Orhan Yildiz

Physiological-dose steroid therapy in sepsis [ISRCTN36253388].

IntroductionThe aim of the study was to assess the prognostic importance of basal cortisol concentrations and cortisol response to corticotropin, and to determine the effects of physiological dose steroid therapy on mortality in patients with sepsis.MethodsBasal cortisol level and corticotropin stimulation test were performed within 24 hours in all patients. One group (20 patients) received standard therapy for sepsis and physiological-dose steroid therapy for 10 days; the other group (20 patients) received only standard therapy for sepsis. Basal cortisol level was measured on the 14th day in patients who recovered. The outcome of sepsis was compared.ResultsOnly Sequential Organ Failure Assessment (SOFA) score was found related to mortality, independent from other factors in multivariate analysis. No significant difference was found between the changes in the percentage of SOFA scores of the steroid therapy group and the standard therapy group in survivors, nor between the groups in basal and peak cortisol levels, cortisol response to corticotropin test and mortality. The mortality rates among patients with occult adrenal insufficiencies were 40% in the steroid therapy group and 55.6% in the standard therapy group.DiscussionThere was a trend towards a decrease in the mortality rates of the patients with sepsis who received physiological-dose steroid therapy. In the advancing process from sepsis to septic shock, adrenal insufficiency was not frequent as supposed. There was a trend (that did not reach significance) towards a decrease in the mortality rates of the patients with sepsis who received physiological-dose steroid therapy.

Actinomycoses and Nocardia pulmonary infections

Purpose of review Actinomycosis and nocardiosis are uncommon pulmonary infections with distinct morphologic features. Both infections most commonly present as chronic, debilitating illnesses with radiographic manifestations simulating lung cancer or tuberculosis. Immunocompromised hosts, however, may develop fulminant disease resembling acute bacterial pneumonia. The purpose of this review is primarily to review the clinical features, diagnosis, and management of actinomycosis and nocardiosis. Recent findings Treatment of actinomycosis is usually simple, requiring long-term, high-dose intravenous penicillin. Short-course chemotherapy, however, has recently been reported to be successful. Pulmonary nocardiosis is an important cause of opportunistic infection in immunosuppressed patients, and the incidence of this infection is increasing. The sulfonamides are still first-line agents in the management of nocardiosis, but resistance is most common among N. farcinica and N. otitidiscaviarum isolates. Carbapenems should be used as an alternative treatment for severely ill patients. Broth microdilution, E-test (AB Biodisk, Solna, Sweden) and BACTEC (Becton Dickinson, Sparks, Maryland, USA) radiometric method may be more useful in the routine clinical laboratory for antimicrobial testing of aerobic actinomycetes. Summary The practical distinction between the two diseases is in the matter of therapy. Diagnosis depends on a high degree of suspicion so as to alert the microbiology and pathology laboratories to employ special methods to identify the organisms. Early recognition and prompt treatment usually results in complete cure.

Incidence, risk factors and mortality of nosocomial pneumonia in Intensive Care Units: A prospective study

To determine the frequency, risk factors and mortality of nosocomial pneumonia a prospective study was conducted in the intensive care units. In the study period, 2402 patients were included. The nosocomial pneumonia was defined according to the Centers for Disease Control Criteria. Overall, 163 (6.8%) of the patients developed nosocomial pneumonia and 75.5% (n = 123) of all patients with nosocomial pneumonia were ventilator-associated pneumonia. 163 patients who were admitted to the intensive care unit during the same period but had no bacteriologic or histologic evidence of pneumonia were used as a control group. The APACHE II score, coma, hypoalbuminemia, mechanical ventilation, tracheotomy, presence of nasogastric tube were found as independent risk factors. Crude and attributable mortality were 65% and 52.6%, respectively. The mortality rate was five times greater in the cases (OR: 5.2; CI 95%: 3.2–8.3). The mean length of stay in the intensive care unit and hospital in the cases were longer than controls (p < 0.0001). Patients requiring mechanical ventilation have a high frequency of nosocomial pneumonia.

