Spread of carbapenem-resistant international clones of Acinetobacter baumannii in Turkey and Azerbaijan: a collaborative study.

Epidemic clones of Acinetobacter baumannii, described as European clones I, II, and III, are associated with hospital epidemics throughout the world. We aimed to determine the molecular characteristics and genetic diversity between European clones I, II, and III from Turkey and Azerbaijan. In this study, a total of 112 bloodstream isolates of carbapenem-resistant Acinetobacter spp. were collected from 11 hospitals across Turkey and Azerbaijan. The identification of Acinetobacter spp. using conventional and sensitivity tests was performed by standard criteria. Multiplex polymerase chain reaction (PCR) was used to detect OXA carbapenemase-encoding genes (bla OXA-23-like, bla OXA-24-like, bla OXA-51-like, and bla OXA-58-like). Pulsed-field gel electrophoresis (PFGE) typing was used to investigate genetic diversity. The bla OXA-51-like gene was present in all 112 isolates, 75 (67 %) carried bla OXA-23-like, 7 (6.2 %) carried bla OXA-58-like genes, and 5 (4.5 %) carried bla OXA-24-like genes. With a 90 % similarity cut-off value, 15 clones and eight unique isolates were identified. The largest clone was cluster D, with six subtypes. Isolates from clusters D and I were widely spread in seven different geographical regions throughout Turkey. However, F cluster was found in the northern and eastern regions of Turkey. EU clone I was grouped within J cluster with three isolates found in Antalya, Istanbul, and Erzurum. EU clone II was grouped in the U cluster with 15 isolates and found in Kayseri and Diyarbakir. The bla OXA-24-like gene in carbapenemases was identified rarely in Turkey and has been reported for the first time from Azerbaijan. Furthermore, this is the first multicenter study in Turkey and Azerbaijan to identify several major clusters belonging to European clones I and II of A. baumannii.

The features of infectious diseases departments and anti-infective practices in France and Turkey: a cross-sectional study.

The aim of this study was to assess the infectious diseases (ID) wards of tertiary hospitals in France and Turkey for technical capacity, infection control, characteristics of patients, infections, infecting organisms, and therapeutic approaches. This cross-sectional study was carried out on a single day on one of the weekdays of June 17-21, 2013. Overall, 36 ID departments from Turkey (n = 21) and France (n = 15) were involved. On the study day, 273 patients were hospitalized in Turkish and 324 patients were followed in French ID departments. The numbers of patients and beds in the hospitals, and presence of an intensive care unit (ICU) room in the ID ward was not different in both France and Turkey. Bed occupancy in the ID ward, single rooms, and negative pressure rooms were significantly higher in France. The presence of a laboratory inside the ID ward was more common in Turkish ID wards. The configuration of infection control committees, and their qualifications and surveillance types were quite similar in both countries. Although differences existed based on epidemiology, the distribution of infections were uniform on both sides. In Turkey, anti-Gram-positive agents, carbapenems, and tigecycline, and in France, cephalosporins, penicillins, aminoglycosides, and metronidazole were more frequently preferred. Enteric Gram-negatives and hepatitis B and C were more frequent in Turkey, while human immunodeficiency virus (HIV) and streptococci were more common in France (p < 0.05 for all significances). Various differences and similarities existed in France and Turkey in the ID wards. However, the current scene is that ID are managed with high standards in both countries.

Comparison of colistin-carbapenem, colistin-sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections.

The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7%): colistin-carbapenem (CC), 69 (32.2%): colistin-sulbactam (CS), and 43 (20.1%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (p = 0.97) and microbiological (p = 0.92) outcomes and 14-day survival rates (p = 0.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (p > 0.05) and also for 14-day survival (p > 0.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (p = 0.02, p = 0.0001, p = 0.0001, p = 0.02, and p = 0.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (p < 0.0001, p < 0.0001, and p = 0.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.

Control of an Acinetobacter [corrected] baumannii outbreak in a neonatal ICU without suspension of service: a devastating outbreak in Diyarbakir, Turkey.

