Profiling infectious diseases in Turkey after the influx of 3.5 million Syrian refugees.

BACKGROUND: Since 2011, the conflict in Syria has led to over five million refugees. Turkey hosts the highest number of Syrian refugees in the world. By February 2019 over 3.6 million people had fled to Turkey to seek safety. Only 6.1% of Syrian refugees live in temporary shelters. Owing to the disrupted healthcare services, many children coming from the conflict zones are less likely to have received vaccination. In temporary shelters immunization coverage is >95% and the refugee population is receptive to vaccination. AIMS: The objective of this study was to review the infectious diseases situation among Syrian refugees in Turkey. SOURCES: We have reviewed the reports and studies provided by the governmental and non-governmental organizations and obtained more detailed data from the Ministry of Health in Turkey. CONTENT: Between 2012 and 2016, 1 299 209 cases of respiratory tract infection and 158 058 episodes of diarrhoea with 59 bloody diarrhoeas were reported; 1354 hepatitis A cases and 108 active tuberculosis cases were detected and treated in the temporary shelters for Syrian refugees. Overall in Turkey, 7794 cutaneous leishmaniasis have been reported. IMPLICATIONS: Since the influx of Syrian refugees, there has been an increase in cases of leishmaniasis and measles. No significant increase was detected for tuberculosis, other vector-borne infections, and healthcare associated or sexually transmitted infections. The Syrian refugees can be considered as a vulnerable group in Turkey due to their living and working conditions. Based on available data and our detailed analysis, the numbers show a stable situation regarding infectious diseases.

Crimean-Congo haemorrhagic fever: transmission to visitors and healthcare workers.

Crimean-Congo haemorrhagic fever is a viral haemorrhagic disease, mostly transmitted by tick bites or through contact with infected animal's blood, and bodily fluids. Nosocomial infections were occasionally reported in healthcare settings. We report nosocomial cluster of Crimean-Congo haemorrhagic fever including the visitor with unknown transmission.

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 (n = 653, 63%) and/or pharyngitis (n = 146, 14%) were the most frequent preliminary diagnoses. The most frequent clinical presentations were oropharyngeal (n = 832, 85.3%), glandular (n = 136, 13.1%) and oculoglandular (n = 105, 10.1%) forms. In 987 patients (95.5%), the lymph nodes were reported to be enlarged, most frequently at the cervical chain jugular (n = 599, 58%), submandibular (n = 401, 39%), and periauricular (n = 55, 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 ß-lactam/ß-lactamase inhibitors (n = 793, 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 26.8 ± 37.5 days. 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 (n = 426, 86.1%), the formation of new lymphadenomegalies under treatment (n = 146, 29.5%), and persisting complaints despite 2 weeks of treatment (n = 77, 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.

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.

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 ≥2 mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3 %) and cholestasis was detected in 215 (66.1 %) patients. Fatigue (91 %), fever (86 %), sweating (83 %), arthralgia (79 %), and lack of appetite (79 %) were the major symptoms. Laboratory tests showed anemia in 169 (52 %), thrombocytopenia in 117 (36 %), leukopenia in 81 (25 %), pancytopenia in 42 (13 %), and leukocytosis in 20 (6 %) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (n = 73), doxycycline plus rifampicin (n = 71), doxycycline plus rifampicin and an aminoglycoside (n = 27). The duration of ALT normalization differed significantly in three treatment groups (p < 0.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (p < 0.05). However, the length of hospital stay did not differ significantly between these three combinations (p > 0.05). During the follow-up, treatment failure occurred in four patients (1 %) and relapse was seen in three patients (0.9 %). 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.

A prospective, multi-center study: factors related to the management of diabetic foot infections.

