Yavuz Havlucu

Drug-resistant pulmonary tuberculosis in western Turkey: prevalence, clinical characteristics and treatment outcome.

BACKGROUND Although high antituberculosis (anti-TB) drug resistance rates have been reported in Turkey, the clinical characteristics and implications for the outcome of anti-TB treatment have not been fully investigated. We determined the prevalence of anti-TB drug resistance and examined demographic data, clinical characteristics and treatment outcome in relation to patterns of resistance. METHODS From the TB case registry of a university hospital and the two largest dispensaries in Manisa city, we identified all pulmonary TB cases with a culture-proven definitive diagnosis and antimicrobial susceptibility results for a 7-year period. We collected and analyzed demographic and clinical data and information on treatment outcome for those cases in relationship to anti-TB drug resistance. RESULTS Of 355 M. tuberculosis strains, 71.5% were susceptible to streptomycin, isoniazid, rifampicin and ethambutol. Any drug resistance and multi-drug resistance (MDR ) rates were 21.1% and 7.3% and were higher in males (53% and 9%, respectively) than in females (22% and 1%, respectively). Drug resistance was significantly higher in old cases (acquired drug resistance) vs new cases (primary drug resistance), and was associated with treatment failure (P<0.001). The prevalence of MDR was significantly higher in the old cases (22.4%) than in the new cases (4.4%) (P<0.001). Symptoms, radiographic findings, associated diseases, and sputum smear positivity were unrelated to the development of resistance. The prevalence of any drug resistance and MDR was significantly higher in those with treatment failure than in patients with treatment success. CONCLUSION High resistance rates, particularly for acquired MDR, indicate a need for improvement in the TB control programme in our region.

Relation between quality of life and morbidity and mortality in COPD patients: Two-year follow-up study.

ABSTRACT Quality of life (QoL) is being recognized as an important outcome when evaluating chronic obstructive pulmonary disease (COPD) patients. This study aims at identifying the relation between QoL parameters and mortality and morbidity in COPD patients by using the St. George Respiratory Questionnaire (SGRQ). In this prospective study, 251 COPD patients as defined by American Thoracic Society (ATS) criteria were included. A total of 218 patients (86.85%) were male and mean age was 65.55 years. A pulmonary function test (PFT) and SGRQ were performed at the beginning, first, and second years. During a two-year follow-up, the first exacerbation day, the number of exacerbations and intubations, the number and duration of hospitalizations, hospitalizations in an intensive care unit, and exitus day were recorded. When the correlation between FEV1, SGRQ scores, and these parameters was investigated, there was significant correlation between these parameters, and this correlation was more significant in SGRQ scores than FEV1 (Pearson correlation test). The activity score of SGRQ was found to be more useful than other scores (Cox regression analysis). Not only PFT but also QoL questionnaires are useful in determining the prognosis of COPD. QoL questionnaires provide a valid and standardized estimate of the overall impact of COPD, and can complement spirometric measurements of baseline assessment of patients in routine practice.

Patient and physician delay in the diagnosis and treatment of non-small cell lung cancer in Turkey.

AIM The early diagnosis and treatment of lung cancer are important for the prognosis of patients with lung cancer. This study was undertaken to investigate patient and doctor delays in the diagnosis and treatment of NSCLC and the factors affecting these delays. MATERIALS AND METHODS A total of 1016 patients, including 926 (91.1%) males and 90 (8.9%) females with a mean age of 61.5±10.1 years, were enrolled prospectively in this study between May 2010 and May 2011 from 17 sites in various Turkish provinces. RESULTS The patient delay was found to be 49.9±96.9 days, doctor delay was found to be 87.7±99.6 days, and total delay was found to be 131.3±135.2 days. The referral delay was found to be 61.6±127.2 days, diagnostic delay was found to be 20.4±44.5 days, and treatment delay was found to be 24.4±54.9 days. When the major factors responsible for these delays were examined, patient delay was found to be more frequent in workers, while referral delay was found to be more frequent in patients living in villages (p<0.05). We determined that referral delay, doctor delay, and total delay increased as the number of doctors who were consulted by patients increased (p<0.05). Additionally, we determined that diagnostic and treatment delays were more frequent at the early tumour stages in NSCLC patients (p<0.05). DISCUSSION The extended length of patient delay underscores the necessity of educating people about lung cancer. To decrease doctor delay, education is a crucial first step. Additionally, to further reduce the diagnostic and treatment delays of chest specialists, multidisciplinary management and algorithms must be used regularly.

