A Prospective, randomized study comparing 7-day and 14-day quadruple therapies as first-line treatments for helicobacter pylori infection in patients with functional dyspepsia.

OBJECTIVE: Standard triple therapy for Helicobacter pylori has a low eradication rate in Turkey. The aim of this study was to evaluate and compare the effectiveness of 7-day and 14-day lansoprazole, amoxicillin, clarithromycin, and bismuth subsalicylate (LACB) treatment regimens as first-line H. pylori eradication therapies. MATERIALS AND METHODS: This study included 70 patients with symptoms of dyspepsia and a positive H. pylori stool antigen test (SAT). Thirty-five patients received the modified quadruple therapy regimen for 7 days (LACB-7) whereas the remaining 35 patients received the treatment for 14 days (LACB-14). Eradication was assessed by SAT 1 month after the end of therapy. RESULTS: A total of 64 patients completed the therapy. The cumulative per-protocol (PP) and intention-to-treat (ITT) eradication rates were 89% (n = 57/64) and 81.4% (n = 57/70), respectively. Both the PP and ITT eradication rates were superior in the LACB-14 group, compared with the LACB-7 group (PP: 90.6% vs. 87.5%; ITT: 81.4% vs. 80%, respectively), but these differences were not statistically significant (P = 0.689). CONCLUSIONS: Both the 7-day and 14-day first-line LACB therapies provided a high cure rate, were well tolerated, and were equally effective against H. pylori infection in Turkey.

Normalization of the psychometric hepatic encephalopathy score for diagnosis of minimal hepatic encephalopathy in Turkey.

AIM: To construct normal values for the tests of the psychometric hepatic encephalopathy score (PHES) and evaluate the prevalence of minimal hepatic encephalopathy (MHE) among Turkish patients with liver cirrhosis. MATERIALS AND METHODS: One hundred and eighty-five healthy subjects and sixty patients with liver cirrhosis without overt hepatic encephalopathy were included in the study. All subjects underwent psychometric tests, which include number connection test-A and B (NCT-A/B), serial dotting test (DST), line drawing test (LDT), and digit symbol test (DST) in the same day. The variables that affected the results of the test were included in the multiple linear regression models and formulas were constructed to predict the expected results for each tests. RESULTS: The results of all PHES tests, except the LDT in the cirrhotic group were significantly different than center of gravity (CG) (P < 0,001). The score of PHES in the cirrhotic group was -2,18 ± 3,3 (median -2; range: 11 to +4), significantly lower than CG (-0.31 ± 2.18 [median, 0; range, -8 to +5]) (P < 0.001). the cutoff of PHES was set -4 point. Therefore, 19 of the 60 cirrhotic patients were diagnosed with MHE (31.6%). Among the patients with MHE, 11 (11/45, 24,4%) had Child-Pugh classification (CTP) A and 8 (8/15, 53.3%) had CTP B. No differences in age and education years were found between the MHE and non-MHE groups (P > 0.05). CONCLUSION: Turkish PHES normograms have been developed for detecting patients with MHE. Future multicenter national studies are needed to validate widely applicable norms.

Comparison of disk diffusion, E-test and broth microdilution test in determination of susceptibility of Aspergillus species to amphotericin B, itraconazole and voriconazole.

In response to the recent increase in Aspergillus infections, new antifungal agents have become available accompanied by studies on antifungal susceptibility tests for epidemiological follow-up. The aim of this study was to compare the efficacy of Clinical Laboratory Standards Institute (CLSI) M 38-A broth microdilution test with the disk diffusion and E-test in determining the susceptibility of Aspergillus spp. to amphotericin B, itraconazole and voriconazole. The study was carried out on 18 A. fumigatus, 7 A. flavus, 5 A. niger and 2 A. versicolor strains isolated from clinical samples. The microdilution method was performed by following the instructions of CLSI M 38-A. The E-test and disk diffusion tests were performed according to the instructions of their manufacturers. The percent agreement between the E-test and CLSI M38-A broth microdilution test at 24 (48) h within +/- 2 dilutions was, respectively, 81% (69%) for amphotericin B, 75% (72%) for itraconazole and 85% (81%) for voriconazole. The disk diffusion test showed good correlation with the E-test but poor correlation with the broth microdilution test for the three antifungal agents we tested. In conclusion, E-test and disk diffusion test have their advantages such as ease of application and interpretation, but their correlation with the broth microdilution should be improved.