The Turkish Association of Clinical Microbiology and Infectious Diseases, Diabetic Foot Infections Working Group conducted a prospective study to determine the factors affecting the outcomes of diabetic foot infections. A total of 96 patients were enrolled in the study. Microbiological assessment was performed in 86 patients. A total of 115 causative bacteria were isolated from 71 patients. The most frequently isolated bacterial species was Pseudomonas aeruginosa (n = 21, 18.3%). Among cases with bacterial growth, 37 patients (43%) were infected with 38 (33%) antibiotic-resistant bacteria. The mean (±SD) antibiotics cost was 2,220.42 (±994.59) USD in cases infected with resistant bacteria, while it was 1,206.60 (±1,160.6) USD in patients infected with susceptible bacteria (p < 0.001). According to the logistic regression analysis, the risk factors related to the growth of resistant bacteria were previous amputation (p = 0.018, OR = 7.229) and antibiotics administration within the last 30 days (p = 0.032, OR = 3.796); that related to the development of osteomyelitis was wound size >4.5 cm(2) (p = 0.041, OR = 2.8); and that related to the failure of the treatment was the growth of resistant bacteria (p = 0.016, OR = 5.333). Diabetic foot osteomyelitis is usually a chronic infection and requires surgical therapy. Amputation is the accepted form of treatment for osteomyelitis. Limited limb-saving surgery and prolonged antibiotic therapy directed toward the definitive causative bacteria are most appropriate. This may decrease limb loss through amputations. As a result the infections caused by resistant bacteria may lead to a high cost of antibiotherapy, prolonged hospitalization duration, and failure of the treatment.

The effect of tigecycline and ertapenem against clinical isolates of Brucella melitensis detected by E-test on different media.

In this study, in vitro activity of tigecycline (TIG) and ertapenem (ERT) against clinical isolates of Brucella melitensis and the effect of different media on in vitro test results were investigated. The in vitro effects of TIG and ERT to 38 B. melitensis isolates were comparatively investigated in brucella agar and 5% sheep blood agar. MIC value of ERT was 0.032 µg/mL in 23 of 38 and 20 of 38 isolates on blood and brucella agar, respectively. Minimum inhibitory concentration values of TIG were substantially different ranging between 0.064-0.25 µg/mL on blood agar. However, MIC values of TIG were similar on brucella agar with 0.25 µg/mL in 15 of 38 isolates and 0.5 µg/mL in 10 of 38 isolates. In conclusion, although ERT and TIG were effective against B. melitensis isolates in vitro, further studies are needed in order to determine the use of these novel drugs in treatment of brucellosis.

Initial high rate of misdiagnosis in Crimean Congo haemorrhagic fever patients in an endemic region of Turkey.

Crimean Congo haemorrhagic fever (CCHF) has been an emerging tick-borne infection in some parts of Turkey since 2002, with a number of fatalities. Many of the initial non-specific symptoms of CCHF can mimic other common infections. Additionally, the seasonal pattern of the epidemic, and the waning attention of healthcare workers to the yearly index cases caused some delays in appropriate patient care and treatment. Between March 2004 and August 2008, 140 confirmed adult cases were evaluated retrospectively for initial diagnosis and treatment delays. This study clearly demonstrated that there are particular delays (4.8 days) in the referral system to initiate effective antiviral treatment in the tertiary-care centre which significantly affect fatality rates (P>0.05). A large number of patients (n=95, 68%) received an initial misdiagnosis of various infections other than CCHF. In conclusion, continuous medical education regarding CCHF in the epidemic area is essential in order to achieve a better survival rate from this deadly infection.

The role of ribavirin in the therapy of Crimean-Congo hemorrhagic fever: early use is promising.

Crimean-Congo hemorrhagic fever (CCHF) is a disease with high fatality. To demonstrate the effectiveness of ribavirin against CCHF. The first group of 21 patients received ribavirin within 4 days of the onset of symptoms (early use of ribavirin, EUR); the second group of 20 patients received ribavirin > or =5 days after the onset of the symptoms of the disease (late use of ribavirin, LUR); and the last group of 11 patients did not receive ribavirin (no use of ribavirin, NUR). At 5-10 days from the onset of symptoms the mean platelet counts of the patients in the EUR group were significantly higher than those of the patients in LUR group, and at 7-9 days, they were significantly higher than that of the patients in the NUR group. The mean aspartate transferase levels in the EUR group were significantly lower than of the NUR group on days 8 and 9, and the mean alanine transferase level was significantly lower on day 8 after the onset of the symptoms. There is a beneficial effect of ribavirin if given at an early phase of the CCHF. We suggest ribavirin use especially in the early phase of the disease.

An unusual presentation of sirolimus associated cough in a renal transplant recipient.

