International Nosocomial Infection Control Consortium (INICC) national report on device-associated infection rates in 19 cities of Turkey, data summary for 2003-2012.

BACKGROUND: Device-associated healthcare-acquired infections (DA-HAI) pose a threat to patient safety, particularly in the intensive care unit (ICU). We report the results of the International Infection Control Consortium (INICC) study conducted in Turkey from August 2003 through October 2012. METHODS: A DA-HAI surveillance study in 63 adult, paediatric ICUs and neonatal ICUs (NICUs) from 29 hospitals, in 19 cities using the methods and definitions of the U.S. NHSN and INICC methods. RESULTS: We collected prospective data from 94,498 ICU patients for 647,316 bed days. Pooled DA-HAI rates for adult and paediatric ICUs were 11.1 central line-associated bloodstream infections (CLABSIs) per 1000 central line (CL)-days, 21.4 ventilator-associated pneumonias (VAPs) per 1000 mechanical ventilator (MV)-days and 7.5 catheter-associated urinary tract infections (CAUTIs) per 1000 urinary catheter-days. Pooled DA-HAI rates for NICUs were 30 CLABSIs per 1000 CL-days, and 15.8 VAPs per 1000 MV-days. Extra length of stay (LOS) in adult and paediatric ICUs was 19.4 for CLABSI, 8.7 for VAP and 10.1 for CAUTI. Extra LOS in NICUs was 13.1 for patients with CLABSI and 16.2 for patients with VAP. Extra crude mortality was 12% for CLABSI, 19.4% for VAP and 10.5% for CAUTI in ICUs, and 15.4% for CLABSI and 10.5% for VAP in NICUs. Pooled device use (DU) ratios for adult and paediatric ICUs were 0.54 for MV, 0.65 for CL and 0.88 for UC, and 0.12 for MV, and 0.09 for CL in NICUs. The CLABSI rate was 8.5 per 1,000 CL days in the Medical Surgical ICUs included in this study, which is higher than the INICC report rate of 4.9, and more than eight times higher than the NHSN rate of 0.9. Similarly, the VAP and CAUTI rates were higher compared with U.S. NHSN (22.3 vs. 1.1 for VAP; 7.9 vs. 1.2 for CAUTI) and with the INICC report (22.3 vs. 16.5 in VAP; 7.9 vs. 5.3 in CAUTI). CONCLUSIONS: DA-HAI rates and DU ratios in our ICUs were higher than those reported in the INICC global report and in the US NHSN report.

Bacterial spectrum and antimicrobial susceptibility pattern of bloodstream infections in children with febrile neutropenia: experience of single center in southeast of Turkey.

Empirical antimicrobial therapy is usually started in febrile neutropenic patients without having culture results. The aim of this study was to help determine the policies of empirical antibiotic usage in febrile neutropenic children by detecting the antimicrobial susceptibility profile in this group of patients. In this study 811 blood cultures taken from neutropenic children hospitalized at the Department of Oncology of Gaziantep Children Hospital November 2007 and February 2010 were retrospectively evaluated. Blood cultures were routinely collected in aerobic and anaerobic media and incubated using the BACTEC system. Identification and antimicrobial susceptibility testing of the isolates to antimicrobial agents was performed using the Vitek2(®) system according to the recommendations of the Clinical and Laboratory Standards Institute. Of 811 isolates analyzed, 128 (56.4%) were gram positive cocci, 43 (18.9%) were gram negative bacilli and fungi accounted for 56 (24.7%). The main isolated Gram-positive bacteria from blood were coagulase-negative staphylococcus (56.7%), followed by methicillin-resistant Staphylococcus aureus (14.1%). S. aureus and Streptococcus spp. were all susceptible to linezolid, vancomycin and teicoplanin. S aureus was still susceptible to few other antimicrobial agents such as tetracycline (82.4%), chloramphenicol (55.6%). Seven E. faecium, 7 E. fecalis and 1 E. hirae was isolated from blood cultures. Vancomycin resistance was detected in 6 out of 15 (40%) Enterococcus spp. isolates. Among gram-negative bacteria E. coli (30.2%) was followed by Klebsiella pneumoniae (20.9%) and Proteus spp. (18.6%). Imipenem (89.2%), meropenem (86.6%), chloramphenicol (88.9%), amicasin (82.4%) and fosfomycin (81.3%) showed highest susceptibility in vitro activity against all Gram-negative isolates. To know the antimicrobial susceptibility profile of the pathogens frequently isolated from febrile neutropenic children and to consider this profile before starting an empirical antibiotic therapy would help the clinics which have any role in the treatment of these patients to determine the empirical antibiotic usage policies.

