Tumer Guven

Comparison of colistin–carbapenem, colistin–sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections

The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7xa0%): colistin–carbapenem (CC), 69 (32.2xa0%): colistin–sulbactam (CS), and 43 (20.1xa0%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (pu2009=u20090.97) and microbiological (pu2009=u20090.92) outcomes and 14-day survival rates (pu2009=u20090.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (pu2009>u20090.05) and also for 14-day survival (pu2009>u20090.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (pu2009=u20090.02, pu2009=u20090.0001, pu2009=u20090.0001, pu2009=u20090.02, and pu2009=u20090.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (pu2009<u20090.0001, pu2009<u20090.0001, and pu2009=u20090.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.

Neurobrucellosis: Clinical and Diagnostic Features

BACKGROUNDnWe describe the neurological involvement in brucellosis and revisited diagnostic criteria for neurobrucellosis.nnnMETHODSnPatients with laboratory-confirmed brucellosis who were consequently hospitalized were observed prospectively in a brucellosis-endemic region. The neurobrucellosis was diagnosed by any one of the following criteria: (1) symptoms and signs consistent with neurobrucellosis; (2) isolation of Brucella species from cerebrospinal fluid (CSF) and/or presence of anti-Brucella antibodies in CSF; (3) the presence of lymphocytosis, increased protein, and decreased glucose levels in CSF; or (4) diagnostic findings in cranial magnetic resonance imaging or CT.nnnRESULTSnLumbar puncture was performed in 128 laboratory-confirmed brucellosis cases who had neurological symptoms and signs, and 48 (37.5%) were diagnosed as neurobrucellosis. The sensitivity of tube agglutination (TA) in CSF was 0.94, specificity 0.96, positive predictive value 0.94, and negative predictive value 0.96. Brucella bacteria were isolated from CSF in 7 of 48 patients (15%). The mean age of 48 neurobrucellosis patients was 42 years (SD, 19 years), and 16 (33%) were female. The most common neurological findings were agitation (25%), behavioral disorders (25%), muscle weakness (23%), disorientation (21%), and neck rigidity (17%). Cranial nerves were involved in 9 of 48 patients (19%). One patient was left with a sequela of peripheral facial paralysis and 2 patients with sensorineural hearing loss.nnnCONCLUSIONSnPatients with severe and persistent headache and other neurologic symptoms and signs should be considered for neurobrucellosis in endemic regions and to possibly receive longer therapy than 6 weeks. Brucella TA with Coombs test in CSF is sensitive and specific by using a cutoff of ≥1:8.

Mortality indicators in pneumococcal meningitis: therapeutic implications

BACKGROUNDnThe aim of this study was to delineate mortality indicators in pneumococcal meningitis with special emphasis on therapeutic implications.nnnMETHODSnThis retrospective, multicenter cohort study involved a 15-year period (1998-2012). Culture-positive cases (n=306) were included solely from 38 centers.nnnRESULTSnFifty-eight patients received ceftriaxone plus vancomycin empirically. The rest were given a third-generation cephalosporin alone. Overall, 246 (79.1%) isolates were found to be penicillin-susceptible, 38 (12.2%) strains were penicillin-resistant, and 22 (7.1%) were oxacillin-resistant (without further minimum inhibitory concentration testing for penicillin). Being a critical case (odds ratio (OR) 7.089, 95% confidence interval (CI) 3.230-15.557) and age over 50 years (OR 3.908, 95% CI 1.820-8.390) were independent predictors of mortality, while infection with a penicillin-susceptible isolate (OR 0.441, 95% CI 0.195-0.996) was found to be protective. Empirical vancomycin use did not provide significant benefit (OR 2.159, 95% CI 0.949-4.912).nnnCONCLUSIONSnCeftriaxone alone is not adequate in the management of pneumococcal meningitis due to penicillin-resistant pneumococci, which is a major concern worldwide. Although vancomycin showed a trend towards improving the prognosis of pneumococcal meningitis, significant correlation in statistical terms could not be established in this study. Thus, further studies are needed for the optimization of pneumococcal meningitis treatment.

