The burden and epidemiology of community-acquired central nervous system infections: a multinational study.

Risk assessment of central nervous system (CNS) infection patients is of key importance in predicting likely pathogens. However, data are lacking on the epidemiology globally. We performed a multicenter study to understand the burden of community-acquired CNS (CA-CNS) infections between 2012 and 2014. A total of 2583 patients with CA-CNS infections were included from 37 referral centers in 20 countries. Of these, 477 (18.5%) patients survived with sequelae and 227 (8.8%) died, and 1879 (72.7%) patients were discharged with complete cure. The most frequent infecting pathogens in this study were Streptococcus pneumoniae (n = 206, 8%) and Mycobacterium tuberculosis (n = 152, 5.9%). Varicella zoster virus and Listeria were other common pathogens in the elderly. Although staphylococci and Listeria resulted in frequent infections in immunocompromised patients, cryptococci were leading pathogens in human immunodeficiency virus (HIV)-positive individuals. Among the patients with any proven etiology, 96 (8.9%) patients presented with clinical features of a chronic CNS disease. Neurosyphilis, neurobrucellosis, neuroborreliosis, and CNS tuberculosis had a predilection to present chronic courses. Listeria monocytogenes, Staphylococcus aureus, M. tuberculosis, and S. pneumoniae were the most fatal forms, while sequelae were significantly higher for herpes simplex virus type 1 (p < 0.05 for all). Tackling the high burden of CNS infections globally can only be achieved with effective pneumococcal immunization and strategies to eliminate tuberculosis, and more must be done to improve diagnostic capacity.

Integrase Strand Transfer Inhibitors (INSTIs) Resistance Mutations in HIV-1 Infected Turkish Patients.

OBJECTIVES: Integrase strand transfer inhibitor (INSTI) is a new class of antiretroviral (ARV) drugs designed to block the action of the integrase viral enzyme, which is responsible for insertation of the HIV-1 genome into the host DNA. The aim of this study was to evaluate for the first time INSTI resistance mutations in Turkish patients. METHODS: This study was conducted in Turkey, between April 2013 and April 2015 using 169 HIV-1-infected patients (78 ARV naive patients and 91 ARV-experienced patients). Laboratory and clinical characteristics of ARV naive and ARV-experienced patients were as follows: gender (M/F): 71/7 and 80/11, median age: 38 and 38.4; median CD4(+) T-cell: 236 and 216 cells/mm(3), median HIV-1 RNA: 4.95+E5 and 1.08E+6 copies/ml. Population-based seqeunces of the reverse transcriptase, protease, and integrase domains of the HIV-1 pol gene were used to detect HIV-1 drug resistance mutations. RESULT: INSTI resistance mutations were not found in recently diagnosed HIV-1-infected patients. However, ARV-experienced patients had major resistance mutations associated with raltegravir and elvitegravir; the following results were generated:F121Y, Y143R, Q148R and E157Q (6/91 - 6.6%). CONCLUSIONS: The prevalence of INSTI resistant mutations in ART-experienced patients suggested that resistance testing must be incorporated as an integral part of HIV management with INSTI therapies.

Outbreak of meningitis due to Serratia marcescens after spinal anaesthesia.

This article describes an outbreak of meningitis caused by Serratia marcescens in patients who had undergone spinal anaesthesia for caesarean section. Bacterial meningitis was diagnosed in 12 of the 46 patients who underwent a caesarean section under spinal anaesthesia in a 75-bed private hospital between 6(th) and 14(th) March 2011. S. marcescens was isolated from samples taken from four prefilled syringes and one bag containing 5% dextrose with norepinephrine, suggesting that medications used in spinal anaesthesia were contaminated extrinsically. Strategies for prevention of anaesthesia-associated infections in operating theatres are discussed.

Surgical site infections and mortality in elderly patients.