Sirolimus-associated pulmonary problems are rare but life threatening. Pulmonary problems due to sirolimus treatment are interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia (BOOP), and alveolar hemorrhage. We present a case of sirolimus-related cough in the absence of any pulmonary radiological findings. A 55-year-old man with a history of 4 years of hemodialysis therapy because of end-stage renal disease of unknown etiology underwent cadaveric renal transplantation in June 2006. Three days following the initiation of sirolimus therapy he complained of dry cough and fever. There were no clinical or laboratory findings compatible with specific pulmonary disease. After switching sirolimus to tacrolimus, the cough improved within 1-2 days and resolved in 5 days. Sirolimus should be considered in the differential diagnosis of pulmonary problems in the early posttransplantation period even in the absence of radiological findings.

Five-year surveillance of nosocomial infections in Ankara Training and Research Hospital.

The objective of this study was to assess the rate of nosocomial infections (NIs), frequency of nosocomial pathogens and antimicrobial susceptibility changes in a 530-bed hospital over a five-year period. Hospital-wide laboratory-based NI surveillance was performed prospectively between 1999 and 2003. The Centers for Disease Control and Prevention's definitions were used for NIs and nosocomial surgical site infections, and NI rates were calculated by the number of NIs per number of hospitalized patients on an annual basis. NI rates ranged between 1.4% and 2.4%. Higher rates were observed in the neurology, neurosurgery, paediatric and dermatology departments; the low rate of NIs overall may be due to the surveillance method used. The most commonly observed infections were urinary tract, surgical site and primary bloodstream infections, and the most frequently isolated pathogens were Escherichia coli, Klebsiella pneumoniae, Enterococcus spp. and Staphylococcus aureus. Carbapenems were the most effective agents against enterobacteriaceae. Meticillin resistance among S. aureus isolates was less than 50%, and all S. aureus and Enterococcus spp. isolates were susceptible to glycopeptides apart from one glycopeptide-resistant E. faecium isolate identified in 2003. Data obtained by the same method enabled comparison between years and assisted in the detection of recent changes. Antimicrobial susceptibility data on nosocomial pathogens provided valuable guidance for empirical antimicrobial therapy of NIs.

Therapy of acute hepatitis C with interferon-alpha2b plus ribavirin in a health care worker.

Hepatitis C virus can be transmitted to health care workers through needlestick accidents. In this report, the result of short-term therapy with interferon-alpha2b plus ribavirin combination of acute hepatitis C in a health care worker who infected through laboratory accident was presented. The patient received combination of interferon-alpha2b (5 MU three times a week) plus ribavirin (1000 mg daily) for three months. Aminotransferase levels were normalised and clearance of HCV RNA was obtained in the first month of the therapy. After 19 months of follow-up, he had undetectable levels of HCV RNA so sustained response (clearance of HCV RNA and normalisation of aminotransferases at least six months after cessation of therapy) was achieved. According to this result, short-term therapy of acute hepatitis C with interferon-alpha2b plus ribavirin may be an alternate to others.

Relationship between nosocomial infection and mortality in a neurology intensive care unit in Turkey.

Few previous studies have evaluated the relationship between nosocomial infection and mortality in a neurology intensive care unit (ICU). In this study, patients treated for more than 24h in the neurology ICU of the Ankara Training and Research Hospital, Turkey were followed until death or two days after discharge by prospective daily surveillance. The study period was 14 months. One hundred and sixty-nine ICU-acquired infections occurred in 74 (38.9%) of 190 patients during 2006 patient-days. The overall rate of ICU-acquired nosocomial infection was 88.9/100 patients and 84.2/1000 patient-days. While the overall mortality rate was 60%, mortality in patients with nosocomial infections was 69%. In univariate analysis, infection (nosocomial and community-acquired) (P=0.002), nosocomial infection (P<0.05), mechanical ventilation (P<0.0001), presence of two or more underlying diseases (P=0.01), parenteral nutrition (P<0.0001), steroid treatment (P=0.003) and a low Glasgow Coma Scale (GCS) score (P=0.0001) were identified as risk factors for mortality. Stepwise logistic regression analysis showed nosocomial infection (P<0.05), mechanical ventilation (P=0.009), the presence of two or more underlying diseases (P<0.05) and a low GCS score (P=0.0001) to be risk factors for ICU mortality. It was concluded that nosocomial infection increases the risk of mortality by a factor of 1.69. The impact of nosocomial infection on mortality in our ICU was higher in patients with high GCS scores and patients aged between 66 and 75 years. In particular, nosocomial infection increased mortality among patients with less severe illnesses.

