucellar epididymo-orchitis in southeastern part of Turkey: an 8 year experience

OBJECTIVE the different clinical and laboratory features and response to treatment of patients with acute brucellar epididymo-orchitis (BEO) reporting to the reference hospital in Southeastern Anatolia of Turkey. MATERIAL AND METHODS in this study, 27 male patients with brucellosis, who presented with epididymitis or epididymo-orchitis (EO) at the university hospital in Diyarbakir from 1998 to 2006, were included. They were compared with the other male patients. Positive blood culture or high agglutination titers of > 1/160 and positive clinical manifestations of brucellosis were the main criteria for diagnosing brucellosis. RESULTS fourteen patients had unilateral EO. Leukocytosis was present in 10 patients; all of them had initial agglutination titers of > 1/160 and 10 patients had a positive blood culture. All patients received combined therapy with streptomycin for the first 21 days (or oral rifampicin for 6-8 weeks) with doxycycline or tetracycline for 6-8 weeks. All showed improvement, fever subsided in 3-7 days, and the scrotal enlargement and tenderness regressed. Only one patient had a relapse within one year. CONCLUSION in brucellosis-endemic areas, clinicians encountering EO should consider the likelihood of brucellosis. In this study, young age was the most common risk factor, and leukocytosis and high CRP level were the most common laboratory findings. Most cases were unilateral. All patients responded to medical management very well. Conservative management with combination antibiotic therapy was adequate for managing BEO. Conclusively, brucellosis must be considered as a cause of orchitis, especially in endemic regions like Turkey.

Retreatment of Chronic Hepatitis C Infection with Telaprevir: Preliminary Results in Turkey

BACKGROUND The use of pegylated interferon alpha and ribavirin (PegIFN/RBV) for the retreatment of chronic hepatitis C virus (HCV) infection without a sustained virological response (SVR) prior to PegIFN/RBV treatment has resulted in low success rates. AIMS To investigate the efficacy and safety of telaprevir (TVR) in combination with PegIFN/RBV in patients infected with HCV genotypes 1 and 4 who were previously treated with PegIFN/RBV and failed to achieve SVR. STUDY DESIGN Multi-center, retrospective, cross-sectional study. METHODS The study included 111 patients: 80 prior relapsers, 25 prior null responders, and six prior partial responders to PegIFN/RBV treatment. The patients were given TVR/PegIFN/RBV for 12 weeks, followed by a 12-week PegIFN/RBV treatment; virological response results were assessed at weeks 4, 12, and 24. Treatment was discontinued in patients with HCV RNA >1000 IU/mL at week 4 or with negative RNA results at week 4 but >1000 IU/mL at week 12. Rapid virological response (RVR), early virological response (EVR), extended rapid virological response (eRVR), and virological response at 24th week of treatment were evaluated. The side effects of combination therapy and the rates of treatment discontinuation were investigated. RESULTS The mean age of the patients was 56.02±9.96 years and 45.9% were male. Ninety-one percent of the patients were infected with viral genotype 1, 69.6% with the interleukin (IL) 28B genotype CT and 20.2% were cirrhotic. The RVR rate was 86.3% in prior relapsers, 56% in prior null responders, and 50% in prior partial responders (p=0.002). EVR rates in those groups were 91.3%, 56%, and 83.3%, respectively (p<0.001). eRVR rates were 83.8% in prior relapsers, 48% in prior null responders, and 50% in prior partial responders (<0.001). The virological response at the 24th week of treatment was found to be the highest in prior relapsers (88.8%); it was 56% in prior null responders and 66.7% in prior partial responders (p<0.001). Common side effects were fatigue, headache, anorexia, malaise, anemia, pruritus, dry skin, rash, dyspepsia, nausea, pyrexia, stomachache, and anorectal discomfort. All treatments were discontinued due to side effects in 9.9% of patients. CONCLUSION High virological response rates were obtained with TVR/PegIFN/RBV treatment. Although side effects were frequently observed, the discontinuation rate of combination therapy was low.

Pregnancy and H1N1 infection in Southeast Turkey

INTRODUCTION H1N1 Influenza made a great impact a worldwide, as well as in Turkey, in 2009. Clinical experiences have shown that it had a more serious prognosis in pregnant women. In this report, we summarize the cases of 16 pregnant women with H1N1 Influenza. METHODOLOGY The study included 16 pregnant women hospitalized in Dicle University Hospital with complaints of fever, sore throat, cough and myalgia between October and December 2009. The diagnosis of pandemic H1N1 Influenza was confirmed on nasopharyngeal specimens using real-time reverse-transcriptase polymerase chain reaction (RT-PCR) in all patients. Patients who had the same complaints but were not diagnosed as H1N1 Influenza were excluded. The epidemiological, clinical, diagnostic, and outcome features of the patients were recorded. RESULTS The median age of the patients was 27 years (range 18-41 years). The mean gestational age was 25.4 weeks (range 5-38 weeks). Two cases were twin pregnancy. Two cases had co-morbid diseases including asthma and anemia. The most frequent admission symptoms were fever in 13 cases (81%), cough in 12 cases (75%) and dyspnea in 6 cases (37,5%). Antiviral treatment (oseltamivir 75 mg p.o. bid) was applied in 15 cases. Four cases needed intensive care monitoring and two of them died (12.5%) because of severe respiratory insufficiency. CONCLUSION Patients with late gestational age, the presence of co-morbid disease, and multiple pregnancy have poor prognosis. Immediate intervention with antiviral treatment is associated with reduced severity of the disease and duration of hospital stay.