Assessment of the requisites of microbiology based infectious disease training under the pressure of consultation needs.

BACKGROUND: Training of infectious disease (ID) specialists is structured on classical clinical microbiology training in Turkey and ID specialists work as clinical microbiologists at the same time. Hence, this study aimed to determine the clinical skills and knowledge required by clinical microbiologists. METHODS: A cross-sectional study was carried out between June 1, 2010 and September 15, 2010 in 32 ID departments in Turkey. Only patients hospitalized and followed up in the ID departments between January-June 2010 who required consultation with other disciplines were included. RESULTS: A total of 605 patients undergoing 1343 consultations were included, with pulmonology, neurology, cardiology, gastroenterology, nephrology, dermatology, haematology, and endocrinology being the most frequent consultation specialties. The consultation patterns were quite similar and were not affected by either the nature of infections or the critical clinical status of ID patients. CONCLUSIONS: The results of our study show that certain internal medicine subdisciplines such as pulmonology, neurology and dermatology appear to be the principal clinical requisites in the training of ID specialists, rather than internal medicine as a whole.

[Comparative evaluation of in vitro activities of carbapenems against gram-negative pathogens: Turkish data of COMPACT study]. / Karbapenemlerin Gram-Negatif Patojenlere Karsi In Vitro Aktivitelerinin Karsilastirmali Degerlendirmesi: COMPACT Çalismasi Türkiye Verisi.

The aim of this study was to determine the in vitro activities of doripenem, imipenem, and meropenem against clinical gram-negative isolates. A total of 596 clinical isolates were obtained from intensive care unit (ICU) and non-ICU patients in 10 centers over Turkey between September-December 2008. The origin of the isolates was patients with nosocomial pneumonia (42.4%), bloodstream infections (%40.4), and complicated intraabdominal infections (17.1%). Of the isolates, 51.8% were obtained from ICU patients. The study isolates consisted of Pseudomonas spp. in 49.8%, Enterobacteriaceae in 40.3%, and other gram-negative agents in 9.9%. The minimum inhibitory concentrations (MIC) for doripenem, imipenem and meropenem were determined for all isolates in each center using Etest® strips (AB Biodisk, Solna, Sweden). Of the isolates, 188 (31.5%) were resistant to at least one of the carbapenems. MIC50 of doripenem against Pseudomonas spp. Was 1 mg/L which was similar to that of meropenem and two-fold lower than imipenem. Susceptibility to carbapenems in P.aeruginosa was 64% for doripenem at an MIC level of 2 mg/L, 53.9% and 63% for imipenem and meropenem at an MIC level of 4 mg/L, respectively. Doripenem and meropenem showed similar activity with the MIC90 of 0.12 mg/L whereas imipenem was four-fold less active at 0.5 mg/L. Against other gramnegative pathogens, mostly Acinetobacter spp., MIC50 was 8 mg/L for doripenem and 32 mg/L for other two carbapenems. P.aeruginosa isolates were inhibited 84.2% with doripenem and 72.1% with meropenem at the MIC level of 8 mg/L. Doripenem generally showed similar or slightly better activity than meropenem and better activity than imipenem against pathogens collected in this study. Against Pseudomonas spp., doripenem was the most active of the three carbapenems. Doripenem and meropenem were equally active against Enterobacteriaceae and at least four-fold more active than imipenem. It was concluded that doripenem seemed to be a promising agent in the treatment of nosocomial pneumonia, blood stream infections and intraabdominal infections particularly in patients who were under risk of developing antimicrobial resistance.

