Direct healthcare costs associated with management of asthma: comparison of two treatment regimens in Indonesia, Thailand and Vietnam.

OBJECTIVE: Daily inhaled corticosteroid (ICS) and long-acting beta-2-agonist (LABA) combinations comprising either regular maintenance therapy with ICS/LABA plus as-needed short-acting beta-2-agonist (SABA) or ICS-formoterol combinations used as maintenance and reliever therapy (MART) are recommended for moderate asthma. This analysis compares the direct costs of twice-daily fluticasone propionate/salmeterol (FP/salm) and budesonide/formoterol MART in three Southeast Asian countries. METHODS: A literature review identified three randomized trials in patients with asthma (≥ 12 years) comparing regular twice-daily FP/salm with as-needed SABA versus MART in moderate asthma: AHEAD (NCT00242775/17 countries/2309 patients), COMPASS (AstraZeneca study SD-039-0735/16 countries/3335 patients), and COSMOS (AstraZeneca study SD-039-0691/16 countries/2143 patients). Economic analyses, conducted from a healthcare sector perspective (medication costs + healthcare utilization costs), applied unit costs from countries where healthcare costs are publicly available: Indonesia, Thailand and Vietnam. Results are expressed in British pound sterling (GBP/patient/year). RESULTS: Annual exacerbation rates were low and differences between treatment strategies were small (range, FP/salm: 0.31-0.38, MART: 0.24-0.25) although statistically significant in favor of MART. Total average (minimum-maximum) direct costs (in GBP/patient/year) across the three studies were £187 (£137-£284), £158 (£125-£190), and £151 (£141-£164) for those who used FP/salm, and £242 (£217-£267), £284 (£237-£340) and £266 (£224-£315) for MART in Indonesia, Thailand and Vietnam, respectively. On average, total direct costs/patient/year with FP/salm were 22.8%, 44.6% and 43.0% lower than with MART for Indonesia, Thailand and Vietnam, respectively. CONCLUSIONS: In the three countries evaluated, total treatment costs with regular twice-daily FP/salm were consistently lower than with budesonide/formoterol MART due to lower direct healthcare costs.

Impact of vaccines on antimicrobial resistance.

DRIVERS OF ANTIMICROBIAL RESISTANCE: Antibiotic use drives the development and spread of resistant bacterial infections. Antimicrobial resistance (AMR) has become a prolific global issue, due to significant increases in antibiotic use in humans, livestock and agriculture, inappropriate use (under-dosing and over-prescribing), and misuse of antibiotics (for viral infections where they are ineffective). Fewer new antibiotics are being developed. THE PROBLEM OF AMR: AMR is now considered a key threat to global health, leading to more mortality and increased healthcare costs threatening future conduct of routine medical procedures. Traditional approaches to address AMR include antibiotic stewardship, better hygiene/infection control, promoting antibiotic research and development, and restricting use for agricultural purposes. VACCINES AS A TOOL TO REDUCE AMR: While antibiotic development is declining, vaccine technology is growing. This review shows how vaccines can decrease AMR by preventing bacterial and viral infections, thereby reducing the use/misuse of antibiotics, and by preventing antibiotic-resistant infections. Vaccines are less likely to induce resistance. Some future uses and developments of vaccines are also discussed. CONCLUSIONS: Vaccines, along with other approaches, can help reduce AMR by preventing (resistant) infections and reducing antibiotic use. Industry and governments must focus on the development of novel vaccines and drugs against resistant infections to successfully reduce AMR. A graphical abstract is available online.

Epidemiology and management of healthcare-associated bloodstream infections in non-neutropenic immunosuppressed patients: a review of the literature.

Advancements in medicine have led to a considerable increase in the proportion of patients living with severe chronic diseases, malignancies, and HIV infections. Most of these conditions are associated with acquired immune-deficient states and treatment-related immunosuppression. Although infections as a result of neutropenia have long been recognized and strategies for management were developed, non-neutropenic immunosuppression has been overlooked. Recently, community-acquired infections in patients with frequent, significant exposure to healthcare settings and procedures have been classified as 'healthcare-associated infections' since they are more similar to hospital-acquired infections. Most of the non-neutropenic immunosuppressed patients have frequent contact with the healthcare system due to their chronic and severe diseases. In this review, we focus on the healthcare-associated bloodstream infections in the most common non-neutropenic immunosuppressive states and provide an update of the recent evidence for the management of these infections.