Soluble interleukin-2 receptor and interleukin-10 levels in patients with chronic hepatitis B infection.

BACKGROUND/AIMS: In the current investigation, we evaluated patients with hepatitis B infection to determine whether serum soluble interleukin-2 receptor and interleukin-10 levels were changed and whether the degree of these changes in serum levels correlated with histologic severity of hepatitis related liver injury. METHODOLOGY: 25 patients diagnosed of chronic active B hepatitis, 25 asymptomatic hepatitis B carriers, 25 healthy people with antibody to hepatitis B surface antigen and 20 healthy people without any hepatitis marker positivity were included in the study. Serum interleukin-10 and soluble interleukin-2 receptor levels were measured. The association between liver pathology, HBV DNA, serum transaminase values and these parameters were researched. RESULTS: Serum soluble interleukin-2 receptor and interleukin-10 levels were significantly higher in chronic hepatitis cases and asymptomatic carriers than that of others (P < 0.01). Serum interleukin-10 levels correlated with histological activity index and HBV DNA values (r = 0.7, P < 0.01) but not with soluble interleukin-2 receptor levels and transaminase values. CONCLUSIONS: Our results support the observation that interleukin-10 and soluble interleukin-2 receptor may play an important role in the inappropriate regulation of immune response in patients with chronic hepatitis B virus infection and interleukin-10 may be responsible for chronicity.

Circulating ICAM-1 levels in bronchial asthma and the effect of inhaled corticosteroids.

BACKGROUND: Even mild asthma has an inflammatory component. Intercellular adhesion molecule-1 (ICAM-1) plays an important role in inflammation. Higher levels of circulating ICAM-1 (cICAM-1) in sera may reflect the upregulation of ICAM-1 expression in allergic inflammation. OBJECTIVE: The aim of this study was to assess cICAM-1 levels in children with atopic bronchial asthma and to determine the effects of inhaled glucocorticoids on cICAM-1 levels. METHODS: The study group consisted of 25 children with moderate atopic bronchial asthma with a mean age of 9.9 +/- 4.2 years, and the control group consisted of 18 healthy children with a mean age of 9.6 +/- 2.6 years. Serum cICAM-1 levels and pulmonary function tests were measured. The patients were treated 2 months with inhaled budesonide 400 to 800 microg (mean 440 microg) per day. After this treatment, cICAM-1 levels and pulmonary function tests were compared with pretreatment levels. The pretreatment cICAM-1 values were compared with healthy control group. RESULTS: The initial cICAM-1 levels of the patient group were significantly higher than the cICAM-1 levels of the control group (P = .001). The post-treatment cICAM-1 levels of the patient group were significantly lower than the pretreatment values (P = .007). Pulmonary function test results (FEV1, FEF25-75, and PEFR) rose significantly with the treatment in patients (P < .05). CONCLUSION: This study revealed the presence of inflammation in children with even moderate atopic asthma as reflected with elevated levels of cICAM-1 levels, which decreased following corticosteroid treatment as a result of decreased inflammation.

The early effect of specific immunotherapy on lymphocyte response to PHA and allergens in atopic patients with allergic rhinitis.

In the first part of this study, peripheral lymphocyte subpopulations and their proliferative response to PHA and allergens were investigated in the 30 patients with allergic rhinitis compared to 20 healthy non-atopic individuals. Data obtained employing a PHA-induced lymphoproliferative response assay revealed that the allergic rhinitis generated significantly less activity than did the normal control group. Significantly decreased ration of CD4+/CD8+ T cells was noted in the patients with allergic rhinitis. Mean values of stimulation indices by allergen extracts were higher in the patients sensitive to same antigen than others especially in concentration of 1000 SQU/ml. Stimulation of active lymphocytes revealed no statistically significant group differences between allergens. In the second part of the study, the early effect of immunotherapy on T cell subsets and lymphocyte proliferative response to PHA and allergens were examined in the peripheral blood lymphocytes of patients. A significant increase in PHA-induced and in allergen induced lymphoproliferative response were observed in all patients after sixth months of immunotherapy. It is concluded that there may be an association between allergic rhinitis and deficiency of circulating CD4+ cells but further studies are required to substantiate this hypothesis.