Brucella melitensis: a rare cause of febrile neutropenia.

Although brucellosis is endemic in Middle Eastern and Mediterranean countries, febrile neutropenia caused by Brucella species has rarely been reported in childhood. In this report the authors described an unusual case of febrile neutropenia due to Brucella melitensis.

Hematologic manifestations of brucellosis in children: 5 years experience of an anatolian center.

BACKGROUND: Brucellosis continues to be an important cause of fever in underdeveloped countries and in the rural areas of developed world. It is a multisystemic disease, associated with a wide variety of symptoms. A wide variety of symptoms, including hematologic abnormalities, such as anemia, thrombocytopenia, pancytopenia, dissemine intravascular coagulation, and leucopenia could be seen. The aim of the study is to review the hematologic findings of brucellosis in childhood. PROCEDURE: In this short study, the records of 146 children with brucellosis were evaluated for hematologic manifestation retrospectively. Among them, 9 patients had pancytopenia and 5 had brucella-induced immune thrombocytopenia and were identified in a 5-year period between June 2004 and July 2009. RESULTS: Eight of the 9 patients with pancytopenia had Brucella melitensis isolated from blood cultures and/or bone marrow cultures, and all 9 patients had Brucella agglutination titers of at least 1:320. All patients with immune thrombocytopenia blood cultures were positive for Brucella. Except 1 patient the pancytopenia in these patients regressed completely and their peripheral blood counts returned to normal after treatment of Brucella infection. One patient was not responding to the brucella treatment and underwent allogeneic hematopoietic stem cell transplantation. All patients with brucella-induced immune thrombocytic purpura were symptomatic and had severe thrombocytopenia, they were placed on intravenous gamma globulin for 2 days. Between day 3 and day 5 platelet counts increased in these patients. CONCLUSION: Brucellosis should be considered as a possible diagnosis among patients with pancytopenia and immune thrombocytopenic purpura in endemic regions.

High incidence of Candida parapsilosis candidaemia in non-neutropenic critically ill patients: epidemiology and antifungal susceptibility.

The epidemiological and antifungal susceptibility data for 35 episodes of candidemia in intensive care units (ICU) in 2007 were evaluated by prospective active surveillance. The incidence of fungaemia was 39.1 cases per 1000 ICU admissions and 2.85 cases per 1000 patient-days. The crude mortality was 65.7%; 70.8% of the fatalities occurred within 7 days of admission to the ICU. Only 2 species were isolated, Candida parapsilosis (77.1%) and Candida albicans (22.9%). There was no association between mortality and patient characteristics, prior antifungal usage, Candida subspecies or antifungal resistance (p > 0.05). Of the isolates, 5.7% were resistant to fluconazole and caspofungin, and 3.4% to voriconazole and amphotericin B. In molecular analysis of the isolates, 2 clusters of C. parapsilosis in the neurology and anaesthesiology ICUs were detected by randomly amplified polymorphic DNA (RAPD), suggesting a nosocomial transmission. In conclusion, a high incidence and high mortality rate of C. parapsilosis candidaemia were found in the ICUs. An excessive use of invasive procedures, total parenteral nutrition and broad-spectrum antibiotics in the ICUs, combined with a lack of proper infection control measures, may possibly explain the high incidence of C. parapsilosis candidaemia in our hospital.

In vitro synergistic activity of tigecycline and colistin against XDR-Acinetobacter baumannii.