BACKGROUND: A nosocomial outbreak of Acinetobacter baumannii bloodstream infections (Ab-BSI) was identified in Diyarbakir Children's Hospital's (Diyarbakir, Turkey) 60-bed Neonatal Intensive Care Unit (NICU) in 2006 and 2007. METHODS: The investigation and control of the outbreak were based on case-control and epidemiological studies as well as multifaceted interventions. Sixty-four neonates (case patients) with Ab-BSI and 128 neonates (control patients) free of Ab-BSI, who had been hospitalized at the unit during the outbreak period, were included in the study. Case and control patients were compared for possible predisposing factors (e.g., gender, length of NICU stay, antibiotic use, intubation, etc.). An intervention program (cohorting, education, reinforcing hand hygiene, antibiotic restriction, improving processes of patient care, environmental cleaning, and barrier isolation) was implemented to control the outbreak. Surveillance cultures were collected from all possible sources, and the epidemiological investigation was supplemented by a pulsed field gel electrophoresis (PFGE) study. RESULTS: Fifty-three neonates (82.8%) died in the case group and 51 (39.8%) in the control group (P < 0.001). The duration of stay at the NICU [odds ratio (OR) 1.15; 95% confidence interval (CI) 1.07-1.23; P < 0.001] and re-intubation (OR 38.62; CI 12.66-117.87; P < 0.001) were found to be significant risk factors for Ab-BSI. Surveillance cultures showed a heavy contamination in the NICU, and the outbreak ended after a series multifaceted interventions. All A. baumannii isolates, both from the cases and environmental samples, had an identical PFGE fingerprint pattern. CONCLUSION: The control of Ab-BSI requires a multifaceted intervention program and complex efforts and implementations, especially if the ICU does not implement any suspension of care provision.

Extended-spectrum beta-lactamases in ceftazidime-resistant Escherichia coli and Klebsiella pneumoniae isolates in Turkish hospitals.

PURPOSE: To study the prevalence of TEM-, SHV- and GES-type beta -lactamases among Escherichia coli and Klebsiella pneumoniae strains having ceftazidime MICs higher than 2 mg/L. METHODS: A total of 63 E. coli and 41 K. pneumoniae isolated from five different university hospitals were studied for the existence of TEM-, SHV- and GES-type beta -lactamases. Susceptibility tests were carried out according to the criteria of National Committee for Clinical Laboratory Standards. MICs were obtained by agar dilution method. Existence of extended-spectrum beta -lactamases (ESBLs) were assessed by double-disc synergy test (DDST). Existence of the above-mentioned beta -lactamase genes were studied both by PCR with specific oligonucleotide primers and isoelectric focusing methods. RESULTS: None of the isolates were carbapenem-resistant. DDSTs were positive in 50 (79.3%) and 33 (80.5%) of E. coli and K. pneumoniae , respectively. TEM gene was detected in 41 (65.1%) and 19 (46.3%), whereas SHV gene in 18 (28.6%) and 20 (48.8%) of E. coli and K. pneumoniae strains, respectively. GES genes were not detected. CONCLUSIONS: TEM and SHV genes are highly prevalent among ESBL-producing E. coli and K. pneumoniae , whereas GES-type ESBLs are absent and found not to be responsible of ceftazidime resistance in Turkish hospitals.

Risk factors for typhoid fever among adult patients in Diyarbakir, Turkey.

We conducted a case-control study to assess risk factors for typhoid fever in Diyarbakir, Turkey, a region where transmission of Salmonella typhi is endemic. We prospectively identified febrile patients from Diyarbakir and the surrounding area who were admitted to hospital. Cases were defined as patients who had S. typhi isolated from at least one blood culture. Sixty-four cases with blood culture-confirmed S. typhi were identified between May 2001 and May 2003. In total, 128 age- and sex-matched controls selected from neighbourhoods as cases were enrolled. We hypothesized that consumption of raw vegetables contaminated with sewage would be associated with an increased risk of typhoid fever. Conditional logistic regression modelling revealed that living in a crowded household (OR 3.31, 95% CI 1.58-6.92, P=0.002), eating cig kofte (a traditional raw food) (OR 5.29, 95% CI 2.20-12.69, P=0.000) and lettuce salad (OR 3.55, 95% CI 1.52-8.28, P=0.003) in the 15 days prior to symptoms onset was independently associated with typhoid fever. We conclude that living in a crowded household and consumption of raw vegetables outside the home increase the risk of typhoid fever in this region.