Putative Bronchopulmonary Flagellated Protozoa in Immunosuppressed Patients

Flagellated protozoa that cause bronchopulmonary symptoms in humans are commonly neglected. These protozoal forms which were presumed to be “flagellated protozoa” have been previously identified in immunosuppressed patients in a number of studies, but have not been certainly classified so far. Since no human cases of bronchopulmonary flagellated protozoa were reported from Turkey, we aimed to investigate these putative protozoa in immunosuppressed patients who are particularly at risk of infectious diseases. Bronchoalveolar lavage fluid samples of 110 immunosuppressed adult patients who were admitted to the Department of Chest Diseases, Hafsa Sultan Hospital of Celal Bayar University, Manisa, Turkey, were examined in terms of parasites by light microscopy. Flagellated protozoal forms were detected in nine (8.2%) of 110 cases. Metronidazole (500 mg b.i.d. for 30 days) was given to all positive cases and a second bronchoscopy was performed at the end of the treatment, which revealed no parasites. In conclusion, immunosuppressed patients with bronchopulmonary symptoms should attentively be examined with regard to flagellated protozoa which can easily be misidentified as epithelial cells.

Antibiotic treatment outcomes in community-acquired pneumonia

Background/aim The optimal empiric antibiotic regimen for patients with community-acquired pneumonia (CAP) remains unclear. This study aimed to evaluate the clinical cure rate, mortality, and length of stay among patients hospitalized with community- acquired pneumonia in nonintensive care unit (ICU) wards and treated with a β-lactam, β-lactam and macrolide combination, or a fluoroquinolone. Materials and methods This prospective cohort study was performed using standardized web-based database sheets from January 2009 to September 2013 in nine tertiary care hospitals in Turkey. Results Six hundred and twenty-one consecutive patients were enrolled. A pathogen was identified in 78 (12.6%) patients. The most frequently isolated bacteria were S. pneumoniae (21.8%) and P. aeruginosa (19.2%). The clinical cure rate and length of stay were not different among patients treated with β-lactam, β-lactam and macrolide combination, and fluoroquinolone. Forty-seven patients (9.2%) died during the hospitalization period. There was no difference in survival among the three treatment groups. Conclusion In patients admitted to non-ICU hospital wards for CAP, there was no difference in clinical outcomes between β-lactam, β-lactam and macrolide combination, and fluoroquinolone regimens.

Neumonía intersticial inespecífica con síntomas poco comunes

The diffuse parenchymal lung diseases (DPLD) are a group of disorders that affect the spacing between the epithelial and endothelial membranes of the lung bases. The approach recommended in patients with DPLD is the detailed study of the clinical history, findings on physical examination, and the performance of certain lab tests, imaging studies, and, in some patients, transbronchial or surgical lung biopsy. A 26-year old woman presented cough, sputum, exertion dypsnea, loss of appetite, night sweats and weight loss. The cough and exertion dypsnea had started 6 years earlier. The sputum and the loss of appetite and weight appeared one year before her first visit to our office. In her clinical history, she informed us that she had been treated for tuberculosis the year before. The diagnosis of tuberculosis was made based on symptoms and a radiologic study. Since the symptoms and the radiological findings did not respond to inspecific treatment, tuberculosis was diagnosed based on the symptoms and www.archbronconeumol.org

