A nosocomial scabies outbreak originating from immunocompromised transplant patients in Turkey: Upholstery as a possible cause.

BACKGROUND: Inpatients with crusted scabies represent an important source of nosocomial transmission with consequent outbreaks among patients and healthcare workers. This study aimed to report the course of an institutional scabies outbreak, which progressed with infestation of immunosuppressed transplant patients, health care workers, and caregivers. METHODS: Patients diagnosed with scabies in a nosocomial outbreak in a 200-bed, tertiary hospital were included. Following a diagnosis of scabies in the index patient, strict contact isolation measures were implemented. During the outbreak, a root cause analysis (RCA) was carried out by an infection prevention and control team. RESULTS: Forty-two individuals were affected (7 patients, 25 health care workers, and 10 family members of the patients) during the outbreak consisting of three attacks. Index case was a multiple myeloma patient who received hematopoietic stem cell transplantation and presented with crusted scabies. A RCA suggested that upholstery could serve as a means of reservoir. All upholstery of the sofa and armchairs in patient rooms as well as in lounge areas were replaced by wipeable leather material. After the 19-week course of the outbreak, no additional cases of scabies have been observed until now. CONCLUSION: A high index of suspicion should be maintained, particularly in immunocompromised patients, in order to achieve rapid diagnosis of scabies and to implement institutional infection control measures. It should also be borne in mind that the transmission may occur through direct contact as well as fomites, such as upholstery.

Nasal colonization with methicillin-resistant Staphylococcus aureus at admission among high-risk Turkish and international patients.

OBJECTIVE: The aim of this study was to detect the frequency of methicillin-resistant Staphylococcus aureus (MRSA) colonization at admission in a group of presumably high-risk international or Turkish patients referred to our center for elective operations, some of whom were from countries with an unknown prevalence of MRSA infection or colonization. METHODS: The results of nasal swab screening for MRSA colonization performed using a specific algorithm between 2011 and 2018 in a private medical center were retrospectively reviewed. Presence of MRSA was ascertained using culture and/or real-time polymerase chain reaction (real-time PCR). RESULTS: A total of 3,795 patients were included in the study. More than half of the patients were ≤19 years of age (2,094, 55.2%), and MRSA positivity was more common among these patients. Turkish patients constituted 24.5% of the study population. International patients were most frequently referred from Iraq (55.92%), Libya (11.44%), Romania (2.69%), and Bulgaria (1.98%). MRSA positivity was significantly more common among patients referred from other countries when compared to Turkish nationals (11.5% vs. 4.4%, P = 0.00001). Countries with the highest prevalence rates of MRSA colonization were as follows with decreasing order: United Arab Emirates, 25.0%; Georgia, 23.1%; Russia, 22.7%; Iraq, 13.0%, Romania, 12.7%. Other countries with high number of admitted patients (>70 patients) had the following MRSA rates: Turkey, 4.4%; Libya, 6.0%; Bulgaria, 5.3%. CONCLUSIONS: Although MRSA has a low prevalence in our center, a variation in the rate of MRSA positivity was observed across patients from different countries. Absence hospital acquired contamination or outbreaks in our institution may be attributed to the screening algorithm used and underscores the importance of risk analysis for patients referred from geographical locations with unknown MRSA frequency, to reduce the risk of transmission.

[Results of a multicenter study investigating plasmid mediated colistin resistance genes (mcr-1 and mcr-2) in clinical Enterobacteriaceae isolates from Turkey]. / Ülkemizde klinik Enterobacteriaceae izolatlarinda plazmit aracili kolistin direnç genlerini (mcr-1 ve mcr-2) arastiran çok merkezli çalismaya ait sonuçlar.

Colistin is a polymyxin antibiotic which is considered as one of the last line agents against infections due to multidrug resistant or carbapenem resistant gram-negative pathogens. Colistin resistance is associated with chromosomal alterations which can usually cause mutations in genes coding specific two component regulator systems. The first plasmid-mediated colistin resistance gene, mcr-1 was described in Escherichia coli and Klebsiella pneumoniae isolates in December 2015 and followed by another plasmid-mediated colistin resistance gene mcr-2 in 2016. The rapid and interspecies dissemination of plasmid-mediated resistance mechanisms through horizontal gene transfer, have made these genes considerably threatening. After the first reports, although mcr-1/mcr-2 producing Enterobacteriaceae isolates have been reported from many countries, there have been no reports from Turkey. Thus, the aim of this study was to investigate the presence of mcr-1/mcr-2 in clinical Enterobacteriaceae isolates from different parts of our country. A total of 329 Enterobacteriaceae isolates from 22 laboratories were collected which were isolated between March, 2015 and February, 2016. mcr-1/mcr-2 were investigated by polymerase chain reaction during February-March, 2016. Two hundred and seventeen of Klebsiella pneumoniae (66%), 75 of Salmonella spp. (22.8%), 31 of Esherichia coli (9.4%), 3 of Enterobacter cloacae (0.9%), 2 of Klebsiella oxytoca (0.6%) and 1 of Enterobacter aerogenes (0.3%) isolates were included to the study. Agarose gel electrophoresis results of PCR studies have shown expected band sizes for positive control isolates as 309 bp for mcr-1 and 567 bp for mcr-2. However, the presence of mcr-1/mcr-2 genes was not detected among the tested study isolates of Enterobacteriaceae. Although mcr-1/mcr-2 were not detected in our study isolates, it is highly important to understand the mechanism of resistance dissemination and determine the resistant isolates by considering that colistin is a last-line antibiotic against infections of multidrug or carbapenem resistant gram-negative bacteria. Thus, it is suggested that these mechanisms should be followed-up in both clinical and non-clinical (e.g. isolates from food animals, raw meats and environment) isolates of special populations.

