Epidemiologic and microbiologic evaluation of nosocomial infections associated with Candida spp in children: A multicenter study from Istanbul, Turkey.

BACKGROUND: The purpose of this study was to establish species distribution of Candida isolates from pediatric patients in Istanbul, Turkey, and to determine risk factors associated with nosocomial Candida infections. METHODS: This study was conducted between June 2013 and June 2014 by participation of 7 medical centers in Istanbul. Candida spp strains isolated from the clinical specimens of pediatric patients were included. Clinical features were recorded on a standardized data collection sheet. RESULTS: A total of 134 systemic Candida infections were identified in 134 patients. The patients were admitted in pediatric and neonatal intensive care units (41.8% and 9.7%, respectively) and in pediatric wards (48.5%). Candida albicans was the most prevalent species (47%), followed by Candida parapsilosis (13.4%), Candida tropicalis (8.2%), Candida glabrata (4.5%), Candida lusitaniae (3.7%), Candida kefyr (2.2%), Candida guilliermondii (1.5%), Candida dubliniensis (0.7%), and Candida krusei (0.7%). Types of Candida infections were candidemia (50.7%), urinary tract infection (33.6%), surgical site infection (4.5%), central nervous system infection (3.7%), catheter infection (3.7%), and intra-abdominal infection (3.7%). In multivariate analysis, younger age (1-24 months) and detection of non-albicans Candida spp was found to be risk factors associated with candidemia (P = 0.040; odds ratio [OR], 4.1; 95% confidence interval [CI], 1.06-15.86; and P = 0.02; OR, 2.4; 95% CI, 1.10-5.53, respectively). CONCLUSIONS: This study provides an update for the epidemiology of nosocomial Candida infections in Istanbul, which is important for the management of patients and implementation of appropriate infection control measures.

Rahnella aquatilis Sepsis in a Premature Newborn.

Rahnella aquatilis is an infrequently isolated Gram-negative rod within the Enterobacteriaceae family. The organism's natural habitat is water. The organism is rarely isolated from clinical specimens and it seldom causes infection in immunocompetent individuals. Here we present a one-month-old boy who was born prematurely at 27th week of gestation by cesarean section with a birth weight of 730 g. He developed sepsis caused by Rahnella aquatilis during the treatment for ventilator associated pneumonia due to Stenotrophomonas maltophilia with ciprofloxacin. He was successfully treated with a combination of amikacin plus meropenem. Although R. aquatilis is one of the saprophyticus organisms, it may cause life-threatening infection in newborn.

Treatment of spontaneous rupture of lung hydatid cysts into a bronchus in children.

PURPOSE: While several publications have reported the treatment of ruptured lung hydatid cysts (HC) in adults, there is limited information on the treatment of children. This study summarizes the treatment approach and outcomes of 11 children with spontaneous rupture of lung HCs into a bronchus. METHODS: The complete medical records of 11 patients with spontaneous lung HC bronchus rupture between March 1993 and April 2012 were examined retrospectively. Gender, age at the time of diagnosis, patient symptoms, lung localization, dimensions of the cyst, medical treatment duration, and associated morbidities were evaluated. Routine chest x-rays, ultrasonography, computed tomography and serological tests were used. RESULT: The study included 11 patients [4 males, 7 females; average age 7.45 (range 5-11) years] presenting to the Emergency Department. The symptoms at the time of presentation were coughing in 81.8% (n=9), hemoptysis in 54.5% (n=6), and chest pain in 54.5% (n=6). The average cyst diameter was 8.71(35-15) cm. The rupture involved the left lung in 7 (63.6%) patients and the right in 4 (36.4%). Serological tests were positive in seven patients and all patients had eosinophilia. The treatment of one patient was discontinued, while all of the other patients were treated medically. Pneumonia developed in four patients and lung abscesses in two. Both patients who developed lung abscesses had cysts with diameters greater than 10 cm. The average follow-up period was 48.4 (range 15-85) months; no mortality occurred. CONCLUSION: In our experience, medical treatment is adequate for patients with lung HCs progressing to spontaneous bronchus rupture. There was a high rate of abscess development within the thoracic cavity in patients with cysts over 10 cm in diameter; these patients can be treated effectively with a medical approach.

Three-year study of health care-associated infections in a Turkish pediatric ward.