The emergence of extensive drug-resistant (XDR) Acinetobacter baumannii limits the therapeutic options and leads to high mortality in intensive care units. Combined antibiotic therapy is frequently recommended for the treatment of these infections. Colistin (CO) and tigecycline (TIG), alone or in combination with other antimicrobials, are the most commonly used antibiotics in the treatment of these resistant infections. In this study, the in vitro synergistic activity of TIG and CO were tested for 25 XDR-A. baumannii strains isolated from ventilator-associated pneumonia by the Etest method. Resistance to CO was not detected, whereas 8% of the strains were resistant to TIG. The TIG-CO combination was more synergistic than TIG-rifampin and CO-rifampin according to the fractional inhibitory concentration index. No antagonism was detected between the drugs in the study. There was no strong correlation between the activity of the combinations with reference to strains or genotypes. Our results suggest that the combined use of TIG and CO may be useful for the treatment of XDR-A. baumannii infections.

Nosocomial Burkholderia cepacia infections in a Turkish university hospital: a five-year surveillance.

BACKGROUND: Burkholderia cepacia has the potential to cause fatal infections in ICUs, and multidrug resistance makes them a serious threat in hospital settings. The aim of this study was to evaluate the epidemiology of B. cepacia infections in our hospital. METHODOLOGY: The incidence, clinical characteristics, antimicrobial susceptibility, and outcomes of nosocomial B. cepacia infections during a five-year period were retrospectively analysed according to the infection control committee records. RESULTS: A total of 39 cases with nosocomial B. cepacia infection were included in the study. B. cepacia was identified from 0.7% of the nosocomial isolates. Its incidence was 0.26 per 1,000 admissions with 53.8% crude mortality rate. The most frequent nosocomial B. cepacia infection was pneumonia (58.9%), followed by bloodstream infections (25.6%), surgical site infections (7.6%), urinary tract infections, (5.1%), and skin-soft tissue infections (2.5%). Nosocomial B. cepacia infections were most commonly observed in intensive care units (61.5%). The most active antimicrobial agents were piperacillin-tazobactam, cefoperazone-sulbactam, and carbapenems. CONCLUSIONS: The incidence of nosocomial B. cepacia infections was rare in our hospital, and no outbreak was detected during the study period. However, infections caused by B. cepacia should be taken into consideration because of their high mortality due to multidrug resistance in ICU settings.

Surveillance of microbial resistance in European Intensive Care Units: a first report from the Care-ICU programme for improved infection control.

PURPOSE: To report initial results from a European ICU surveillance programme focussing on antibiotic consumption, microbial resistance and infection control. METHODS: Thirty-five ICUs participated during 2005. Microbial resistance, antibiotic consumption and infection control stewardship measures were entered locally into a web-application. Results were validated locally, aggregated by project leaders and fed back to support local audit and benchmarking. RESULTS: Median (range) antibiotic consumption was 1,254 (range 348-4,992) DDD per 1,000 occupied bed days. The proportion of MRSA was median 11.6% (range 0-100), for ESBL phenotype of E. coli and K. pneumoniae 3.9% (0-80) and 14.3% (0-77.8) respectively, and for carbapenem-resistant P. aeruginosa 22.5% (0-100). Screening on admission for alert pathogens was commonly omitted, and there was a lack of single rooms for isolation. CONCLUSIONS: The surveillance programme demonstrated wide variation in antibiotic consumption, microbial resistance and infection control measures. The programme may, by providing rapid access to aggregated results, promote local and regional audit and benchmarking of antibiotic use and infection control practices.

[Constitutive and inducible clindamycin resistance among nosocomially acquired staphylococci]. / Nozokomiyal stafilokok izolatlari arasinda yapisal ve indüklenebilir klindamisin direnci.