Molecular epidemiology of invasive Salmonella typhi in southeast Turkey.

The objective of this study was to determine the molecular epidemiology of Salmonella typhi isolates from patients with typhoid fever in southeast Turkey and to determine the relationship between the clinical strains and environmental subtypes. Both demographic and clinical data were obtained by chart review and compared to the molecular subtyping results.

Tuberculous meningitis in adults in Turkey: epidemiology, diagnosis, clinic and laboratory [corrected].

A retrospective study was performed to assess the epidemiology, diagnosis, clinic, and laboratory of the patients with tuberculous meningitis (TBM) in a multicentral study. The medical records of adult cases with TBM treated at 12 university hospitals throughout Turkey, between 1985 and 1998 were reviewed using a standardized protocol. The diagnosis of TMB was established with the clinical and laboratory findings and/or microbiological confirmation in cerebrospinal fluid (CSF). The non-microbiologically confirmed cases were diagnosed with five diagnostic sub-criteria which CSF findings, radiological findings, extra-neural tuberculosis, epidemiological findings and response to antituberculous therapy. A total of 469 patients were included in this study. Majority of the patients were from Southeast Anatolia (164 patients, 35.0%) and (108 patients, 23.0%) from East Anatolia regions. There was a close contact with a tuberculous patient in 88 of 341 patients (25.8%) and with a tuberculous family member in 53 of 288 patients (18.4%). BCG scar was positive in 161 of 392 patients (41.1%). Tuberculin skin test was done in 233 patients and was found to be negative in 75. Totally 115 patients died (24.5%) of whom 23 died in 24 hour after admittance. The diagnosis was confirmed with clinical findings and CSF culture and/or Ziehl-Nelson staining in 88 patients (18.8%). Besides clinical criteria, there were three or more diagnostic sub-criteria in 252 cases (53.7%), two diagnostic sub-criteria in 99 cases (21.1%), and any diagnostic sub-criteria in 30 patients (6.4%). Since TBM is a very critical disease, early diagnosis and treatment may reduce fatal outcome and morbidity.

Predictors of outcome in patients with tuberculous meningitis.

OBJECTIVE: To assess predictors of mortality and neurological sequelae in patients with tuberculous meningitis (TBM). METHODS: Patients with TBM treated at 12 university hospitals in Turkey between 1985 and 1997 were evaluated using a standardised protocol applied retrospectively. Variables associated with hospital mortality as well as with the presence of neurological sequelae at 6 months were determined using logistic regression models. RESULTS: Four hundred and thirty-four patients between the ages of 13 and 83 years (mean 33 years) were evaluated. Sixty-eight per cent of these patients presented with Medical Research Council Stage II or III. One hundred and one patients (23.3%) died and 67 (27%) of evaluable survivors had neurological sequelae. In multi-variable analysis, convulsion (OR 3.3, 95%CI 1.2-9.0, P = 0.02), comatose mental status (OR 6.0, 95%CI 3.6-10.2, P = 0.01), and delayed or interrupted treatment (OR 5.1, 95%CI 2.4-11.2, P = 0.01) were shown to be predictors for mortality. The presence of extra-meningeal tuberculosis (OR 2.1, 95%CI 1.1-4.2, P = 0.035), cranial nerve palsy (OR 2.6, 95%CI 1.4-4.2, P = 0.01), hemiparesia/focal weakness (OR 9.3, 95%CI 3.8-22.6, P = 0.01), hemiplegia/multiple neurological deficit (OR 7.1, 95%CI 2.14-23.38, P = 0.01) and drowsiness (OR 4.2, 95%CI 2.04-8.82, P = 0.01) were independent predictors of neurological sequelae at 6 months following hospital discharge. CONCLUSION: The results of this study emphasise the importance of prompt and uninterrupted anti-tuberculosis therapy for tuberculous meningitis. The presence of seizures or coma on admission to hospital are important predictors for mortality, while the presence of focal neurological signs is a predictor for persistent neurological sequelae in survivors.