Catheter-related bacteremia due to Kocuria rosea in a patient undergoing peripheral blood stem cell transplantation

BackgroundMicrococcus species may cause intracranial abscesses, meningitis, pneumonia, and septic arthritis in immunosuppressed or immunocompetent hosts. In addition, strains identified as Micrococcus spp. have been reported recently in infections associated with indwelling intravenous lines, continuous ambulatory peritoneal dialysis fluids, ventricular shunts and prosthetic valves.Case presentationWe report on the first case of a catheter-related bacteremia caused by Kocuria rosea, a gram-positive microorganism belonging to the family Micrococcaceae, in a 39-year-old man undergoing peripheral blood stem cell transplantation due to relapsed Hodgkin disease. This uncommon pathogen may cause opportunistic infections in immunocompromised patients.ConclusionsThis report presents a case of Kocuria rosea catheter related bacteremia after stem cell transplantation successfully treated with vancomycin and by catheter removal.

Doxycycline plus streptomycin versus ciprofloxacin plus rifampicin in spinal brucellosis [ISRCTN31053647]

BackgroundThe optimal treatment regimen and duration of the therapy is still controversial in spinal brucellosis. The aim of this study is to compare the efficacy, adverse drug reactions, complications and cost of ciprofloxacin plus rifampicin versus doxycycline plus streptomycin in the treatment of spinal brucellosis.MethodsThe patients diagnosed as spinal brucellosis between January 2002 to December 2004 were enrolled into the study. Patients were enrolled into the two antimicrobial therapy groups (doxycycline plus streptomycin vs. ciprofloxacin plus rifampicin) consecutively. For the cost analysis of the two regimens, only the cost of antibiotic therapy was analysed for each patient.ResultsDuring the study period, 31 patients with spinal brucellosis were enrolled into the two antimicrobial therapy groups. Fifteen patients were included in doxycycline plus streptomycin group and 16 patients were included in ciprofloxacin plus rifampicin group. Forty-two levels of spinal column were involved in 31 patients. The most common affected site was lumbar spine (n = 32, 76%) and involvement level was not different in two groups. Despite the disadvantages (older age, more prevalent operation and abscess formation before the therapy) of the patients in the ciprofloxacin plus rifampicin group, the duration of the therapy (median 12 weeks in both groups) and clinical response were not different from the doxycycline plus streptomycin. The cost of ciprofloxacin plus rifampicin therapy was 1.2 fold higher than the cost of doxycycline plus streptomycin therapy.ConclusionClassical regimen (doxycycline plus streptomycin), with the appropriate duration (at least 12 weeks), is still the first line antibiotics and alternative therapies should be considered when adverse drug reactions were observed.

Genotypic analysis of Acinetobacter bloodstream infection isolates in a Turkish university hospital

Acinetobacter baumannii is a significant pathogen of bloodstream infections in hospital patients that frequently causes single clone outbreaks. We aimed to evaluate the genetic relatedness and antimicrobial susceptibility of Acinetobacter spp. bloodstream isolates, in order to obtain insight into their cross-transmission. This prospective study was conducted at the Erciyes University Hospital. During a 1-y period, all patients with nosocomial BSI caused by Acinetobacter spp. were included in the study. All data with regard to the patients, underlying diseases and risk factors for BSI and the severity of disease were collected. Blood culture isolates of Acinetobacter spp. were identified according to their morphology and biochemical reactions. The antimicrobial susceptibility was determined using the Kirby-Bauer disk diffusion test according to the NCCLS; the genetic relatedness of isolates was determined by RAPD-PCR analysis and pulsed-field gel electrophoresis (PFGE). 41 patients acquired a nosocomial bloodstream infection caused by A. baumanii during this period. 88% of these infections (36 of 41) occurred while the patients were treated in the intensive care unit. Nearly 80% of the isolates belonged to 3 genotypes, suggesting cross-transmission in ICU settings where infection control practices are poor. All Acinetobacter isolates were multidrug-resistant and the crude mortality of patients infected with A. baumanii was 80.5%. We concluded that the genetic relatedness of Acinetobacter spp. causing BSI was very high, indicating cross-transmission within the ICU setting. Essential components of an infection control programme to prevent nosocomial transmission of A. baumannii are early detection of colonized patients, followed by strict attention to standard precautions and contact isolation.