OBJECTIVE: We present the characteristics and outcome of surgical site infections (SSI) in patients 65 years of age or more, and determine the factors influencing mortality. METHODS: We conducted a prospective observational cohort study, comparing patients who survived with those who died, to identify risk factors associated with mortality among elderly patients presenting with SSI. The diagnosis of SSI was made for each patient, according to the CDC's standardized criteria. RESULTS: Seventy-five patients presenting with SSI were included in the study. The mean age of patients was 75 ± 6 (65-92), 68% were male patients. The most frequently isolated pathogen was Acinetobacter baumannii (n = 24). The overall in-hospital mortality rate was 25.3%. The statistical analysis revealed that gastrointestinal surgery, organ/space infections, polymicrobial infections, and higher SOFA scores were significantly associated with hospital mortality (P = 0.005, P = 0.0001, P = 0.047, P = 0.0001). According to laboratory tests, higher white blood cell (WBC) and neutrophil count, higher total bilirubin level, and lower thrombocyte count and albumin levels were significantly associated with hospital mortality (P = 0.040, P = 0.014, P = 0.001, P = 0.019, P=0.002). Multivariate analyses revealed that serum albumin (P = 0.004, OR = 11.3, CI 95% 2.16-59.07), organ/space SSI (P = 0.0001, OR = 11.65, CI 95% 3.003-45.21), and SOFA score (P = 0.030, OR = 2.742, 1.100-6.84) were independent risk factors associated with mortality. CONCLUSIONS: Serum albumin levels, organ/space infections, and higher SOFA scores were independently significantly associated with hospital mortality in older patients with SSI. Serum albumin levels should be closely monitored, and if necessary, early surgery should be performed.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey. METHODS: A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach. RESULTS: In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.) CONCLUSIONS: The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: We aimed to evaluate the impact of a multidimensional infection control strategy for the reduction of the incidence of catheter-associated urinary tract infection (CAUTI) in patients hospitalized in adult intensive care units (AICUs) of hospitals which are members of the International Nosocomial Infection Control Consortium (INICC), from 40 cities of 15 developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon, Macedonia, Mexico, Morocco, Panama, Peru, Philippines, and Turkey. METHODS: We conducted a prospective before-after surveillance study of CAUTI rates on 56,429 patients hospitalized in 57 AICUs, during 360,667 bed-days. The study was divided into the baseline period (Phase 1) and the intervention period (Phase 2). In Phase 1, active surveillance was performed. In Phase 2, we implemented a multidimensional infection control approach that included: (1) a bundle of preventive measures, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CAUTI rates, and (6) feedback of performance. The rates of CAUTI obtained in Phase 1 were compared with the rates obtained in Phase 2, after interventions were implemented. RESULTS: We recorded 253,122 urinary catheter (UC)-days: 30,390 in Phase 1 and 222,732 in Phase 2. In Phase 1, before the intervention, the CAUTI rate was 7.86 per 1,000 UC-days, and in Phase 2, after intervention, the rate of CAUTI decreased to 4.95 per 1,000 UC-days [relative risk (RR) 0.63 (95% confidence interval [CI] 0.55-0.72)], showing a 37% rate reduction. CONCLUSIONS: Our study showed that the implementation of a multidimensional infection control strategy is associated with a significant reduction in the CAUTI rate in AICUs from developing countries.

Living, training and playing in the heat: challenges to the football player and strategies for coping with environmental extremes.

Dehydration and hyperthermia both, if sufficiently severe, will impair exercise performance. Dehydration can also impair performance of tasks requiring cognition and skill. Body temperature may exceed 40 °C in competitive games played in hot weather, but limited data are available. Football played in the heat, therefore, poses a challenge, and effects on some aspects of performance become apparent as environmental temperature increases above about 12-15 °C. Prior acclimatization will reduce the impact of high environmental temperatures but provides limited protection when humidity is also high. Ingestion of fluids is effective in limiting the detrimental effects on performance: drinks with added carbohydrate and electrolytes are generally more effective than plain water and drinks may be more effective if taken cold than if taken at ambient temperature. Pre-exercise lowering of body temperature may aid some aspects of performance, but the efficacy has not been demonstrated in football.

Hydration and sweating responses to hot-weather football competition.