Long-Term Omalizumab Treatment: A Multicenter, Real-Life, 5-Year Trial

Background: Omalizumab has demonstrated therapeutic benefits both in controlled clinical trials and real-life studies. However, research concerning the long-term effects and tolerability of omalizumab is needed. The main objective of this study was to evaluate the effectiveness and tolerability of treatment with omalizumab for up to 5 years. Methods: A multicenter, retrospective, chart-based study was carried out to compare documented exacerbations, hospitalizations, systemic steroid requirement, FEV1, and asthma control test (ACT) results during 1 year prior to omalizumab treatment versus at 1, 3, and 5 years of treatment. Adverse events and reasons for discontinuation were also recorded at each time point. Results: Four hundred and sixty-five patients were enrolled in the study. Outcome variables had improved after the 1st year and were sustained after the 3rd and 5th years of treatment with omalizumab. Omalizumab treatment reduced the asthma exacerbation rate by 71.3% (p < 0.001) at 1 year, 64.3% (p < 0.001) at 3 years, and 54.8% (p = 0.002) at 5 years. The hospitalization rate also decreased; by the 5th year of the treatment no patients were hospitalized. ACT results had also improved significantly: 12 (p < 0.001) at 1 year, 12 (p < 0.001) at 3 years, and 12 (p = 0.002) at 5 years. Overall, 12.7% of patients reported adverse events (most of these were mild-to-moderate) and the overall dropout rate was 9.0%. Conclusion: Omalizumab had a significant effect on asthma outcomes and this effect was maintained over 5 years. The drug was found to be generally safe and treatment compliance was good.

The Role of Endobronchial Biopsy in the Diagnosis of Pulmonary Sarcoidosis

Bronchofiberscopy (BFS) with endobronchial biopsy (EBB) was performed in 66 patients with pulmonary sarcoidosis (PS). Transbronchial biopsy (TBB) was made in 49 patients from this group to compare the diagnostic value of EBB and TBB. The normal endoscopic picture was observed in 19.6% of patients. Bronchial mucosal hypervascularization and thickening were found in 25.7% of cases; the signs of enlarged bronchopulmonary lymph nodes were detected in 13.6%; catarrhal endobronchitis in 10.6%, and tuberosity changes in 4.5%. Epithelioid granulomas in the bronchial mucosa were identified in 37.8% of cases (30.75 and 39.6% in the intact and abnormal mucosa, respectively). The diagnostic value of TBB was 65.3%. EBB could reveal epithelioid-cell granulomas in 4 of the 17 patients with negative TBB. The findings suggest that BFS with EBB should be included as a necessary diagnostic method for the examination of patients with PS.

Knowledge Level of the Primary Healthcare Providers on Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation

Introduction. Awareness of the healthcare providers on chronic obstructive pulmonary disease (COPD), which is an important cause of mortality and morbidity in our country and all over the world, and on pulmonary rehabilitation (PR) which plays an important role in its nonpharmacological treatment will provide effectiveness in diagnosis and treatment of COPD. The present study aimed at determining knowledge level of the healthcare providers about COPD and PR. Materials and Methods. In this cross-sectional study, family practitioners and staff of home-care in central county of Manisa City were applied a questionnaire in order to determine their knowledge level on COPD and pulmonary rehabilitation during the in-service training on “pulmonary rehabilitation, home-care services for the pulmonary diseases, and respiratory exercises.” Results. 65.5% of the healthcare providers responded to the survey. Rate of those correctly knowing at least one of four items was 97.2%. No responder knew all items correctly. Average value for correct answers was 5.30 ± 2.1 (range: 1–10). The physicians, men, and those working in family health centers had higher level of knowledge on COPD compared to nonphysician healthcare providers (p = 0.006), women (p = 0.002), and those working in other practices (p = 0.019), respectively. Conclusion. Knowledge level of the primary healthcare providers on COPD and PR remains inadequate. Dynamic postgraduate training on this topic will be useful in referring the patients to centers giving service for this condition.