Antimicrobial resistance in Staphylococcus aureus and coagulase-negative staphylococci (CNS) has become an increasing problem in hospital settings. These strains often reveal resistance to various drug classes in addition to beta-lactam resistance. Clindamycin, as a well-tolerated and cost-effective antimicrobial agent, is used widely in the treatment of intra-abdominal and skin-soft tissue infections. However, a major concern with regard to the use of clindamycin for staphylococcal infections is the possible presence of inducible resistance to clindamycin. The aim of this study was to determine the prevalence of constitutive and inducible clindamycin resistance among nosocomially acquired S. aureus and CNS strains. A total of 375 staphylococcal isolates were tested for clindamycin and erythromycin by the disk diffusion induction test (D-test) according to CLSI criteria. Oxacillin disks were used for the detection of methicillin resistance. The isolates resistant to erythromycin (ER-R) and susceptible to clindamycin (CL-S) with a D-shaped zone around clindamycin disk were considered positive for inducible resistance (D-test positive). Constitutive clindamycin resistance was found in 64.6% of methicillin-resistant S. aureus, 11.8% of methicillin-susceptible S.aureus, 53.8% of methicillin-resistant CNS and 4.9% of methicillin-susceptible CNS. Erythromycin-resistant clindamycin-susceptible (ER-R/CL-S) phenotype was found more frequent in CNS than in S. aureus strains. Among these strains, inducible clindamycin resistance was detected in 90% of S. aureus and 52.2% of CNS. In conclusion, to avoid using clindamycin when the antibiotic susceptibility test result showed an ER-R/CL-S phenotype may prevent a possible clindamycin treatment failure since inducible clindamycin resistance is frequent among such isolates, however, it may also deter the use of clindamycin in the treatment of infections that would likely respond to clindamycin therapy. Decision about clindamycin use for staphylococci with the ER-R/CL-S phenotype should be made according to the local prevalence data.

In vitro synergistic activity of antibiotic combinations against Brucella melitensis using E-test methodology

The treatment of brucellosis is still problematic, because of high rates of treatment failure or relapses. As the microorganism is an intracellular pathogen, treatment requires combined regimens. However, limited existing data on in vitro combinations are avaliable for Brucellae. The aim of this study was to investigate the in vitro efficacy of various traditional and new antibiotic combinations against 16 Brucella melitensis strains. The combination effect of antimicrobial agents was evaluated by E-test synergy method to obtain a fractional inhibitory concentration (FIC) index. Co-Trimoxazole (SXT) and moxifloxocin (MXF) exhibited the lowest MIC, while Rifampin (RIF) had the highest MIC in the study. Combinations with RIF showed the best synergistic activity (100% of RIF-tetracycline (TET), and 87.5% of RIF-SXT). Synergistic activity was also detected at seven (43.7%) of ciprofloxocin (CIP)-SXT, four (25%) of TET-MXF, and two (12.5%) of TET-SXT combinations. The combinations that demonstrated additivity were TET-SXT, CIP-SXT and TET-MXF. Antagonism was observed only with the TET-Streptomycin (STR) combination in three strains (18.8%). Further work including randomized controlled clinical trials is required to fully evaluate the usefulness of these data.

O tratamento da brucelose é problemático devido à alta freqüência de tratamentos mal sucedidos e recidivas. Por tratar-se de um patógeno intracelular, o tratamento requer procedimentos combinados. Entretanto, existem poucos dados sobre combinações in vitro para Brucellae. O objetivo deste trabalho foi investigar a eficiência de vários tratamentos tradicionais e novas combinações de antibióticos contra 16 isolados de Brucella melitensis. O efeito combinado foi avaliado através do método do E-test para obtenção do FIC (índice de concentração inibitória fracional). Co-trimoxazol (SXT) e moxifloxocina (MXF) apresentaram o MIC mais baixo, enquanto rifampicina (RIF) apresentou o MIC mais alto. Combinações com RIF mostraram a melhor atividade sinergística (100% para RIF-tetraciclina e 87,5% para RIF-SXT). Atividade sinergística foi também detectada para sete (43,7%) combinações de ciprofloxacina (CIP-STX), quatro (25%) de TET-MXF e duas (12,5%) de TET-SXT. As combinações que apresentaram efeito aditivo foram TET-SXT, CIP-SXT e TET-MXF. Antagonismo foi observado somente para a combinação TET-estreptomicina (STR) em três isolados (18,8%). Mais pesquisas utilizando ensaios clínicos randomizados controlados são necessárias para avaliar a utilidade desses dados.

In vitro synergistic activity of antibiotic combinations against Brucella melitensis using E-test methodology.