Spinal subdural tuberculous abscess.

OBJECTIVES: Spinal subdural abscess is rare and only 48 cases have been described to date. In this report, we present an additional spinal subdural tuberculous abscess. METHOD: Tuberculous meningitis was diagnosed with clinical and laboratory findings in a 45-year-old man. A spinal subdural abscess was demonstrated using MRI. Presence of the abscess was revealed by surgical intervention. The diagnosis was confirmed by pathological examination. RESULTS: The patient had been treated for tuberculous meningitis 2 years previously. The disease recurred when anti-tuberculous therapy was prematurely discontinued. During the second treatment, the patient also underwent a ventriculo-peritoneal shunt operation for hydrocephalus. Dizziness and weakness of both legs developed after the postoperative period. Spinal MRI showed a spinal subdural abscess as a iso-intense mass with spinal cord in the T1 and T2 weighted images, ring like enhancement and compression on the spinal cord at T3-T4 level. The patient underwent surgery and the abscess was drained. CONCLUSION: Tuberculosis may cause a spinal subdural abscess and although it is a rare disorder, when encountered MRI is very useful in the diagnosis.

The complications of chronic otitis media: report of 93 cases.

The aim of this study was to investigate the incidence, mortality and morbidity of complications due to chronic otitis media (COM). During the nine-year period 1990-1999, 2890 cases of COM were reviewed, 93 (3.22 per cent) having 57 (1.97 per cent) intracranial complications (IC) and 39 (1.35 per cent) extracranial complications (EC). In three patients more than one complication was observed. Meningitis and brain abscess were common in the IC group. Subperiosteal abscess (mastoid and Bezold's abscess) was a common complication in the EC group. Cholesteatoma and granulation/polyp in the middle ear/mastoid were the major findings in both groups. Fifteen patients died from IC. Overall, the mortality rate was 16.1 per cent in all patients having complications, and in patients with IC it was 26.3 per cent. In all of the patients with complications, the morbidity rate was 11.8 per cent. Our study supports the finding that meningitis and brain abscess are the common complications of COM and the main reason for mortality.

CT of the brain in tuberculous meningitis. A review of 289 patients.

PURPOSE: In this retrospective study, CT findings of 289 patients with tuberculous meningitis (TBM) are presented and diagnostic criteria are discussed. MATERIAL AND METHODS: The medical records of patients who were diagnosed as having central nervous system tuberculosis were investigated. Cranial CT investigations of 289 patients with TBM were reviewed. Of these 289 patients, 214 were children and 75 adults; 157 patients were male and 132 were female. CT images were obtained with and without i.v. contrast administration. RESULTS: CT findings were normal in 35 patients and abnormal in 254. The abnormalities were hydrocephalus (172 children, 32 adults), parenchymal enhancement (56 children, 6 adults), contrast enhancement of basal cisterns (32 children, 17 adults), cerebral infarct and focal or diffuse brain edema (29 children, 10 adults), and tuberculoma (9 children, 5 adults). CONCLUSION: CT is pathologic in the great majority of patients with TBM and is helpful in assessing the complications associated with the disease.

Tuberculous meningitis in adults: an eleven-year review.