Stenotrophomonas maltophilia as a Pathogen of Nosocomial Pneumonia: Seven Case Reports

Özet GİRİŞ Stenotrophomonas maltophilia, hastane ortamında giderek artan nozokomiyal patojenlerden biri haline gelmiştir. Bu bakteri ile ilişkilendirilen klinik tablolar; pnömoni, santral venöz kateter ilişkili bakteremi, deri ve yumuşak doku infeksiyonları, endokardit, idrar yolu infeksiyonları, menenjit, mastoidit, sinüzit, cerrahi alan infeksiyonları, intraabdominal infeksiyonlar, göz infeksiyonları ve kemik eklem infeksiyonlarıdır [1,2]. Bu yazıda balgam kültürlerinde S. maltophilia üremesi saptanan nozokomiyal pnömonili hastaların klinik özellikleri değerlendirilmiştir. OLGU SUNUmU Şubat 2010-Mart 2011 tarihleri arasında Devlet Hastanesi yoğun bakım servisinde yatan ve balgam kültürlerinde Stenotrophomonas maltophilia üremesi saptanan yedi pnömonili hastanın yaş, cinsiyet, altta yatan hastalıkları ve risk faktörleri, laboratuar ve radyografik bulguları ile antibiyotik duyarlılıkları değerlendirilmiştir. Kültürde S. maltophilia üremesi saptanan olguların antibiyotik duyarlılık testleri disk difüzyon yöntemi ile yapıldı. S. maltophilia üremesi saptanan 2’si kadın 7 olgunun yaş, cinsiyet, altta yatan hastalıkları ve risk faktörleri, laboratuar ve radyolojik (Resim 1-3) bulguları Tablo 1’de gösterilmiştir. S. maltophilia üremesi saptanan olguların antibiyotik duyarlılıkları Tablo 2’de gösterilmiştir. TARTIŞmA Nozokomiyal S. maltophilia enfeksiyonlarının insidansı son 15 yıl içersinde artış göstermiştir. Türkiye’den yapılan çalışmalar irdelendiğinde, S. maltophilia genel hastane infeksiyonu etkeni olarak %0-1.6 oranları arasında izole edilmekte ve bu oran YBÜ (Yoğun Bakım Ünitesi) kökenlerinde %4’lere kadar çıkabilmektedir [3-5]. Yurt içi ve yurt dışı çalışmaların çoğunda, pnömoni ve bakteremi en sık saptanan ve mortalitesi yüksek olan infeksiyonlar olarak bildirilmektedir [1,2,4,6]. SENTRY Antimikrobiyal Sürveyans Program çalışmasında Kanada, Amerika Birleşik Devletleri, Latin Amerika, Avrupa ve Asya Pasifik’ten 842 S. maltophilia izolatının etken olduğu infeksiyonda pnömoni görülme oranının bakteriemilere göre dört kat daha fazla olduğu saptanmıştır [6]. Dizbay ve ark. [4] yaptığı çalışmada pnömoni %42.6, Avcı ve ark. [7] yaptığı çalışmada da pnömoni %38 olarak saptanmıştır. Bizim de 7 olgumuzda S. maltophilia’ya bağlı pnömoni gelişmiş olup, 3 hastamız hayatını kaybetmiştir. Bu olgu, TüSAD 33. Ulusal kongre’si-SOLUNUm 2011’de (15-19 Ekim 2011, İzmir) sunulmuştur. Yazışma Adresi / Address for correspondence: Levent Özdemir, Dörtyol Devlet Hastanesi, Göğüs Hastalıkları ve Tüberküloz Kliniği, Hatay, Türkiye Tel: +90 533 388 89 84 E-posta: levent2408@mynet.com ©Telif Hakkı 2013 Türk Toraks Derneği Makale metnine www.toraks.dergisi.org web sayfasından ulaşılabilir. ©Copyright 2013 by Turkish Thoracic Society Available online at www.toraks.dergisi.org Hastane ortamında ve yoğun bakımda uzun süreli yatışlar, santral venöz kateter gibi invaziv işlemler, mekanik ventilasyon uygulanması, öncesinde