Candida spp. colonization and serum anticandidal antibody levels in patients with chronic urticaria.

BACKGROUND: The role of Candida infections in the pathogenesis of chronic urticaria (CU) is debatable. Objective. In this study, we investigated the role of Candida spp. colonization and infection in patients with CU. METHODS: In total, 38 patients with CU and a control group of 42 healthy individuals consented for inclusion in the study. Stool and oral specimens from all participants were cultured and evaluated quantitatively. Candida albicans ELISA IgG/IgM/IgA test kits were used for the detection of antibodies against C. albicans in the sera of patients and controls. RESULTS: Yeasts were isolated from the stools of 60.5% of the patients and 50.0% of the controls (P = 0.78, Student's t-test) and from oral specimens in 47.4% and 42.9% (P = 0.85, Student's t-test), respectively. Colony counts in the positive specimens of both groups were not significantly different. IgG, IgM and IgA antibodies were positive in 36.8%, 23.8% and 5.3% of the patients and in 42.9%, 19.1% and 4.8% of the controls, respectively. The qualitative and quantitative results of the antibodies were not significantly different between the two groups (chi2 test). CONCLUSION: Intestinal and oral colonization of Candida spp. and serological evidence of Candida infections were not significantly different between patients with CU and controls. Claims of triggering of CU by Candida spp. should be explored in studies that measure allergic reactivity to Candida, and also in those that include eradication therapy.

Antibiotic-associated diarrhea in a Turkish outpatient population: investigation of 288 cases.

Oral antibiotics are often prescribed, especially for respiratory tract infections in the community. The widespread use of broad-spectrum antibiotics causes an increased incidence of antibiotic-associated diarrhea (AAD). Although AAD has been studied in hospitalized patients, there is little available information concerning the characteristics of AAD in outpatient populations. The aim of this study was to investigate the clinical and laboratory findings of adult patients with community-acquired AAD. Between June 1998 and December 2003, the clinical reports of 288 patients were retrospectively reviewed. We observed that the duration between the start of antibiotic treatment and onset of symptoms was 7 days in most of the patients (86%), and the mean time was 9+/-1.0 days. The diarrhea was self-limited in all cases and mean duration of symptoms was 3 (+/-1.0) days (1-7 days). The most common symptoms were abdominal discomfort and tenesmus (61.1%), while elevated WBC counts and fever were detected rarely. We were able to perform microbiologic investigations in only 88 patients because of the financial problems. Of the 88 stool specimens tested, none of them were positive for pathogenic bacterial growth or toxin A production.

Comparison of three differential media for the presumptive identification of yeasts.

This study evaluated three differential media, CHROMagar Candida, BiGGY agar and Albicans ID2 agar, for the presumptive identification of yeast species. In total, 215 yeast isolates were included in the study. The sensitivity and specificity of CHROMagar Candida, BiGGY agar and Albicans ID2 agar for the detection of Candida albicans were 100% and 100%, 91% and 92.7%, and 99.2% and 92.7%, respectively. CHROMagar Candida was a reliable tool for the presumptive identification of C. albicans, Candida tropicalis, Candida krusei and Candida glabrata. Albicans ID2 agar was useful for the detection of C. albicans.

Evaluation of semisolid agar screening tests for determining fluconazole and amphotericin B susceptibilities of Candida strains by using three different media.