Turkish doctors' cohort: healthy despite low screening.

OBJECTIVES: We aimed to determine the prevalence of chronic diseases and unhealthy lifestyle behaviors of Turkish doctors as compared with the general population and the frequency of compliance with preventive clinical practices among doctors. METHODS: This was an observational, prospective cohort study that enrolled graduates between 1975 and 2004 from six medical schools in Turkey. Data on demographics, disease conditions, and unhealthy lifestyle behaviors were gathered. Preventive care practices were analyzed with regards to age and gender. RESULTS: A total of 7228 doctors participated in the study. Comparison with the national data revealed higher hyperlipidemia and coronary artery disease rates. While 54.5% of the doctors had a doctor visit in the last 12 months, only 31.5% of those over 40 years of age reported a recent blood pressure measurement. Colon cancer screening rate over 50 years of age with any of the acceptable methods was only 3%. One-fourth of the female doctors over 40 years of age underwent mammography within the last two years. Only 7.1% of the doctors over 65 years of age and 10% of the doctors having an indication for a chronic disease had a pneumococcal vaccine, while nearly one-fifth had no hepatitis B vaccine. CONCLUSION: In this cohort of mainly middle-aged Turkish doctors, the age-standardized rates of chronic diseases were lower than the rates in the general population except for the rates of hyperlipidemia and coronary artery disease. However, doctors did show quite low rates of receipt of screening practices. These results might provoke questions about how to use Turkish doctors' health behaviors to further improve doctors' and, relatedly, patients' health.

Epidemiology of candidaemia in a tertiary care university hospital: 10-year experience with 381 candidaemia episodes between 2001 and 2010.

Defining the epidemiology of and risk factors for candidaemia is necessary to guide empirical treatment. The objectives of this study were to determine the ranking of Candida among positive blood cultures, to define the epidemiology of candidaemia and to investigate patient characteristics and their relationship with C. albicans vs. non-albicans Candida (NAC) candidaemia. Candidaemia episodes between January 2001 and December 2010 were evaluated retrospectively. Patient characteristics were compared across Candida species. Candida ranked as the fifth most frequently isolated pathogen. Among 381 candidaemia episodes, 58.3% were due to C. albicans, followed by C. parapsilosis (15.2%), C. tropicalis (13.4%) and C. glabrata (6.8%). No statistically significant difference was observed in the distribution of C. albicans vs. NAC (P = 0.432). Patients with NAC had significantly higher rates of haematological disorders (P < 0.001) and neutropenia (P = 0.003), and were older (P = 0.024) than patients with C. albicans, whereas patients with urinary catheters had higher rates of C. albicans (P = 0.007). On species basis, C. tropicalis was more frequently isolated from patients with haematological disorders (P < 0.001) and neutropenia (P = 0.008). Patients with urinary catheters were less likely to have C. parapsilosis (P = 0.043). C. glabrata was most prevalent among patients with solid organ tumours (P = 0.038), but not evident in patients with haematological disorders. Local epidemiological features and risk factors may have important implications for the management of candidaemia.

Epidemiology and emerging resistance in bacterial bloodstream infections in patients with hematologic malignancies.

BACKGROUND: The objective of this study was determine the frequency of bloodstream infections (BSIs) and the causative bacteria and their resistance patterns in patients with hematological malignancies (HMs) in a large tertiary care university hospital in Turkey over a 5-year period. METHODS: A total of 2098 patients with HMs with 3703 neutropenic episodes were included. Patients were classified as high-risk (n = 843) and low-risk (n = 1255) groups and evaluated for frequency of BSIs, causative bacteria, and their resistance patterns. RESULTS: The frequency of BSIs was 14.5%. The frequency of gram-negative BSIs in high-risk and low-risk groups was 10.7% and 5.4% (p < 0.001), respectively. The frequency of gram-positive BSIs in high-risk and low-risk groups was 7.0% and 3.9% (p < 0.001), respectively. Gram-negative bacteria predominated (52.6%), with Escherichia coli (17.3%) and Klebsiella spp. (11.0%) as the most frequent organisms. Coagulase-negative staphylococci (10.4%) and Corynebacterium spp. (6.3%) were the most common gram-positive bacteria (35.8%). The rate of extended-spectrum beta-lactamase (ESBL) production was 45% for E. coli and 58% for Klebsiella spp. Quinolone resistance was 58% for E. coli and 11% for Klebsiella spp.. The overall frequency of ceftazidime resistance in Pseudomonas aeruginosa was 28%, and 87% of Acinetobacter spp. were multidrug-resistant. Of Staphylococcus aureus isolates, 24.8% were resistant to methicillin. CONCLUSION: The dominating causes of BSIs in patients with HMs in our hospital are resistant gram-negative bacteria, which has made empirical antimicrobial choice a highly challenging issue in this patient population.