antibiyotik kullanım öyküsünün olması, altta yatan malignite ve nötropeni önemli risk faktörleridir [1]. Hastalarımızda da risk faktörü olarak, yoğun bakımda uzun süreli yatış, idrar sondası, öncesinde antibiyotik kullanımı, santral venöz kateter, mekanik ventilasyon uygulanması, cerrahi operasyon, intravenöz madde kullanımı saptanmıştır. S. maltophilia kullanımda olan bir çok antibiyotiğe karşı dirençlidir. Dünya çapında Ocak 1997-Aralık 2003 tarihleri arasında gerçekleştirilen SENTRY Antimikrobiyal Sürveyans Program çalışmasında antibiyotik duyarlılıkları incelendiğinde trimetoprim-sulfametoksazol, levofloksasin, siprofloksasine karşı duyarlılık yüksek düzeyede saptanmıştır [6]. Aynı şekilde ülkemizde yapılan Çaylan ve ark.’nın [8], Dizbay ve ark. [4], ve Avcı ark.’nın [7] çalışmalarında da benzer şeklide trimetoprim-sulfametoksazol, siprofloksasine duyarlılığın fazla olduğu, karbapenem gurubu antibiyotiklere direncin yüksek olduğu saptanmış. Bizim olgularımızın antibiyotik duyarlılıklarına baktığımızda tüm olguların Trimetoprimsulfametoksazol ve amikasine duyarlı olduğu, 1 olguda siprofloksasin, 6 olguda da imipenem dirençli olduğu saptandı. Sonuç olarak, risk faktörü taşıyan hastalarda karbapenem grubu antibiyotiklerin kullanımında dikkatli olunmasının Tablo 1. S. maltophilia üreyen hastaların özellikleri Yaş Altta Yatan Risk Faktörü Laboratuar Radyoloji hastane Durum cinsiyet hastalık yatış /gün Olgu 1 76 K Diyabet İdrar sondası Hb: 9.2 Lober konsolidasyon 56 Ex Kalp Yetmezliği Öncesinde antibiyotik alımı Plt: 273 Plevral sıvı Hipertansiyon Santral venöz kateter BK: 10.8 SVH Mekanik ventilasyon CRP: 35.2 Olgu 2 79 E KOAH İdrar sondası Hb: 12.1 Lober konsolidasyon 51 Ex SVH Öncesinde antibiyotik alımı Plt: 680 Plevral sıvı Santral venöz kateter BK: 24.1 Mekanik ventilasyon CRP: 13.8 Olgu 3 81 K Diyabet İdrar sondası Hb: 11 Lober konsolidasyon 13 Ex Kalp Yetmezliği Öncesinde antibiyotik alımı Plt: 197 Plevral sıvı Hipertansiyon Santral venöz kateter BK: 22.2 Mekanik ventilasyon CRP: 8.9 Olgu 4 61 E KOAH İdrar sondası Hb: 11.3 İnterstisyel konsolidasyon 42 Yaşıyor Öncesinde antibiyotik alımı Plt: 191 Mekanik ventilasyon BK: 14.9 İmmun suprese tedavi CRP: 13.3 Olgu 5 53 E Diyabet Yok Hb: 11.6 İnterstisyel konsolidasyon 8 Yaşıyor Kalp Yetmezliği Plt: 344 Hipertansiyon BK: 12.5 KOAH CRP: 1.8 Olgu 6 28 E Yok Öncesinde antibiyotik alımı Hb: 14.1 Lober Konsolidasyon, 7 Yaşıyor İntravenöz madde kullanım Plt: 293 atelektazi Cerrahi operasyon BK: 15.6 CRP: 32 Olgu 7 71 E Akciğer karsinomu Öncesinde antibiyotik alımı Hb: 12.8 Segmenter konsolidasyon 6 Yaşıyor Plt: 345 BK: 12.8 CRP: 11 BK: (N: 4.1-10.9), Hb: (N: 12-18.1), Plt: (N: 142-424), CRP: (N: 0-0.5 mgr/dL) Tablo 2. S. maltophilia üremesi saptanan olguların antibiyotik duyarlılıkları TMP-SMX AK CIP IMP Olgu 1 S S S R Olgu 2 S S S R Olgu 3 S S S R Olgu 4 S S R R Olgu 5 S S S S Olgu 6 S S S R Olgu 7 S S S R TMP-SMX: Trimetoprim-sulfametoksazol, AK: Amikasin, CIP: Siprofloksasin, IMP: İmipenem 73 Turk Toraks Derg 2013; 14: 72-4