The susceptibilities of 164 Candida isolates against fluconazole and amphotericin B were determined by semisolid agar screening tests and the microdilution method according to NCCLS M27-A standards. The semisolid agar screening tests were performed with three different media containing 0.5% agar and 2, 8, and 40 microg/ml of fluconazole or 0.5 and 2.0 microg/ml of amphotericin B. These media were MOPS buffered RPMI 1640, brain-heart infusion and 1/3 diluted Sabouraud dextrose agar. The results of both methods were interpreted as susceptible, dose dependent susceptible and resistant for fluconazole and susceptible and resistant for amphotericin B. The agreement rates of semisolid agar screening tests using RPMI 1640, brain-heart infusion and Sabouraud dextrose media with the reference microdilution method were found to be 71.4%, 51.2%, and 57.3% for fluconazole and 79.3%, 53.7%, and 56.7% for amphotericin B, respectively. Overall, we conclude that semisolid agar screening tests using RPMI 1640 can be used for determining the susceptibilities of Candida isolates against fluconazole and amphotericin B in clinical microbiology laboratories.

Detection of toxin production in Clostridium difficile strains by three different methods.

OBJECTIVE: To compare two immunoassays for detection of toxins produced in vitro by isolates of Clostridium difficile with the standard tissue culture assay, to help in the diagnosis of C. difficile-associated diarrhoea. METHODS: Toxin production was investigated in 42 strains of C. difficile of various serotypes, ribotypes and S-protein types. These included strains from our laboratory collection, strains freshly isolated from stool specimens of patients suspected of suffering from C. difficile-associated disease or of carrying it asymptomatically, and one reference strain (NCTC 11223). Toxin was assayed by (i) a rapid slide immunoassay (C. difficile toxin A test, Clearview, Oxoid), (ii) an enzyme-linked microplate immunoassay (C. difficile toxin A/B test, Techlab), and (iii) a tissue culture assay. The rapid slide assay and the enzyme immunoassay were performed according to the manufacturers' recommendations. The tissue culture assay was performed using Vero cells. RESULTS: Thirty of the 42 strains (71%) were shown to be positive for toxin A by the slide immunoassay and 34 of the strains (81%) were found to be toxin A/B producers by the enzyme immunoassay. The same 34 strains that were positive in the enzyme immunoassay also produced toxin B (cytotoxin) in the tissue culture assay. The sensitivity, specificity, and positive and negative predictive values for the rapid slide immunoassay method were calculated to be 88.2%, 100.0%, 100.0% and 66.7%, respectively, when compared to tissue culture assay results as the reference method. These values for the enzyme immunoassay method were all 100.0%. In this study eight strains were found to be non-toxin-producing by all methods. It is possible that there were four strains that only produced toxin B (A- B+), and were missed by the rapid A-only assay. CONCLUSIONS: We can recommend the use of the Techlab A + B enzyme immunoassay for the detection of toxin production by C. difficile strains because of its high sensitivity and specificity, its ease of use, and its capability of detecting both A- and B-type toxins.

Use of chromogenic tube and methyl blue-sabouraud agar for the identification of Candida albicans strains.

This study was performed to investigate the use of chromogenic tube and methyl blue-Sabouraud agar for the presumptive identification of Candida albicans. 124 clinical isolates, including 111 C.albicans and 13 Candida spp strains, which had been identified by morphology on cornmeal tween 80 agar and Vitek automated identification system, were included. Three different identification procedures, a) germ tube test, b) chromogenic tube test by using CHROMagar Candida and c) methyl blue-Sabouraud agar test, were performed to the strains. 88 of 111 (79.3%) C.albicans strains were detected to be positive by germ tube test. 87 (78.4%), 97 (87.4%) and 102 (91.9%) of these isolates were identified as C.albicans by chromogenic tube test after 2, 8 and 24 hours of incubation, respectively. 88 (79.3%), 92 (82.9%) and 88 (79.3%) of the isolates were correctly identified as C.albicans by methyl blue-Sabouraud agar test after 2, 8 and 24 hours of incubation, respectively. The sensitivity and specificity values were found to be 79.3 and 69.2 for the germ tube test. These values ranged between 78.4-91.9% and 69.2-76.9% for chromogenic tube test and 79.3-82.9% and 76.9-84.6% for methyl blue-Sabouraud agar depending on the incubation period. It can be concluded that the use of chromogenic tube and methyl blue-Sabouraud agar are rapid, simple and objective methods for the identification of C.albicans strains.