Urine neutrophil gelatinase-associated lipocalin levels predict acute kidney injury in acute decompensated heart failure patients.

BACKGROUND: Acute heart failure (HF) syndromes are frequently complicated with cardiorenal syndromes. The aim of this study was to evaluate the performance of admission neutrophil gelatinase associated lipocalin (NGAL) levels to predict diuretic dose requirement and to predict the occurrence of acute kidney injury (AKI) in patients presenting with acute decompensated HF. METHODS: Patients admitted with HF symptoms between December 2010 and October 2011 were prospectively enrolled. Samples were obtained for NGAL and brain natriuretic peptide. Patients were followed up until discharge or for three days, whichever happened first. They were grouped either to have AKI according to "Acute Kidney Injury Network" criteria or not ("no-AKI"). RESULTS: One hundred patients were enrolled. Urine NGAL levels were higher in AKI group (median 31.3 vs. 16.2 ng/mL) (p < 0.001). Oral furosemide using rates on admission was 60.5% in AKI group, 31.6% in no-AKI group. More AKI developed in patients using less furosemide orally on admission (p = 0.023). Although the mean furosemide doses were similar on the first day (80 mg), diuretic dose increment was less on the following days in AKI group. Urine NGAL levels with 12 ng/mL cut-off value had sensitivity of 79% and specificity of 67% for predicting AKI. Multiple logistic regression analysis yielded an odds ratio of 10.9 for NGAL levels to predict AKI. CONCLUSION: Urine NGAL level in decompensated HF patients was not a significant predictor of diuretic dose requirement, but was a good marker for predicting AKI at 12 ng/mL cut-off value.

A new approach to the analysis of antibiotic resistance data from hospitals.

We aimed to develop a new approach to the analysis of antimicrobial resistance data from the hospitals, which allows simultaneous analysis of both individual- and population-level determinants of bacterial resistance. This was a retrospective cohort study that included adult patients who stayed in the hospital >2 days. We analyzed data using shared frailty Cox models and tested our approach using a priori hypotheses based on biology and epidemiology of antibiotic resistance. For gram-negative bacteria, the use of the major selecting antibiotic by an individual was the main risk factor for acquiring resistant species. Hazard ratios (HRs) were strikingly high for ceftazidime-resistant Enterobacter species (HR=11.17; 95% confidence interval [CI]: 5.67-22.02), ciprofloxacin-resistant Pseudomonas aeruginosa (HR=4.41; 95% CI: 2.14-9.08), and imipenem-resistant P. aeruginosa (HR=7.92; 95% CI: 4.35-14.43). Ward-level use was significant for vancomycin-resistant enterococci (VRE) (HR=1.40; 95% CI: 1.07-1.83) and for imipenem-resistant P. aeruginosa (HR=1.40; 95% CI: 1.08-1.83). Previous incidence of infection in the same ward increased the risk of acquiring methicillin-resistant Staphylococcus aureus (HR=1.22; 95% CI: 1.15-1.30) and VRE (HR=1.53; 95% CI: 1.38-1.70). Our results were consistent with our hypotheses and showed that combining population- and individual-level data is crucial for the exploration of antimicrobial resistance development.

Screening for latent tuberculosis infection in psoriasis and psoriatic arthritis patients in a tuberculosis-endemic country: a comparison of the QuantiFERON®-TB Gold In-Tube test and tuberculin skin test.

Since the introduction of biologic therapies for tuberculosis (TB), screening for latent TB infection has increased in importance, especially in countries in which TB is endemic. The aim of this study was to evaluate the effect of psoriasis on tuberculin skin test (TST) results and to compare two TB screening tests, the TST and QuantiFERON(®)-TB Gold In-Tube (QFT-GIT) test, in psoriasis and psoriatic arthritis (PA) patients living in a TB-endemic country (Turkey). This prospective study included 61 psoriasis and 40 PA patients, and 58 healthy controls. Demographic data, medical history, human immunodeficiency virus (HIV) status, level of education, smoking status, exposure to TB, personal and family histories of TB, and bacillus Calmette-Guérin (BCG) vaccination status were recorded for all participants. The TST and QFT-GIT were performed in all participants. The mean ± standard deviation TST indurations in the patient and control groups were 12.6 ± 6.4 mm and 10.2 ± 6.5 mm, respectively (P = 0.051). The TST positivity rate was higher in patients than in controls (86.1% vs. 37.9%; P < 0.001), whereas QFT-GIT positivity did not differ significantly (patients: 20.8%; controls: 17.2%; P = 0.737). False positive results can lead to unnecessary prophylactic TB treatment; therefore, the cut-off point for TST positivity in psoriasis and PA patients should be re-evaluated, or other tests, such as the QFT-GIT, should be used.