In vitro activities of colistin, tigecycline and tobramycin, alone or in combination, against carbapenem-resistant Enterobacteriaceae strains.

The aim of this study was to investigate the activities of various antibiotics, alone or in combination, against carbapenem-resistant Enterobacteriaceae (CRE). Minimum inhibitory concentrations (MICs) of meropenem, colistin, tigecycline and tobramycin were determined by microbroth dilution against 40 clinical strains. Carbapenemase-encoding genes were detected by PCR using specific primers. The in vitro synergistic activities of tigecycline, colistin and tobramycin in double antibiotic combinations were determined by the microbroth chequerboard technique, and results were interpreted using the fractional inhibitory concentration index (FICI). To confirm the results acquired by the chequerboard method, time-kill assays were performed on eight isolates representing four different susceptibility patterns. Based on MIC90 values, colistin was the most potent agent, followed by tigecycline and tobramycin. According to PCR studies, carbapenem resistance in tested Enterobacteriaceae isolates was most often mediated by OXA-48-type carbapenemases. With an FICI of ≤0.5 as the cut-off, synergistic interactions were most frequent with tigecycline+tobramycin (30%); other results for synergistic interactions were 23% for colistin+tobramycin and 9% for colistin+tigecycline. By time-kill assays, all tested antibiotic combinations demonstrated synergistic activity against at least three of the eight strains at 1× or 4× MIC. Overall, the combinations used in this study were effective regimens, demonstrating synergy or no interaction (indifference) against all tested strains. No antagonism was observed with either of the techniques. The findings of this study might play a useful role in selecting appropriate combinations when a single agent is inadequate against CRE strains.

The mgrB gene as a key target for acquired resistance to colistin in Klebsiella pneumoniae.

OBJECTIVES: Alterations in the PhoPQ two-component regulatory system may be associated with colistin resistance in Klebsiella pneumoniae. MgrB is a small transmembrane protein produced upon activation of the PhoPQ signalling system, and acts as a negative regulator on this system. We investigated the role of the MgrB protein as a source of colistin resistance in a series of K. pneumoniae. METHODS: Colistin-resistant K. pneumoniae isolates were recovered from hospitalized patients worldwide (France, Turkey, Colombia and South Africa). The mgrB gene was amplified and sequenced. A wild-type mgrB gene was cloned and the corresponding recombinant plasmid was used for complementation assays. Clonal diversity was evaluated by MLST and Diversilab analysis. RESULTS: Of 47 colistin-resistant isolates, 12 were identified as having a mutated mgrB gene. Five clonally unrelated isolates had an mgrB gene truncated by an IS5-like IS, while one clone also harboured an insertional inactivation at the exact same position of the mgrB gene, but with ISKpn13. Another clone harboured an insertional inactivation due to ISKpn14 at another location of the mgrB gene. Two clonally related isolates harboured an IS (IS10R) in the promoter region of mgrB. Finally, three clonally unrelated isolates harboured substitutions leading to anticipated stop codon in the MgrB protein. Complementation assays with a wild-type MgrB protein restored full susceptibility to colistin for all colistin-resistant isolates identified with qualitative or quantitative MgrB modifications. CONCLUSION: The inactivation or down-regulation of the mgrB gene was shown to be a source of colistin resistance in K. pneumoniae. Interestingly, identical genetic events were identified among clonally unrelated isolates.

Serologic response to Epstein-Barr virus antigens in patients with systemic lupus erythematosus: a controlled study.