Genitourinary brucellosis: results of a multicentric study

This study reviewed the clinical, laboratory, therapeutic and prognostic data on genitourinary involvement of brucellosis in this largest case series reported. This multicentre study pooled adult patients with genitourinary brucellar involvement from 34 centres treated between 2000 and 2013. Diagnosis of the disease was established by conventional methods. Overall 390 patients with genitourinary brucellosis (352 male, 90.2%) were pooled. In male patients, the most frequent involved site was the scrotal area (n=327, 83.8%), as epididymo-orchitis (n=204, 58%), orchitis (n=112, 31.8%) and epididymitis (n=11, 3.1%). In female patients, pyelonephritis (n=33/38, 86.8%) was significantly higher than in male patients (n=11/352, 3.1%; p<0.0001). The mean blood leukocyte count was 7530±3115/mm3. Routine laboratory analysis revealed mild to moderate increases for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The mean treatment duration and length of hospital stay were significantly higher when there were additional brucellar foci (p<0.05). Surgical operations including orchiectomy and abscess drainage were performed in nine (2.3%) patients. Therapeutic failure was detected in six (1.5%), relapse occurred in four (1%), and persistent infertility related to brucellosis occurred in one patient. A localized scrotal infection in men or pyelonephritis in women in the absence of leucocytosis and with mild to moderate increases in inflammatory markers should signal the possibility of brucellar genitourinary disease.

Laboratory-acquired brucellosis in Turkey

BACKGROUNDnLaboratory healthcare workers (HCWs) are at risk of laboratory-acquired brucellosis (LAB).nnnAIMnTo describe the risk factors of LAB among HCWs.nnnMETHODSnA multicentre survey study was conducted by face-to-face interview in 38 hospitals from 17 provinces of Turkey. A structured survey was administered to the HCWs, working in infectious diseases clinics and microbiology departments, who were at risk of brucella infection.nnnFINDINGSnThe survey response rate was 100%. Of the 667 laboratory workers, 38 (5.8%) had a history of LAB. In multivariate analysis, factors independently associated with an increased risk of LAB included working with the brucella bacteria (odds ratio: 5.12; 95% confidence interval: 2.28-11.52; Pxa0<xa00.001) and male gender (2.14; 1.02-4.45; Pxa0=xa00.042). Using a biosafety cabinet level 2 (0.13; 0.03-0.60; Pxa0=xa00.009), full adherence to glove use (0.27; 0.11-0.65; Pxa0=xa00.004) and longer duration of professional life (0.86; 0.80-0.92; Pxa0<xa00.001) were found to be protective.nnnCONCLUSIONSnWorking with the brucella bacteria, being male, a lack of compliance with personal protective equipment and biosafety cabinets were the independent risk factors for the development of LAB in our series. Increased adherence to personal protective equipment and use of biosafety cabinets should be priority targets to prevent LAB.

Withdrawal of Staphylococcus aureus from intensive care units in Turkey

BACKGROUNDnIn the past, Staphylococcus aureus infections have displayed various patterns of epidemiologic curves in hospitals, particularly in intensive care units (ICUs). This study aimed to characterize the current trend in a nationwide survey of ICUs in Turkey.nnnMETHODSnA total of 88 ICUs from 36 Turkish tertiary hospitals were included in this retrospective study, which was performed during the first 3 months of both 2008 (period [P] 1) and 2011 (P2). A P value ≤.01 was considered significant.nnnRESULTSnAlthough overall rates of hospital-acquired infection (HAI) and device-associated infection densities were similar in P1 and P2, the densities of HAIs due to S aureus and methicillin-resistant Sxa0aureus (MRSA) were significantly lower in P2 (P < .0001). However, the proportion of HAIs due to Acinetobacter was significantly higher in P2 (P < .0001).nnnCONCLUSIONSnThe incidence of S aureus infections is declining rapidly in Turkish ICUs, with potential impacts on empirical treatment strategies in these ICUs.