During a football match played in warm (34.3 ± 0.6 °C), humid (64 ± 2% rh) conditions, 22 male players had their pre-match hydration status, body mass change, sweat loss and drinking behavior assessed. Pre-match urine specific gravity (1.012 ± 0.006) suggested that all but three players commenced the match euhydrated. Players lost 3.1 ± 0.6 L of sweat and 45 ± 9 mmol of sodium during the 90-min match and replaced 55 ± 19% of their sweat losses and hence by the end of the game were 2.2 ± 0.9% lighter. The water volume consumed during the game was highly variable (1653 ± 487 mL; 741-2387 mL) but there was a stronger relationship between the estimated pre-game hydration status and water volume consumed, than between sweat rate and water volume consumed. In a second match, with the same players 2 weeks later in 34.4 ± 0.6 °C, 65 ± 3% rh, 11 players had a sports drink available to them before and during the match in addition to water. Total drink volume consumed during the match was the same, but approximately half the volume was consumed as sports drink. The results indicate that substantial sweat water and electrolyte losses can occur during match play in hot conditions and a substantial water and sodium deficit can occur in many players even when water or sports drink is freely available.

The effects of exercise, heat, cooling and rehydration strategies on cognitive function in football players.

We investigated the cognitive effects of exercising in the heat on the field players of two football teams in a series of three matches. Different rehydration and cooling strategies were used for one of the teams during the last two games. Cognitive functions were measured before, during and immediately after each football match, as well as core temperature, body mass, plasma osmolality and glucose levels, allowing an estimate of their differential impacts on cognition. The pattern of results suggests that mild-moderate dehydration during exercise in the heat (up to 2.5%) has no clear effect on cognitive function. Instead, plasma glucose and core temperature changes appear to be the main determinants: higher glucose was related to faster and less accurate performance, whereas core temperature rises had the opposite effect. The 50% correlation between plasma glucose and core temperatures observed during exercise in the heat may help to stabilize cognitive performance via their opposing effects. The glucose-like effects of sports drinks appear to be mediated by increased plasma glucose levels, because drinks effects became non-significant when plasma glucose levels were added to the models. The cooling intervention had only a beneficial effect on complex visuo-motor speed.

Effect of hot environmental conditions on physical activity patterns and temperature response of football players.

Heat stress may contribute to decreased match performance when football is played in extreme heat. This study evaluated activity patterns and thermal responses of players during soccer matches played in different environmental conditions. Non-acclimatized soccer players (n=11, 20±2 years) played two matches in conditions of moderate heat (MH) and high heat (HH) index. Core temperature (T(c) ) and physical performance were measured using a telemetric sensor and a global positioning system, respectively. The average ambient temperature and relative humidity were MH 34±1 °C and 38±2%; HH 36±0 °C and 61±1%. Peak T(c) in the MH match was 39.1±0.4 °C and in the HH match it was 39.6±0.3 °C. The total distance covered in the first and second halves was 4386±367 and 4227±292 m for the MH match and 4301±487 and 3761±358 m for the HH match. Players covered more distance (P<0.001) in the first half of the HH match than in the second half. In football matches played at high environmental temperature and humidity, the physical performance of the players may decrease due to high thermal stress.

A pilot study: longer duration of posttransplant hepatitis C virus therapy may increase the sustained response rate.

BACKGROUND: Although end of treatment virological responses are similar in posttransplant patients with recurrent chronic hepatitis C virus infection and nontransplant patients, the sustained virological response rate is lower in the posttransplant setting. We investigated the efficacy of a longer duration (3 years) of therapy. METHODS: Thirteen patients with biopsy-proven recurrent hepatitis C were included in the study. In the first year of therapy, all patients were treated with a standard regimen of interferon alpha 2b 3MU 3 times in a week plus ribavirin (800 to 1000 mg/d). After the availability of pegylated interferon, patients were converted to pegylated interferon (1.5 microg/kg body weight). Hepatitis C virus RNA was evaluated at months 3, 6, 9, 12, 24, 36, and 42. If hepatitis C virus RNA was negative at month 12, the patients continued treatment for 36 months. RESULTS: Hepatitis C virus RNA was negative in six patients at 12 months, including two who became hepatitis C virus RNA negative after 3 months; two, after 6 months; and two, after 12 months of therapy. Those six continued treatment completing 3 years of treatment with a sustained virological response. Four of those six patients with sustained virological response required colony-stimulating factors during treatment. CONCLUSION: Although the hepatitis C virus RNA status of patients at 12 weeks is a good marker to predict a sustained virological response in the nontransplant setting, it is not valid in posttransplant patients. A prolonged duration of therapy for patients who are viral responders at 12 months may prevent recurrence and increase the sustained virological response rate.