The treatment of brucellosis is still problematic, because of high rates of treatment failure or relapses. As the microorganism is an intracellular pathogen, treatment requires combined regimens. However, limited existing data on in vitro combinations are avaliable for Brucellae. The aim of this study was to investigate the in vitro efficacy of various traditional and new antibiotic combinations against 16 Brucella melitensis strains. The combination effect of antimicrobial agents was evaluated by E-test synergy method to obtain a fractional inhibitory concentration (FIC) index. Co-Trimoxazole (SXT) and moxifloxocin (MXF) exhibited the lowest MIC, while Rifampin (RIF) had the highest MIC in the study. Combinations with RIF showed the best synergistic activity (100% of RIF-tetracycline (TET), and 87.5% of RIF-SXT). Synergistic activity was also detected at seven (43.7%) of ciprofloxocin (CIP)-SXT, four (25%) of TET-MXF, and two (12.5%) of TET-SXT combinations. The combinations that demonstrated additivity were TET-SXT, CIP-SXT and TET-MXF. Antagonism was observed only with the TET-Streptomycin (STR) combination in three strains (18.8%). Further work including randomized controlled clinical trials is required to fully evaluate the usefulness of these data.

Tigecycline: its potential for treatment of brucellosis.

The in vitro efficacy and synergistic activity of tigecycline in comparison with other antimicrobials used in brucellosis, were tested for 16 Brucella melitensis strains by the E-test method. Tigecycline had the lowest minimal inhibitory concentration levels, and rifampin the highest, in the study. Tigecycline also provided the better synergistic activity compared to doxycycline according to the fractional inhibitory concentration index. The results of this in vitro study suggest tigecycline as a therapeutic alternative for brucellosis. These observations need to be supported with clinical studies.

First recurrent infection with vancomycin-resistant enterococcus from Turkey.

Here we describe a case of a neuroblastoma patient with recurrent vancomycin-resistant enterococcal infection successfully treated with ciprofloxacin. This is the first case of recurrent vancomycin-resistant enterococcal infection in our hospital and Turkey.

Disseminated cryptococcosis in a human immunodeficiency virus-negative patient: a case report.

Cryptococcus neoformans is a widely distributed saprophytic fungus that may cause opportunistic infections in normal and immunocompromised individuals particularly in patients with HIV infection. Disseminated infection in HIV-negative individuals is occasionally seen: a 57-year-old HIV-negative Turkish female initially presented with enlarged mediastinal lymph nodes and a large pulmonary parenchymal nodule, eventually diagnosed with disseminated cryptococcosis and tuberculosis.

Brucella endocarditis with repeated mitral valve replacement.

Brucella endocarditis, although a rare complication of brucellosis, is a life threatening and often under-diagnosed complication. Despite its high mortality rate with combined medical and surgical treatment, has a low occurrence rate in cases of brucellosis. Here we describe a patient who underwent mitral valve replacement for 3 times due to underdiagnosis of Brucella endocarditis. If a valve replacement fails because of an unknown reason, the doubt of a Brucella infection should be kept in mind for accurate treatment of such patients.

[Case report: difficulty in treating one event of Streptococcus pneumoniae meningitis]. / Olgu raporu: Streptococcus pneumoniae menenjitli bir olguda tedavi güçlügü.

Streptococcus pneumoniae is one of the leading causes of acute bacterial meningitis and the emergence of antibiotic resistant pneumococci is an increasing problem worldwide. In this report, a 22-years-old woman was presented with pneumococcal meningitis occurring twice in a 5 months period. After the first meningitis attack, the patient had been vaccinated by 23-valent polysaccharide vaccine but the illness has relapsed. Although S. pneumoniae which was isolated from the patient has been found intermediate resistant to penicillin and susceptible to ceftriaxone by E-test, the patient could be treated only with meropenem. The case has been presented and discussed for ceftriaxone failure in spite of in-vitro susceptibility. On the other hand, this case indicated that vaccination might fail to prevent recurrence.