Disk diffusion method for fluconazole susceptibility testing of Candida albicans strains.

This study evaluated the usefulness of the disk diffusion method by using different media for the susceptibility testing of fluconazole against Candida albicans strains. The susceptibility of 108 clinical isolates of C. albicans against fluconazole were determined by microdilution and disk diffusion methods by using RPMI 1640 agar and 25 microg disks. 93 of these isolates were also tested by disk diffusion technique on four different media (yeast nitrogen base agar, Sabouraud dextrose agar, Mueller Hinton agar and Mueller Hinton methylene blue agar). The results of the microdilution method were evaluated visually and optically. The disk diffusion results were determined after 24 and 48 hours of incubation. When the 24-hour zone diameters were compared to the minimal inhibitory concentrations determined visually and optically, the best results were obtained for RPMI 1640 agar and yeast nitrogen base agar. The correlation coefficients were r=-0.34, -0.41 and r=-0.33, -0.32 for the first and second media, respectively. The best values (r=-0.29, -0.39) were obtained for Mueller Hinton methylene blue agar when the 48-hour zone diameters were considered. Agreement between the disk diffusion and microdilution methods was best for RPMI 1640, yeast nitrogen base and Mueller Hinton methylene blue agar after 24 hours of incubation (87-89%, 88-90%, 93-96%, respectively) and for Mueller Hinton methylene blue agar after 48 hours of incubation (89-96%). Disk diffusion method using RPMI 1640, yeast nitrogen base and Mueller Hinton methylene blue agar appears to be a useful, rapid and reliable screening technique for testing the susceptibility of C. albicans strains to fluconazole.

Brucellar spondylitis: MRI findings.

This study was carried out to identify the distinguishing features of brucellosis on magnetic resonance imaging (MRI). MRI examinations were performed in 14 patients with spinal brucellosis. A 1-T Magnetom (Erlangen, Siemens) was used to obtain T1-weighted (TR/TE 500/30) and T2-weighted (TR/TE 2000/80/20) spin echo sequences, in both sagittal and axial planes. Thirty-three percent of the vertebrae and 18 levels of disc were involved in the 14 brucellar spondylitis cases. Eleven patients (79.8%) with discitis revealed anterior superior vertebral body involvement. Fourteen (77.7%) of the levels with discitis displayed soft tissue swelling without presence of abscess formation. Seven facet joints of five patients with discitis displayed signal increase after contrast enhancement. Vertebral body signal changes without morphologic changes marked signal increase in the intervertebral disc on T2-weighted and contrast-enhanced sequences, and soft tissue involvement without abscess formation can be accepted as specific MRI features of brucellar spondylitis. The facet joint signal changes following contrast enhancement is another MRI sign of spinal brucellosis, which has not been mentioned so far.

In-vitro synergistic effect of fluconazole with nonsteroidal anti-inflammatory agents against Candida albicans strains.