OBJECTIVE: To assess the presentation, diagnosis and outcome of patients with tuberculous meningitis (TBM). DESIGN: The medical records of adults with TBM who were treated at Dicle University Hospital between January 1985 and October 1996 were reviewed. RESULTS: In total, 101 patients were identified and stratified according to the stage of disease at presentation. The mean duration of the symptoms of TBM before admission was 12 days. The majority of patients had headaches (96.0%), fever (91.1%), nuchal rigidity (91.1%), vomiting (81.2%), meningism (79.2%) and abnormal mental state (72.3%). The mean cerebrospinal fluid (CSF) leukocyte count was 0.38 x 10(9)/L, protein 1410 mg/L, glucose 2.0 mmol/L and CSF/blood glucose ratio 27%. Cranial computerized tomography (CT) scans were performed during the course of TBM in 64 patients. The results were normal in 6.3%, and abnormal in 93.7% of the cases; the most frequent abnormality found on CT was hydrocephalus (45.3%). Forty-four patients (43.5%) died. Minor neurological sequelae developed in 11 patients (10.9%), major sequelae in 10 (9.9%), and 31 patients (30.7%) completely recovered. There was no follow-up for five patients (5.0%). Five factors were important in predicting fatal outcome: stage III at presentation, low glucose levels, low CSF/blood glucose ratio, high protein levels, and CT scanning abnormality. CONCLUSION: TBM is a very critical disease in terms of fatal outcome and permanent sequelae: 43.5% of the patients died and only 30.7% experienced complete recovery. Early treatment may reduce fatal outcome and morbidity.

Acute bacterial meningitis in adults: analysis of 218 episodes.

A retrospective study was conducted to examine the laboratory, clinical features and outcome of 206 adult acute bacterial meningitis patients (218 episodes) during the years 1985-1996. Pneumonia (8.7 per cent), head trauma (7.8 per cent) and chronic otitis media (6.0 per cent) were identified as the main predisposing factors for acute bacterial meningitis. Aetiology was described only in 61 episodes (28.0 per cent). Streptococcus pneumonia was the most commonly identified pathogen overall, causing 33 of the 218 episodes (15.2 per cent). Antibiotic treatment before admission was given to 48.4 per cent of patients. On admission, the following symptoms of meningitis were predominant: 83 per cent had neck stiffness, 81 per cent had a headache and 73 per cent had fever. Case fatality rate was 27.1 per cent (59 patients). The important factors in mortality were as follows: old age, a long duration of symptoms before admission, a lack of neck stiffness, obtunded mental state on admission, low glucose levels in first CSF, low CSF/blood glucose ratio, and abnormality in computerised tomography scanning.

Recurrent bacterial meningitis: a 6-year experience in adult patients.

Ten adult patients with recurrent bacterial meningitis (RBM) of 22 episodes were diagnosed and treated at the Dicle University Hospital from January 1990 to December 1995. Apart from 22 episodes of RBM these patients had an additional 25 episodes treated at other hospitals. The RBM attacks developed after closed head trauma in four patients, asplenia and chronic otitis media in one patient, chronic otitis media and oto-mastoiditis in one patient, chronic maxillary sinusitis in one patient, chronic mastoiditis in one patients, and suppurative foci of facial bones caused by shrapnel pieces and no predisposing condition in one patient. In 10 RBM episodes, Streptococcus pneumoniae was isolated from cerebrospinal fluid (CSF) and/or blood culture, and in one episode Proteus vulgaris was isolated from CSF and otitis media suppuration. In the four episodes both cultures were negative, but direct microscopy showed Gram-positive diplococci on Gram-staining. Three of the patients died from meningitis-related complications.

Effects of nimodipine on the cerebrovascular and neuronal changes during pneumococcal meningitis in the rat.

It was investigated whether treatment with the calcium channels blocker Nimodipine, a 1,4-dihydropyridine derivative, influences vasculopathy and neuronal injury in experimental pneumococcal meningitis. Rats were randomly assigned to one of three experimental groups. The first group (Control group, n = 20) was given saline (0.4 ml/day) intraperitoneally (i.p.), whereas the second group (group C, n = 22) was treated only with ceftriaxone in a dosage of 30 mg/day/i.p.. The third group (group C-N, n = 22) was treated with the combination of ceftriaxone 30 mg/day/i.p., and nimodipine 0.6 mg/day/i.p.. Treatment was begun at the time of inoculation in all three groups. The control group was compared clinically and histopathologically with groups C and C-N at 24 h, three and six days after inoculation. Six rats in the control group and eight rats in group C and group C-N were sacrificed at 24 hours and seven rats in each group were sacrificed on the third and sixth day after inoculation. Clinically, there were no significant differences between group C and group C-N (p>0.05). There were significant differences between group C and group C-N for vasculopathy and neuronal injury (p < 0.0001 and p < 0.005, respectively).