Low seroprevalence of diphtheria, tetanus and pertussis in ambulatory adult patients: the need for lifelong vaccination.

BACKGROUND: Tetanus, diphtheria, pertussis and measles are vaccine preventable diseases that have been reported to cause morbidity and mortality in adult population in the recent years. We aimed to document the seropositivity rates and vaccination indication for these four vaccine preventable diseases among adult and elderly patients who were seen as outpatients in a university hospital. METHODS: Blood samples for tetanus, diphtheria, pertussis and measles antibodies were obtained. Results were evaluated with regards to protection levels and booster vaccine indications according to the cut-off values. RESULTS: A total of 1367 patients consented for the study and 1303 blood samples were available for analysis at the end of the study. The antibody levels against measles conferred protection in 98% of patients. However, 65% of the patients had no protection for diphtheria, 69% had no protection for tetanus and 90% of the patients had no protection for pertussis. Only 1.3% of the study population had seropositivity against three of the diseases-Tdap booster was indicated in 98.7%. Multivariable logistic regression showed that tetanus protection decreased with increasing age. Having a chronic disease was associated with a lower rate of protective antibodies for pertussis. CONCLUSIONS: We demonstrated very low rates of protection against three of the vaccine preventable diseases of childhood-diphtheria, pertussis and tetanus. Booster vaccinations are required in adult life in accordance with national and international adult vaccination guidelines. The concept of "lifelong vaccination" should be implemented and every encounter with the patient should be regarded as a chance for catch-up.

Utilization and comparative effectiveness of caspofungin and voriconazole early after market approval in the U.S.

OBJECTIVES: Both caspofungin and voriconazole were initially approved by the FDA with very narrow indications. Our aim was to evaluate the utilization patterns and comparative effectiveness of these agents early after marketing before any labeling change occurred. METHODS: This was a retrospective cohort study utilizing a large healthcare database in the United States. Patients who received at least one dose of systemic antifungal agent between the years 2001 and 2003 were included. Information was available for each hospital-day including underlying conditions, medications, procedures and disease severity scores. Tests for proportions, trend tests and logistic regression were used for evaluation of utilization. Propensity score analysis was used in comparison of mortality. RESULTS: The study cohort included 381,245 patients with serious underlying conditions. In just two years after marketing, caspofungin and voriconazole use increased to 40% of the total systemic antifungal consumption. However, only 3.4% of caspofungin and 12.5% of voriconazole were used as indicated in labeling. In the propensity score analyses, caspofungin was associated with 7% decrease in mortality (OR: 0.93 95% CI: 0.85-0.98). Voriconazole use was not found to be associated with mortality (OR: 1 . 95% CI: 0.89-1.12). CONCLUSIONS: Caspofungin and voriconazole were mostly used of unapproved indications immediately after their marketing. Although unapproved drug use might be due to a crucial need by clinicians, this may create problems in further antifungal drug development. Our results suggest a survival benefit with caspofungin; however, similar comparative effectiveness studies must be repeated using more recent data.

Risk factors for intensive care unit acquired nasal colonization of MRSA and its impact on MRSA infection.