Risk factors for occupational brucellosis among veterinary personnel in Turkey

Veterinarians and veterinary technicians are at risk for occupational brucellosis. We described the risk factors of occupational brucellosis among veterinary personnel in Turkey. A multicenter retrospective survey was performed among veterinary personnel who were actively working in the field. Of 712 veterinary personnel, 84 (11.8%) had occupational brucellosis. The median number of years since graduation was 7 (interquartile ranges [IQR], 4-11) years in the occupational brucellosis group, whereas this number was 9 (IQR, 4-16) years in the non-brucellosis group (p<0.001). In multivariable analysis, working in the private sector (odds ratio [OR], 2.8; 95% confidence interval [95% CI], 1.55-5.28, p=0.001), being male (OR, 4.5; 95% CI, 1.05-18.84, p=0.041), number of performed deliveries (OR, 1.01; 95% CI, 1.002-1.02, p=0.014), and injury during Brucella vaccine administration (OR, 5.4; 95% CI, 3.16-9.3, p<0.001) were found to be risk factors for occupational brucellosis. We suggest that all veterinary personnel should be trained on brucellosis and the importance of using personal protective equipment in order to avoid this infection.

Evaluation of tularaemia courses: a multicentre study from Turkey

In this multicentre study, which is the largest case series ever reported, we aimed to describe the features of tularaemia to provide detailed information. We retrospectively included 1034 patients from 41 medical centres. Before the definite diagnosis of tularaemia, tonsillitis (nxa0=xa0653, 63%) and/or pharyngitis (nxa0=xa0146, 14%) were the most frequent preliminary diagnoses. The most frequent clinical presentations were oropharyngeal (nxa0=xa0832, 85.3%), glandular (nxa0=xa0136, 13.1%) and oculoglandular (nxa0=xa0105, 10.1%) forms. In 987 patients (95.5%), the lymph nodes were reported to be enlarged, most frequently at the cervical chain jugular (nxa0=xa0599, 58%), submandibular (nxa0=xa0401, 39%), and periauricular (nxa0=xa055, 5%). Ultrasound imaging showed hyperechoic and hypoechoic patterns (59% and 25%, respectively). Granulomatous inflammation was the most frequent histological finding (56%). The patients were previously given antibiotics for 1176 episodes, mostly with β-lactam/β-lactamase inhibitors (nxa0=xa0793, 76%). Antituberculosis medications were provided in seven (2%) cases. The patients were given rational antibiotics for tularaemia after the start of symptoms, with a mean of 26.8xa0±xa037.5xa0days. Treatment failure was considered to have occurred in 495 patients (48%). The most frequent reasons for failure were the production of suppuration in the lymph nodes after the start of treatment (nxa0=xa0426, 86.1%), the formation of new lymphadenomegalies under treatment (nxa0=xa0146, 29.5%), and persisting complaints despite 2xa0weeks of treatment (nxa0=xa077, 15.6%). Fine-needle aspiration was performed in 521 patients (50%) as the most frequent drainage method. In conclusion, tularaemia is a long-lasting but curable disease in this part of the world. However, the treatment strategy still needs optimization.

The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Liver involvement in patients with brucellosis: results of the Marmara study

Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system. But, the extent of liver damage in due course of the disease is unclear. This study included 325 brucellosis patients with significant hepatobiliary involvement identified with microbiological analyses from 30 centers between 2000 and 2013. The patients with ≥5 times of the upper limit of normal for aminotransferases, total bilirubin level ≥2xa0mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3xa0%) and cholestasis was detected in 215 (66.1xa0%) patients. Fatigue (91xa0%), fever (86xa0%), sweating (83xa0%), arthralgia (79xa0%), and lack of appetite (79xa0%) were the major symptoms. Laboratory tests showed anemia in 169 (52xa0%), thrombocytopenia in 117 (36xa0%), leukopenia in 81 (25xa0%), pancytopenia in 42 (13xa0%), and leukocytosis in 20 (6xa0%) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (nu2009=u200973), doxycycline plus rifampicin (nu2009=u200971), doxycycline plus rifampicin and an aminoglycoside (nu2009=u200927). The duration of ALT normalization differed significantly in three treatment groups (pu2009<u20090.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (pu2009<u20090.05). However, the length of hospital stay did not differ significantly between these three combinations (pu2009>u20090.05). During the follow-up, treatment failure occurred in four patients (1xa0%) and relapse was seen in three patients (0.9xa0%). Mortality was not observed. Hepatobiliary involvement in brucellosis has a benign course with suitable antibiotics and the use of doxycycline and an aminoglycoside regimen seems a better strategy in select patients.