Previous studies showed a link between systemic lupus erythematosus (SLE) and Epstein-Barr virus (EBV) infection. We sought to determine the features of serologic response to EBV in SLE patients and whether this response differs from those of systemic sclerosis (SSc) and primary antiphospholipid syndrome (PAPS) patients as well as healthy individuals. Sera from 198 consecutive SLE patients have been tested to detect IgG antibodies to EA/D, EBNA-1, VCA P18 and for comparison, cytomegalovirus (CMV) using commercially available ELISA kits (Trinity Biotech, USA). Forty-six SSc patients and 38 PAPS patients were enrolled as diseased control groups and sixty-five individuals as healthy controls. Significantly more SLE (54%, P = 0.001, OR 5.77, 95% CI 2.8-11.6), SSc (41.3%, P = 0.005, OR 3.4, 95% CI 1.4-8.2) and PAPS sera (36.8%, P = 0.023, OR 2.86, 95% CI 1.14-7.22) reacted against EA/D than healthy controls (16.9%). The mean age of anti-EA/D-positive SLE patients was significantly higher, and their disease duration was longer compared to anti-EA/D-negative SLE patients (41 ± 14 vs. 33.8 ± 10.8 years, P < 0.001 and 100 ± 73 vs. 71 ± 62 months, P = 0.003). In SLE patients, EA/D reactivity was associated with Raynaud's phenomenon and the presence of any anti-ENA antibodies. Although it did not reach a statistical significance, anti-EBNA-1 reactivity was slightly lower in patients with SLE. The frequency of anti-CMV Ig G positivity was found significantly higher in SLE patients (100%) when compared to patients with SSc (95.7%), PAPS (94.7%) and healthy controls (95.4%) (P = 0.035, P = 0.025 and P = 0.015 respectively). Our results support the proposed link between EBV and SLE. The finding that SSc and PAPS patients also have increased frequency of anti-EA/D response has revealed that this immune interaction may not be unique to patients with SLE, and there may be a common mechanism involving EBV in these autoimmune diseases.

Trial of garlic as an adjunct therapy for multidrug resistant Pseudomonas aeruginosa pneumonia in a critically ill infant.

We present a case of a critically ill infant with severe multidrug-resistant Pseudomonas aeruginosa pneumonia and bacteremia who was treated with garlic and antibiotics after in vitro demonstration of a change in the resistance pattern via the disc diffusion method on garlic-treated Mueller Hinton agar. To our knowledge, this is the first report of therapeutic garlic use in a critically ill infant in the literature.

[Detection of human bocavirus DNA by polymerase chain reaction in children and adults with acute respiratory tract infections]. / Akut solunum yolu enfeksiyonlu çocuk ve eriskinlerde insan bokavirus DNA'sinin polimeraz zincir reaksiyonu ile saptanmasi

Human bocavirus (HBoV) which was described in 2005 by molecular techniques, is a member of Parvoviridae. The role of HBoV is being questioned in acute respiratory diseases (ARD) in many recent studies. The aim of this study was to determine the presence of HBoV DNA in the respiratory specimens of patients with ARD. A total of 155 throat swab and/or washing specimens from 76 children and 79 adults with ARD were examined. HBoV DNA was investigated by single step in-house polymerase chain reaction (PCR) using NS1 primers (5-'TATGGCCAAGGCAATCGTCCAAG-3', 5'-GCC GCGTGAACATGAGAAA-CAG-3') which amplify the 290 base pair region of NS1 gene located between nucleotides 1545-1835 of prototype HBoV st1 strain. HBoV DNA was detected in 5 (6.5%) of 76 children and 2 (2.5%) of 79 adults. Three sequenced samples showed 100% homology with the reference sequences. This study in which HBoV DNA was detected in children and adults with ARD, is the first HBoV prevalence study in Turkey. Larger scale prospective clinical and molecular studies are required to explain the association between HBoV and respiratory disease.

High occurrence of cyclosporiasis in Istanbul, Turkey, during a dry and warm summer.

We evaluated the incidence of Cyclospora cayetanensis in immunocompetent, diarrheic patients during the summers of 2006-2009 in Istanbul. Stools from 1876 patients were examined using microscopic techniques. Cyclospora oocysts were observed in wet preparations by light and epifluorescence microscopy and in fecal smears that were stained by Kinyoun's modified acid-fast stain. Characteristic Cyclospora oocysts were observed in 2 patients in 2006, 17 in 2007, and one in 2009. Samples positive for Cyclospora were further analyzed by a single step polymerase chain reaction (PCR) with Cyclospora-specific primers from the ITS-1 region of the genome.The majority of the Cyclospora positive cases (15) were clustered during about 15 days in June 2007, indicating an unusual incidence of cyclosporiasis in this time period. The climatic characteristics of 2007 could have played a role in this high occurrence rate.

Acute prostatitis as an uncommon presentation of brucellosis.

The present report concerns a 46-year-old man who presented with acute prostatitis due to Brucella melitensis infection. He was first treated with doxycycline and ciprofloxacin, but after 3 months he was admitted again with the same diagnosis. The relapse was probably related to ciprofloxacin use, or the length of treatment not being sufficient. The patient was successfully treated with a combination of doxycycline and rifampin for 3 months. In conclusion, prostatitis due to Brucella, such as spondylitis, meningoencephalitis and endocarditis, should be treated for longer courses.