OBJECTIVE: We aimed to determine the risk factors of methicillin-resistant Staphylococcus aureus (MRSA) colonization, and the impact of colonization on MRSA infection to evaluate the necessity of MRSA survey program in intensive care units (ICUs) in Turkey. METHODS: The patients hospitalized in medical and neurosurgical ICUs longer than 24 hr were included into the study. To determine anterior nares MRSA colonization, swabs were taken from each patient in the first 48 hr, and followed by once a week till discharge from ICUs. RESULTS: During the one-year follow-up period, the number of the hospitalized patients who spent more than 24 hr in ICUs was 195 of 372 and 85 of 619 in medical and neurosurgical ICUs, respectively. Totally, 23 out of 280 patients (14 from medical ICU, 9 from neurosurgical ICU) were colonized with MRSA, and 11 out of 23 colonized patients were accepted as ICU-acquired infection. The duration of ICU hospitalization in patients with ICU-acquired MRSA colonization was found to be longer than the noncolonized patients (18 days vs. 8 days, P value < 0.001). The presence of gastrostomy and femoral catheter were determined as risk factors for ICU-acquired MRSA colonization. The percentages of MRSA infection in patients with and without MRSA colonized were 8.6% and 1.1%, respectively (P value: 0.009). CONCLUSION: The presence of gastrostomy and femoral catheter, and the duration of ICU hospitalization were found to be related with ICU-acquired MRSA colonization. Also, MRSA nares colonization increased the rates of both MRSA infection and ICU hospitalization.

Subclinical infections with Crimean-Congo hemorrhagic fever virus, Turkey.

To investigate Crimean-Congo hemorrhagic fever virus in Turkey, we conducted a seroepidemiologic survey during January-April 2009. Seroprevalence of infection was 10% in a sample from an outbreak region and increased with patient age, indicating that the virus had been previously present in Turkey. We also estimated that 88% of infections were subclinical.

Ribavirin for patients with Crimean-Congo haemorrhagic fever: a systematic review and meta-analysis.

BACKGROUND: Crimean-Congo haemorrhagic fever (CCHF) is a potentially fatal tick-borne infection. The virus is widely distributed around the world and reports of sporadic cases and outbreaks have recently increased significantly. Some authors have proposed that ribavirin improves survival in CCHF and this view appears to be widely accepted. METHODS: We evaluated the efficacy of ribavirin in reducing mortality by conducting a systematic review and meta-analysis. We included randomized controlled trials and observational studies that compared the outcomes of CCHF patients who were treated with ribavirin with those of patients that were not treated. The main endpoint we assessed was survival. We also evaluated secondary endpoints, i.e. adverse events, length of stay in the hospital, time taken for laboratory values to return to normal and requirement for blood products. A pooled estimate of the relative risks for survival from each study was obtained by using random effects models. RESULTS: One randomized controlled trial and seven observational studies met our inclusion criteria. Most observational studies suffered from different types of bias due to inappropriate selection of controls. Compilation of data from all included studies showed that ribavirin did not improve survival in CCHF (relative risk 1.06, 95% confidence interval 0.97-1.16). Analysis of secondary endpoints did not suggest a clinically significant beneficial effect either. CONCLUSIONS: Our systematic review and meta-analysis revealed that the available data in the literature are inadequate to support a claim of efficacy of ribavirin in CCHF. We believe a real uncertainty exists over the benefit of ribavirin in the treatment of CCHF, which necessitates the urgent conduct of a randomized placebo-controlled trial.

Permanent pacemaker and implantable cardioverter defibrillator infections: seven years of diagnostic and therapeutic experience of a single center.

BACKGROUND: Increasing evidence-based indications for the implantation of permanent pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) have led to an increase in the rate of device infections. The aim of the present study was to evaluate infection frequency, clinical characteristics, risk factors, and microbiologic and therapeutic features in patients with PM/ICD infections. HYPOTHESIS: Clinical and demographic characteristics of the patients can affect the PM/ICD infections. METHODS: The PM/ICD infection group consisted of 57 patients diagnosed and treated with PM/ICD infections in our hospital. The control group in this case-control study consisted of 833 patients in whom a PM or ICD had been implanted and no infections were noted. RESULTS: Patients with PM/ICD infections (median age 65 years; range, 18-104 years) were older than those without PM/ICD infections (median age 58 years; range, 18-86 years; P = 0.005). The percentage of generator replacement was higher in the PM/ICD infection group compared with the control group (16% vs 8%, P = 0.003). Independent predictors of PM/ICD infections were advanced age (>60 years; odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.2-4.0, P = 0.021) and device revision (OR: 3.8, 95% CI: 1.5-5.5, P = 0.002). Primary antibiotic prophylaxis during the procedure reduced the risk for PM/ICD infection (OR: 0.5, 95% CI: 0.4-0.8, P = 0.011). CONCLUSIONS: PM/ICD infections occur in a significant number of patients. It is important to be aware of the risk factors for PM/ICD infections so that patients with an increased risk can be identified and preventive measures can be implemented.