The in-vitro interaction and synergistic activity of the combination of fluconazole with some nonsteroidal anti-inflammatory drugs (sodium salicylate, piroxicam, tenoxicam and diclofenac sodium) were investigated in Candida albicans strains (n=7) by the microdilution checkerboard assay. The results were evaluated visually and by a spectrophotometric microplate reader at 492 nm wavelength. Fractional inhibitory index was calculated for every strain and combination according to the minimal inhibitory concentration (MICs). The combination of fluconazole with sodium salicylate, tenoxicam and diclofenac sodium showed synergy against 5, 5 and 3 of the C. albicans strains, respectively. The effect of fluconazole with piroxicam was synergistic against one strain but indifferent/additive against the others. These data suggest that combinations of sodium salicylate, tenoxicam and diclofenac sodium with fluconazole may prove to be useful as chemotherapeutic agents for the treatment of C. albicans infections caused by especially fluconazole-resistant strains. However, additional preclinical work and in vivo studies are necessary to determine their definite clinical use.

Antimicrobial resistance of gram-negative isolates from intensive care units in Turkey: comparison to previous three years.

Resistance rates to selected antibiotics of gram-negative bacteria isolated from intensive care units (ICU) of 16 Turkish hospitals during 1998 were evaluated and compared to data from the previous 3 years. Antibiotic susceptibilities to imipenem, ceftazidime, ceftazidime-clavulanate, cefoperazone-sulbactam, ceftriaxone, cefepime, cefodizime, cefuroxime, piperacillin-tazobactam, ticarcillin-clavulanate, gentamicin, amikacin and ciprofloxacin were determined by Etest. A total of 1,404 isolates from 1,060 patients were collected, mainly from urinary and respiratory tracts. As in the previous 3 years, Pseudomonas spp. was the most frequently isolated gram-negative species (29.7%), followed by Escherichia coli, Acinetobacter and Klebsiella spp. Imipenem was the most active in vitro agent (73.4% susceptible), followed by ciprofloxacin (60.6%), cefoperazone-sulbactam (58.7%), cefepime (56.7%), piperacillin-tazobactam (55.0%) and amikacin (54.7%). In 1996, a decline in susceptibility rates of all antibiotics was evident. With the exception of imipenem, resistance to which remained stable, rates somewhat increased in 1997. In 1998, susceptibility to imipenem and cefepime remained stable, amikacin resistance tended to increase and susceptibility rates to other antibacterials showed a favorable increase. These results may in part be due to the implementation of a surveillance program and increased understanding of the magnitude of the resistance problem.

Surveillance of antimicrobial resistance among gram-negative isolates from intensive care units in eight hospitals in Turkey.

With the participation of eight major reference hospitals in Turkey, 749 aerobic Gram-negative isolates obtained from 473 intensive care patients in 1997 were tested for their susceptibility to 13 commonly employed antibacterial agents. The frequency with which species were isolated and resistance rates were compared with data from the previous 2 years. Imipenem was the most active agent against the majority of isolates (75%), followed by ciprofloxacin, cefepime and amikacin. The per cent susceptibility to all antibiotics declined from 1995 to 1996. With the exception of imipenem, for which there was no change in resistance, the per cent susceptibility somewhat increased in 1997. However, it was still lower than in 1995.

Acute renal failure in Central Anatolia.

BACKGROUND: The aetiological spectrum of acute renal failure (ARF) has changed in developed countries. It was the purpose of the study to evaluate whether similar changes have occurred in this part of the world as well. METHODS: In a prospective study a total of 439 patients with ARF were evaluated. They had been admitted to one hospital during two successive periods, i.e. 1983-1990 and 1991-1997. RESULTS: Of 439 patients with ARF, 116 were admitted in 1983-1990 (first period) and 323 in 1991-1997 (second period). The age of presentation increased from 49.8+/-6.2 years in the first period to 58.8+/-16.4 years in the second. Medical causes were present in 259 cases (59%), surgical causes in 110 cases (25%), and obstetric causes in 70 cases (16%). The frequency of surgical cases decreased from 28.4% in the first period to 23.8% in the second period. The respective figures for obstetric cases were 18.9% and 14.8%. Mortality did not change with time (33.6% in the first and 31.0% in the second period); the overall mortality was 31.7%. The mortality was higher for surgical (45.5%) than for obstetric (27.8%) and medical ARF (24.3%). CONCLUSION: In the mid-1970s, the most common causes of ARF in Turkey were obstetric complications and septic abortion. The aetiological spectrum of ARF has changed and today medical causes predominate. ARF resulting from septic abortion has become rare, possibly because of liberalization of abortion in 1983 in Turkey.