The acquisition time of infection: a determinant of the severity of hepatitis C virus-related liver disease in renal transplant patients.

BACKGROUND: The aim of this study was to compare the clinical and histopathological course of HCV infection acquired before and during or after renal transplantation. METHODS: According to HCV status, 197 RT patients were divided into three groups. At the time of RT, anti-HCV antibody was positive in 47 patients (pre-RT HCV group). In 27 patients, in whom anti-HCV negative at the time of RT, anti-HCV and/or HCV RNA was found to be positive following an ALT elevation episode after RT (post-RT HCV group). Both anti-HCV and HCV RNA were negative at all times in remaining 123 patients (control group). RESULTS: Liver biopsy was performed in 31 of 47 patients in pre-RT and 24 of 27 in post-RT HCV group after RT. Duration of follow-up was similar in all groups with a mean of 7.1 +/- 4.0 yr. Ascites and encephalopathy were seen in only post-RT HCV group (22%). Histological grade (6.5 +/- 2.7 vs. 4.1 +/- 1.4) and stage (2.0 +/- 1.5 vs. 0.8 +/- 0.8) was significantly severe in post-RT HCV group (p < 0.01). Three patients died due to liver failure in post-RT HCV group. CONCLUSIONS: HCV infection acquired during or after RT shows a severe and rapidly progressive clinicopathological course, which is significantly different from pre-transplant anti-HCV positive patients.

Safety, tolerability, and efficacy of pegylated-interferon alfa-2a plus ribavirin in HCV-related decompensated cirrhotics.

BACKGROUND: Pretransplantation clearance of hepatitis C virus (HCV)-RNA reduces the risk of HCV recurrence after transplantation. Furthermore, a sustained virological response could reduce disease progression and slow clinical deterioration in nontransplanted patients. AIM: To evaluate the safety, tolerability and efficacy of pegylated-interferon (PEG-IFN) alfa-2a plus ribavirin therapy in HCV-related decompensated cirrhotics. METHODS: Twenty HCV-related decompensated cirrhotics (44-67 years, 12 males, six Child-Pugh score A, 14 Child-Pugh score B, all with genotype 1b) were enrolled into the study. Treatment with PEG-IFN alfa-2a (135 microg, once a week) plus ribavirin (1000-1200 mg/day) was commenced. A 48-week treatment was planned in patients who had early virological response. RESULTS: Treatment was stopped in 8 (40%) patients. The remaining 12 (60%) patients completed 48 weeks of therapy; nine (45%) of them obtained end-of-therapy virological response and six (30%) of them obtained sustained virological response. Living donor liver transplantation was performed in three (15%) patients. Eight (40%) and six (30%) patients needed to reduce PEG-IFN alfa-2a and ribavirin dosages, respectively. No patient died during the follow-up period. CONCLUSION: PEG-IFN alfa-2a plus ribavirin therapy is safe, tolerable and efficacious in selected HCV-related decompensated cirrhotics.

Living donor liver transplantation from hepatitis B core antibody positive donors.

UNLABELLED: Liver allografts from donors previously exposed to hepatitis B virus (HBV) carry the risk of transmission of HBV infection to immunosuppressed recipients. However, exclusion of donor candidates with the serologic evidence of resolved hepatitis B-HBV surface antigen (HbsAg) negative and HBV core antibody (anti-HBc) positive-is not feasible in countries endemic for HBV. AIM: Our aim was to assess the safety of living donor liver transplantation from anti-HBc positive donors. MATERIALS AND METHODS: In our institution, 152 transplants were performed between June 1999 and April 2004. Fifty-six (37%) of the living donors were anti-HBc positive. Twenty of these liver grafts were transplanted to HbsAg-negative recipients. We excluded four HBsAg negative recipients who died because of early complications after transplantation. Lamivudine (100 mg/day) was given for prophylaxis of de novo HBV infection. RESULTS: The mean follow-up time for 16 HBsAg-negative recipients was 21.7 (7-48) months. None of them experienced de novo HBV infection. CONCLUSION: The use of liver allografts from anti-HBc-positive living donors is reasonably safe in HBsAg-negative recipients under lamivudine prophylaxis.