Assessment of latent tuberculosis infection in Takayasu arteritis with tuberculin skin test and Quantiferon-TB Gold test.

A possible relationship between Takayasu arteritis (TA) and tuberculosis (TB) has been suggested. An increased frequency of tuberculin skin test (TST) was observed in TA patients. Quantiferon-TB Gold test (QFT) is a new in vitro assay measuring interferon-gamma response to M. tuberculosis antigens and helpful in diagnosing latent TB infection. The aim of this study was to investigate latent TB infection among TA patients by the use of both TST and QFT Gold test. Ninety-four (male/female: 7/87) TA patients fulfilling ACR 1990 TA criteria from three different university hospitals in Turkey and 107 control subjects without inflammatory diseases were included in the study. Data about medical history (TA and TB) were collected for both groups. TST and QFT were performed. TST values > or =5 mm for TA patients and > or =15 mm for controls was accepted as TST positivity. Even though TA group was older (40 +/- 12 vs. 32 +/- 8, P < 0.001), there was no significant difference between TA patients and controls regarding demographic characteristics. Six TA patients and one control had a history of previous TB infection (P = 0.054). Although TST positivity was higher in TA group [55 patients (62.5%) vs. 24 controls (41.4%), P = 0.008], QFT positivity was similar between two groups [21 patients (22.3%) vs. 24 controls (22.4%), P > 0.05]. QFT was negative in two of six TA patients with previous TB history. Rate of latent TB infection in TA patients measured with QFT is no more than controls. QFT seems to be a good and favorable test compared with TST in detecting LTBI in TA.

Galactomannan on the stage: prospective evaluation of the applicability in routine practice and surveillance.

Invasive aspergillosis (IA) presents a diagnostic and therapeutic dilemma for the physicians who take care of the patients with severe underlying diseases and immunosuppression. This study aimed to evaluate the usefulness of serum galactomannan (GM) measurements in the routine practice and surveillance of IA along with possible caveats in diagnosis and treatment. Adult patients with high-risk haematological malignancies admitted to the Internal Medicine wards during the 2-year study period were followed up by daily visits for vital signs, existing or newly developing signs and symptoms, clinical and laboratory findings. Blood samples were analysed for GM levels by the ELISA method at the end of the study period. Data of 58 hospitalisation episodes in 45 patients were analysed. Proven IA was diagnosed in one patient, probable IA was diagnosed in four patients. The sensitivity was 60% and the specificity was 21% when the index cut-off for positivity was accepted as 0.5. The yield of GM testing may be influenced by many variables and each centre should evaluate the usefulness of this test in its own conditions.

Successful outpatient management of pelvic actinomycosis by ceftriaxone: a report of three cases

Pelvic actinomycosis is a chronic granulomatous suppurative disease caused by actinomyces israeli. Intravenous penicillin is the preferred antimicrobial but it requires hospitalization up to one month. An outpatient treatment strategy would be cost effective and a good choice for patients. Here we present three cases in which intramuscular ceftriaxone was successfully used in the outpatient settings following surgery and IV penicillin treatment in the hospital.

Efficacy of oral ribavirin treatment in Crimean-Congo haemorrhagic fever: a quasi-experimental study from Turkey.

OBJECTIVE: The aim of this study was to evaluate the efficacy of oral ribavirin treatment in patients with Crimean-Congo haemorrhagic fever (CCHF). METHODS: In 2004, all patients diagnosed with CCHF were treated with oral ribavirin, however in 2003 none of the CCHF patients had been given treatment due to lack of confirmatory diagnostic information at that time in Turkey. In this study, patients treated with ribavirin in 2004 (n=126) were compared with ribavirin-untreated CCHF patients (n=92) in 2003. Patients only with a definitive diagnosis of CCHF (clinical symptoms plus the presence of specific IgM antibodies against CCHF virus and presence of viral antigen) were included in this study. RESULTS: There was no difference in the case-fatality rate between treated and untreated patients (7.1% vs. 11.9%; P>0.05). A Cox Proportional Hazards regression analysis revealed that altered sensorium and prolonged international normalized ratio were independent predictors of mortality. CONCLUSION: Our results showed that oral ribavirin treatment did not improve the survival rate in CCHF patients. Ribavirin and supportive care are the only available choices for treatment of CCHF patients, but to ascertain the efficacy of ribavirin, more laboratory and observational studies are necessary and ultimately, to elucidate these conflicting results and evaluate the efficacy undoubtedly, a multicenter randomised controlled trial will be needed.