Clinical Experience with Tigecycline in the Treatment of Carbapenem-Resistant Acinetobacter Infections

Abstract Tigecycline is a promising therapeutic option against many current multidrug resistant pathogens. The aim of this retrospective study was to determine the clinical and microbiological outcomes of patients treated with tigecycline for serious infections caused by carbapenem-resistant Acinetobacter calcoaceticus Acinetobacter baumannii complex (Acb-complex). A retrospective study was conducted to define the patients who received tigecycline for carbapenem-resistant Acb-complex infections between 1 June, 2008 and 1 may, 2009. A total of 21 patients were eligible for the study. The median age of the patients was 48 years and 6 patients were female. Eighteen patients were treated with tigecycline for carbapenem-resistant Acb-complex as the sole microorganism while 3 received it for polymicrobial infections. All Acb-complex isolates were susceptible to tigecycline. The most common indication of tigecycline treatment was surgical-site infections (SSI) followed by ventilator associated pneumonia (VAP). Tigecycline was the sole antibiotic administered in 7 patients while concurrent antibiotics were used in 14 patients. The median duration of tigecycline therapy was 14days. Two patients died within 14 days of initiating treatment, representing an attributable mortality rate of 9.5% while 4 patients died within 30 days representing a crude mortality rate of 19.1%. Seventeen out of 21 patients had successful clinical outcomes, cure in 11 patients and improvement in 6. Fourteen of 21 patients had microbiological failure. Correlation between microbiological response with clinical outcome was poor. Clinical failure was more common in patients with VAP. Patients with bacteremia were more likely to have microbiological failure while microbiological outcome was better in patients with SSI. In this retrospective study, 81% (17 of 21) of the patients infected with carbapenem-resistant Acb-complex had a positive outcome under tigecycline therapy. However, these preliminary results should be evaluated cautiously in the absence of well-controlled studies.

Severe thrombotic microangiopathy associated with brucellosis: successful treatment with plasmapheresis.

Brucellosis is a disease that may lead to changes in hematologic parameters such as anemia, neutropenia, and thrombocytopenia; however, thrombotic microangiopathy (TMA) is a rare finding. Severe TMA may be associated with life-threatening hematologic, renal, and neurologic disorders. To prevent this mortality caused by brucellosis, prompt recognition of this complication and prompt therapy are essential. A patient with TMA associated with Brucella melitensis is presented who initially presented with fever, skin purpura, epistaxis, confusion, microangiopathic hemolytic anemia, and thrombocytopenia. TMA was treated with plasmapheresis with cryosupernatant plasma replacement, energetically. A rapid improvement in platelet count, lactate dehydrogenase level, hemolytic anemia, and neurologic symptoms was observed with this treatment. For cases with infection-induced thrombotic microangiopathy, short-term plasmapheresis may be applied as an urgent therapy in addition to antimicrobial therapy.

Disseminated nocardiosis due to unusual species: Two case reports

Pulmonary nocardiosis is the major clinical manifestation of human nocardiosis and disseminated infection can be seen in immunocompromised patients. N. asteroides is the predominant pathogen associated with disseminated diseases. We report 2 cases of pulmonary nocardiosis admitted with disseminated infection, caused by rare species of Nocardia: Nocardia transvalensis and Nocardia cyriacigeorgica.

Evaluation of hepatitis B virus transmission and antiviral therapy among hepatitis B surface antigen-positive pregnant women

The aim of the present study was to assess the potential risk of hepatitis B virus (HBV) vertical transmission among Turkish parturient women and to evaluate the efficacy and safety of antiviral agents.