Efflux pump genes and antimicrobial resistance of Pseudomonas aeruginosa strains isolated from lower respiratory tract infections acquired in an intensive care unit.

The aim of this study was to determine the antimicrobial resistance rates and the resistance genes associated with efflux pumps of Pseudomonas aeruginosa strains isolated from the patients who acquired lower respiratory tract infection (LRTI) in intensive care unit (ICU). Fifty P. aeruginosa strains isolated from the lower respiratory tract specimens of the patients who acquired LRTIs in ICU were included in this study. P. aeruginosa strains were isolated from tracheal aspirate (27), bronchoalveolar lavage (14) and sputum (9). The susceptibilities of the isolates were investigated by the disk diffusion method. Multiplex PCR assay was carried out for the detection of 13 antibiotic-resistance genes. Antimicrobial resistance rates of the isolates were found high and the highest resistance rate of the isolates studied was determined against to mezlocillin (50%) followed by norfloxacin (48%), ciprofloxacin (46%), meropenem (40%). Fourty-three isolates (86%) were determined to carry one and more resistance genes. NfxB gene was most often determined in the genes that were investigated. The significant relation between the resistance to cefepime, piperacilline/tazobactam and the mexC gene, that between the resistance to mezlocillin, piperacilline/tazobactam, ceftazidime, cefepime and ampC genes, and that between the resistance to ciprofloxacin, norfloxacin and oprJ, oprN and nfxB genes was identified. Resistance caused by genes for carbapenemases, aminoglycoside-modifying enzymes and other mechanisms were not identified in this study. Understanding the prevalence and mechanism of antimicrobial resistance in P. aeruginosa may help to select empirical therapy for nosocomial LRTIs due to P. aeruginosa in our ICU.

Evaluation of nosocomial infections and risk factors in critically ill patients.

BACKGROUND: Nosocomial infections are one of the most serious complications in intensive care unit patients because they lead to high morbidity, mortality, length of stay and cost. The aim of this study was to determine the nosocomial infections, risk factors, pathogens and the antimicrobial susceptibilities of them in intensive care unit of a university hospital. MATERIAL/METHODS: The patients were observed prospectively by the unit-directed active surveillance method based on patient and the laboratory. RESULTS: 20.1% of the patients developed a total of 40 intensive care unit-acquired infections for a total of 988 patient-days. The infection sites were the lower respiratory tract, urinary tract, bloodstream, wound, and the central nervous system. The respiratory deficiency, diabetes mellitus, usage of steroid and antibiotics were found as the risk factors. The most common pathogens were Enterobacteriaceae, Staphylococcus aureus, Candida species. No vancomycin resistance was determined in Gram positive bacteria. Imipenem and meropenem were found to be the most effective antibiotics to Enterobacteriaceae. CONCLUSIONS: Hospital infection rate in intensive care unit is not very high. The diabetes mellitus, length of stay, usage of steroids, urinary catheter and central venous catheter were determined as the risk factors by the final logistic regression analysis. These data, which were collected from a newly established intensive care unit of a university hospital, are important in order to predict the infections and the antimicrobial resistance profile that will develop in the future.

Inducible nitric oxide synthase and histopathological correlation in chronic viral hepatitis.

BACKGROUND: Chronic liver disorders represent a serious health problem. Nitric oxide (NO) synthesized by inducible nitric oxide synthase (iNOS) can function as an antimicrobial agent able to kill or reduce replication of microorganisms, and plays an important role in immune regulation. This study was undertaken to evaluate the expression of iNOS in chronic viral hepatitis and its relation to histopathology. METHODS: This study included 56 patients with chronic viral hepatitis (38 hepatitis B, 18 hepatitis C). There were 35 men and 21 women with a mean age of 38.6+/-21.731 years. A modified form of the histology activity index (HAI) designed by Ishak and colleagues was used to assess grading and staging of chronic viral hepatitis. The needle biopsy specimens were fixed in 10% formalin and routinely processed. Routine hematoxylin-eosin, periodic acid-Schiff, and reticulin staining, and iNOS immunoperoxidase technique were performed on paraffin-embedded tissues. RESULTS: We demonstrated that all liver samples had a marked iNOS expression, with a diffuse distribution pattern. iNOS consistently labeled mononuclear cells infiltrating portal tracts in all samples. Statistical evaluation of data showed that the iNOS expression correlated with the HAI and fibrosis. Furthermore a correlation between iNOS and severity of disease was detected (r=0.772, p=0.000). CONCLUSIONS: Further investigations are required to determine whether iNOS-related treatment protocols could be useful in reducing disease severity.