INTRODUCTION: Health care-associated infections (HCAIs) can cause an increase in morbidity, mortality and costs, especially in developing countries. As information on the epidemiology of HCAIs in pediatric patientsinTurkey is limited, we decided to study the annual incidence and antibiotic resistance patterns in our pediatric ward at Marmara University Hospital. METHODOLOGY: All hospitalized patients in the pediatric ward were assessed with regard to HCAIs between January 1, 2008 and December 31, 2010. Data was prospectively collected according to standard protocols of the National Nosocomial Infections Surveillance System (NosoLINE). RESULTS: A total of 16.5% of all hospitalized patients developed HCAIs in the three years studied. The most frequent HCAIs were urinary tract infections (UTI) (29.3%), bloodstream infections (27%) and pneumonias (21%). While the most frequent agent isolatedfrom UTI was Escherichia coli (26%), the most common agent in blood stream infections was Staphylococcus epidermidis (30.4%). Vancomycin resistance was found in 73.3% of all Enterococcus faecium strains. Extended-spectrum ß-lactamase was detected in 58.3% of Klebsiella pneumoniae and E. coli isolates. CONCLUSIONS: Continual HCAI surveillance is important to determineits rate. Knowledge of the HCAI incidence can influence people's use of broad-spectrum antibiotics and encourage antibiotic rotation. Moreover, the knowledge of HCAI incidence may support the infection control programmes, including education and isolation methods which ultimately may help to reducethe rate of the HCAIs.

Refractory invasive aspergillosis controlled with posaconazole and pulmonary surgery in a patient with chronic granulomatous disease: case report.

Invasive aspergillosis is an important cause of morbidity and mortality in immunocompromised patients. Among primary immunodefiencies, chronic granulomatous disease (CGD) has the highest prevalence of invasive fungal diseases. Voriconazole is recommended for the primary treatment of invasive aspergillosis in most patients. In patients whose aspergillosis is refractory to voriconazole, therapeutic options include changing class of antifungal, for example using an amphotericin B formulation, an echinocandin, combination therapy, or further use of azoles. Posaconazole is a triazole derivative which is effective in Aspergillosis prophylaxis and treatment. Rarely, surgical therapy may be needed in some patients. Lesions those are contiguous with the great vessels or the pericardium, single cavitary lesion that cause hemoptysis, lesions invading the chest wall, aspergillosis that involves the skin and the bone are the indications for surgical therapy.Chronic granulomatous disease (CGD) is an inherited immundeficiency caused by defects in the phagocyte nicotinamide adenine dinucleotidephosphate (NADPH) oxidase complex which is mainstay of killing microorganisms. CGD is characterized by recurrent life-threatening bacterial and fungal infections and by abnormally exuberant inflammatory responses leading to granuloma formation, such as granulomatous enteritis, genitourinary obstruction, and wound dehiscence. The diagnosis is made by neutrophil function testing and the genotyping.Herein, we present a case with CGD who had invasive pulmonary aspergillosis refractory to voriconazole and liposomal amphotericine B combination therapy that was controlled with posaconazole treatment and pulmonary surgery.

The umbilical cord alpha-fetoprotein levels for predicting hyperbilirubinemia in term neonates.

OBJECTIVE: The aim of this study was to investigate the possible relationship between cord bloodalpha-fetoprotein (AFP) level and development of subsequent neonatal hyperbilirubinemia. STUDY DESIGN: The term newborns born between March 2005 and October 2005 were included in the study. Infants with Coombs-positive ABO and/or Rh incompatibility and/or hemolytic jaundice, asphyxia, congenital anomaly and signs of bleeding were excluded from the study. Cord blood AFP levels were measured in 504 full term newborns in this period. Infants were followed-up for possible neonatal hyperbilirubinemia. The capillary bilirubin level (CBL) was examined expeditiously in newborns developing jaundice and in other infants at the time discharge while the screening test was being performed. RESULTS: The mean umbilical cord AFP level was 49.1 ± 44.9 mg/L (range 1.1-396.2 mg/L), mean CBL was 5.8 ± 3.1 mg/dL (range 1-19.4 mg/dL), and the mean bilirubin detection time was 37 ± 23.2 hours (range 12-144 h) of age. Although a significant positive correlation was found between umbilical cord AFP and CBL levels, it was weak (r = 0.187, p < 0.001). Comparison of AFP levels in terms of bilirubin percentile values appropriate for postnatal age also showed a significant weak positive correlation (r = 0.113, p < 0.001). CONCLUSION: The umbilical cord AFP levels may not be used as a strong predictor for the determination of newborns at risk for hyperbilirubinemia.