A surveillance study of antimicrobial resistance of gram-negative bacteria isolated from intensive care units in eight hospitals in Turkey.

This study was carried out with the participation of eight hospitals in Turkey to determine the frequency of gram-negative bacteria isolated in intensive care units (ICU) and to compare their resistance rates to selected antibiotics. Aerobic gram-negative bacteria isolated from ICUs during 1996 were studied. Antibiotic susceptibilities to imipenem, ceftazidime, ceftazidime-clavulanate, ceftriaxone, cefotaxime, cefepime, cefodizime, cefuroxime, piperacillin/tazobactam, amoxycillin-clavulanate, gentamicin, amikacin and ciprofloxacin were determined by Etest. A total of 748 isolates were obtained from 547 patients. The majority of organisms were isolated from the respiratory (38.8%) and urinary tracts (30.9%). Pseudomonas spp. were the most frequently isolated gram-negative species (26.8%), followed by Klebsiella spp. (26.2%). Escherichia coli, Acinetobacter spp. and Enterobacter spp. were the other commonly isolated organisms. High resistance rates were observed for all antibiotics studied. Imipenem appeared to be the most active agent against the majority of isolates. Although resistance rates exceeded 50%, ciprofloxacin, cefepime and amikacin were found to be relatively effective. Extended-spectrum beta-lactamase (ESBL) production appeared to be a major mechanism of resistance to beta-lactam antibiotics. In contrast to ceftazidime-clavulanate, piperacillin/tazobactam showed poor activity against organisms thought to produce ESBL, suggesting the presence of an enzyme resistant to tazobactam action. This study has yielded high rates of resistance in aerobic gram-negative isolates from ICUs in Turkey. High resistance rates to all the other antibacterials studied leave imipenem as the only reliable agent for the empirical treatment of ICU infections in Turkey.

Collagenous colitis in a patient with Addison's disease: a case report.

Diarrhea is a non-specific symptom which may be associated with Addison's disease and several causes had been demonstrated in the aetiology. We describe a patient with Addison's disease who was suffering from chronic diarrhea for three months. She was diagnosed as having collagenous colitis and successfully treated with Sulphasalazine, 2 g/day. Collagenous colitis is an uncommon cause of chronic diarrhea and the association of collagenous colitis with Addison's disease has not previously been described. We think that collagenous colitis may play a role in the aetiology of diarrhea in patients with Addison's disease and therefore we suggest a full colonoscopic examination in other patients with Addison's disease and diarrhea to determine the incidence of collagenous colitis in the aetiology of diarrhea.

Ureaplasma urealyticum-induced urinary tract stones in rats.

This study investigated the possible role of Ureaplasma urealyticum, which is predominantly located in the urogenital tract, in the formation of infectious stones. A standardized Ureaplasma urealyticum broth culture isolated from a human urogenital specimen was inoculated into the renal medulla of five male rats (Rattus norvegicus L., Wistar C, weighing 170 +/- 10 g) and the same amount of culture media was used for five identical control rats. Five days after the inoculation, the rats were killed and fresh preparations from the bladders and the inoculated kidneys of both groups were prepared. At the same time biochemical and histopathological analysis of the contents of the bladders and the inoculated kidneys of both groups was performed. Crystal formation within the bladders of the inoculated rats was demonstrated and biochemical analysis of the crystals showed calcium, magnesium and phosphate, which indicated the existence of infection-induced crystals. These findings were absent in the control rats. The role of Ureaplasma in the production of urinary tract infectious stones was thus demonstrated in vivo.