The Place and the Efficacy of Infectious Disease Consultations in the Hospitals

Abstract Our study aims to determine the efficacy of infectious disease consultations and the interrelations between doctors in this social laboratory. This study was conducted at 34 centers located in 22 cities across Turkey and contributed by 210 infectious disease specialists (IDSs) and 970 non–infectious disease specialists (NIDSs), totaling 1180 medical doctors. Infectious disease specialists and NIDSs have separately contributed by responding to questionnaires designed specifically for the consultation process. It appears that a satisfactory collaboration has been established between IDSs and NIDSs during the consultation practices. There are some discrepancies in the perceptions of some of the NIDSs. These are the evaluation of patients holistically, the expectation of NIDSs in critical infection cases to start the therapy immediately, losing the support of drug companies by NIDSs, and the restriction of NIDSs in routine medical practice. On the other hand, NIDSs seem to have real problems in the diagnosis or treatment of infectious diseases. The consultation service provided by the IDSs in Turkey is widely accepted among other clinicians and appears to be of a crucial importance.

Comparative activity of carbapenem testing (the COMPACT study) in Turkey

BackgroundRecent evidence indicates that Gram-negative bacterial pathogens, the most common of which are Pseudomonas spp., Enterobacteriaceae, and Acinetobacter baumannii, are frequent causes of hospital-acquired infections. This study aims to evaluate the in vitro activity of doripenem and comparator carbapenem antibiotics against Gram-negative clinical isolates collected from COMParative Activity of Carbapenem Testing (COMPACT) study centres in Turkey.MethodsTen centres in Turkey were invited to submit Pseudomonas aeruginosa, Enterobacteriaceae, and other Gram-negative isolates from intensive care unit (ICU)/non-ICU patients with complicated intra-abdominal infections, bloodstream infections, or nosocomial pneumonia, including ventilator-associated pneumonia, between May and October 2008. Susceptibility was determined by each centre using E-test. A central laboratory performed species confirmation as well as limited susceptibility and quality-control testing.ResultsFive hundred and ninety six isolates were collected. MIC90 values for doripenem, meropenem, and imipenem, respectively, were 32, ≥ 64, and ≥ 64 mg/L against Pseudomonas spp.; 0.12, 0.12, and 0.5 mg/L against Enterobacteriaceae; and ≥ 64 mg/L for each against other Gram-negative isolates. In determining the susceptibility of hospital isolates of selected Gram-negative pathogens to doripenem, imipenem, and meropenem, we found that against all pathogens combined, the MIC90 for ICU compared with non-ICU isolates was higher.ConclusionsDoripenem showed similar or slightly better activity than meropenem and better activity than imipenem against the Gram-negative pathogens collected in Turkey.

An unusual presentation of brucellosis: acute hepatitis

We report a case where hepatitis was the only manifestation of acute brucellosis.A 33-year-old female patient was admit-ted to our clinic with complaints of fever, chills, headache, nausea and dark urine. Her temperature was 38.4°C, pulse was 76/min, respiratory rate was 16/min and blood pressure was 110/80 mmHg. Physi-cal examination revealed yellow sclera and a hepatosplenomegaly of 1 cm. The labora-tory test results revealed a leukocyte count of 3.8x109/L, C-reactive protein (CRP) of 26 mg/L, and an erythrocyte sedimenta-tion rate (ESR) of 17 mm/h. Serum alanine transferase (ALT) level was 372 U/L, se-rum aspartate transferase (AST) 303 U/L, serum alkaline phosphatase 454 U/L, se-rum γ-glutamyl transpeptidase 192 U/L and total bilirubin concentration was 3.2 mg/dL. The HBs-Ag, anti-HBc IgM, anti-HAV IgM, anti-HCV, anti-CMV IgM, anti-VCA IgM and Gruber Widal tests were negative. The patient had a positive history of fresh cheese ingestion, so a Wright agglutination test was also performed and the titer was found to be positive at 1/320. Abdominal ultrasonography showed moderate hepat-osplenomegaly, without any structural or morphological changes. With these findings, she was diagnosed as having acute hepatitis due to brucellosis. Blood cultures had been performed before the antibiotic therapy was started. Doxycycline 200 mg/d and strepto-mycin 1 g/d treatment were started. The fe-ver subsided on the fourth day of the treat-ment and blood cultures isolated

Snakebite-Induced Acute Kidney Injury: Data from Southeast Anatolia

Renal failure is an important complication of snakebite and a major cause of mortality. We aimed to study the clinical profile of snake envenomation in Southeast Anatolia, Turkey, in an adult population. We retrospectively analyzed the records of 200 snakebite victims from 1998 to 2006 at the Dicle University School of Medicine, Diyarbakir, Turkey. Sixteen patients (8%) developed AKI (acute kidney injury). Of those, 25% required dialysis and 18% died. There was no difference between groups in age, arrival time to hospital, and hospital stay time. Both groups received similar hydration and therapy at admission. Disseminated intravascular coagulation (DIC) was observed in 25% of the AKI group and was significantly higher than the non-AKI group (7.1%; p = 0.014). There was no significant difference regarding hemoglobin, platelet levels, and prothrombin time at admission. The prevalence of thrombocytopenia (<150,000 K/UL ) was 60% in the AKI group and 40% in the non-AKI group (p > 0.05). WBC count was significantly higher in the AKI group than in those without AKI (p = 0.001); serum albumin was significantly lower in the AKI group than in those without AKI (p = 0.013). AKI is an important complication of snakebite that may lead to mortality. Despite some troublesome aspects due to its retrospective design, this is a large series from Southeast Anatolia of Turkey in an adult population. Subjects with high WBC, low albumin, and DIC should be closely followed up for the development of AKI.