[Serotype distribution and antibiotic susceptibilities of Streptococcus pneumoniae causing acute exacerbations and pneumonia in children with chronic respiratory diseases]. / Kronik Akciger Hastaligi Olan, Akut Alevlenme ve Pnömoni Tanisi ile Basvuran Çocuklarda Streptococcus pneumoniae Serotip Dagilimi ve Antimikrobiyal Duyarliliklari

This study aimed to investigate serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates obtained from children with chronic respiratory diseases admitted to hospital with a diagnosis of acute exacerbations between 2008-2010 at Marmara University Hospital, Istanbul, Turkey. Sixty one S.pneumoniae strains isolated from the respiratory samples of patients were studied for erythromycin, clindamycin, tetracyline, trimethoprim-sulphametoxazole (TMP-SMX), vancomycin, levofloxacin susceptibilities by disk diffusion method; MIC values of penicillin and ceftriaxone were determined by E-test (AB Biodisk, Sweden). Results were evaluated according to the CLSI standards. The erythromycin-clindamycin double disc method was applied for the detection of macrolide resistance phenotypes. The presence of macrolide resistance genes, ermB, mef(A)/(E), ermTR were determined by PCR using specific primers for each gene. The serotypes were determined by multiplex PCR using specific primers for 40 different serotypes. According to CLSI criteria, penicillin resistance in S.pneumoniae isolates were found to be 8.2% (5/61) and intermediate resistance rate was 54% (33/61) for oral penicillin. Penicillin resistance were found to be only 1.6% (1/61) for parenteral penicillin. Resistance rates of erythromycin, clindamycin, tetracyline, TMP-SMX were detected as 55.8%, 46%, 47.5% and 67.2%; respectively. No resistance was detected to vancomycin and levofloxacin. Constitutive macrolide-lincosamide-streptogramin B (cMLSB) phenotype and M phenotype were observed in 82.4% (n= 28) and 17.6% (n= 6) of the macrolide resistant isolates, respectively. Inducible macrolide-lincosamide-streptogramin B (iMLSB) phenotype was not detected. The macrolid resistance genotypes, ermB, mef(A)/(E), were positive 50% and 14.7%; respectively. Both ermB and mef(A)/(E) genes were detected 35.3% of the macrolid resistant isolates. None of the isolates were positive for ermTR gene. The most common S.pneumoniae serotypes were determined as serotype 19F, 23F and 6, furthermore penicillin (34%, 15.7% and 18.4%, respectively) and macrolide (38.2%, 20.6% and 14.7%, respectively) resistance rates of those serotypes were found relatively high. Serotype covarage of 7-, 10-, 13-valent conjugated pneumococcal vaccines and 23-valent pneumococcal vaccine were 65%, 67%, 69%, and 78.6%, respectively. In our country, use of the vaccines with these coverage rates has been observed to be effective in children exposed to intensive use of antibiotics with chronic lung disease.

Clinical and epidemiological features of Turkish children with 2009 pandemic influenza A (H1N1) infection: experience from multiple tertiary paediatric centres in Turkey.

BACKGROUND: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey. METHODS: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals. RESULTS: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis. CONCLUSIONS: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.

Recurrent fatal necrotizing fasciitis due to Streptococcus pyogenes in a child with hereditary sensory and automic neuropathy type IV.

Although necrotizing fasciitis (NF) is a rapidly progressive infection, recurrent NF is very rare. Herein we report a rare case of recurrent NF due to Streptococcus pyogenes. A 12-year-old female with hereditary sensory and autonomic neuropathy (HSAN) type IV presented with fever and swelling on her left knee. NF was diagnosed and she was treated successfully. Two years later she was readmitted with NF of the right knee and limb. Despite treatment, progressive tissue necrosis developed and proximal femur amputation was performed. Eight months following the second attack she was readmitted with NF of her left knee and her entire leg. Despite a wide surgical debridement and antibiotic treatment, the clinical status of the patient failed to improve and she subsequently died. Although many conditions have been reported to be predisposing factors for NF, this is the first report of an association between HSAN type IV and recurrent NF due to S. pyogenes. We recommend antibiotic prophylaxis for patients with NF due to S. pyogenes, especially for those with predisposing factors.