Antibacterial activity of propolis against MRSA and synergism with topical mupirocin.

OBJECTIVES: The aim of the present study was to investigate the activity of the propolis and its combinations with mupirocin against methicillin-resistant Staphylococcus aureus (MRSA) in nasal carriage. METHODS: This study was carried out between June and August 2005. To infect nares of the rabbits, MRSA (ATCC 33591) strain was used. Minimum inhibitory concentration was determined according to National Committee for Clinical Laboratory Standards. Each inoculum was prepared in the same medium at a density adjusted to a 0.5 McFarland turbidity standard (10(5) colony-forming units [cfu]/mL) and diluted 1:100 for the broth microdilution procedure. Ten microliters (10 microL) (10(5) cfu/mL) of the bacterial suspension containing approximately 1000 cfu of MRSA was administered with sterile microsyringe through both nostrils of each rabbit. Ninety-six (96) hours after inoculation, the presence of infection was confirmed by using bacterial cultures. Twenty-six young New Zealand rabbits were randomly divided into 4 groups. Each treatment group (1, 2, and 3) included 7 rabbits and control group (group 4) included 5 rabbits. Group 1 was treated with topical mupirocin + ethanolic extract of propolis drops, group 2 received topical mupirocin, group 3 was administered ethanolic extract of propolis drops, and the control group (group 4) was only treated with phosphate-buffered solution drops for 7 days. At the end of study, nasal cultures and smears were obtained for bacterial count and cytologic examination. RESULTS: The colony numbers of bacteria in group 1 were determined to be significantly lower than in group 2 (p = 0.0001), group 3 (p = 0.0001), and group 4 (p = 0.0001). The mean bacterial cell counts of groups 1-4 were 360.2 +/- 52.4 cfu/mL, 4120.6 +/- 860.4 cfu/mL, 5980.8 +/- 1240.6 cfu/mL, and 11500.0 +/- 2568.4 cfu/mL, respectively. Mupirocin + propolis administration (group 1) resulted in a significant reduction in the polymorphonuclear leukocyte (PMNL) count in the mucous membranes of rabbits compared with the other treatment groups (p < 0.05). CONCLUSIONS: Propolis addition to mupirocin regimen was found to result in more profound reduction in bacterial cell count and inflammatory response compared with the rest of the treatment modalities.

Cutaneous manifestations in brucellosis: a prospective study.

Brucellosis remains an important public health problem in Turkey, just as it is in other regions of the world. This study was conducted to determine the types and rates of cutaneous lesions that occur in patients with brucellosis. Brucellosis was diagnosed by standard tube agglutination testing for Brucella antibodies at a titer of 1/160 or higher in the presence of compatible clinical findings. A total of 140 patients who had been given a diagnosis of brucellosis were prospectively observed in the dermatology clinic. Of these patients, 102 (72.9%) were female, with a mean age of 44.11+/-18.22 y, and 38 (27.1%) were male, with a mean age of 46.44+/-14.58 y. The duration of symptoms was less than 2 mo (acute) in 75 patients (53.5%), from 2 to 12 mo (subacute) in 30 patients (21.4%), and longer than 12 mo (chronic) in 35 patients (25.0%). Cutaneous findings related to brucellosis were observed in 8 (5.71%) of the 140 cases. Maculopapular eruptions were observed in 2 patients (25%), erythema nodosum-like lesions in 2 (25%), psoriasiform lesions in 1 (12.5%), palmar erythema in 1 (12.5%), malar eruption in 1 (12.5%), and palmar eczema in 1 (12.5%). The investigators concluded that although cutaneous findings encountered in brucellosis are generally not specific to this disease, the presence of these findings may be useful in diagnosing brucellosis in persons who live in, or used to live in, endemic regions.

Causes of nosocomial pneumonia and evaluation of risk factors in a university hospital in Turkey.

OBJECTIVE: To determine the incidence, risk factors, mortality rate, and organisms causing nosocomial pneumonia (NP). METHODS: We carried out this study in the Intensive Care Units (ICUs), General Medical and Surgical wards of Baskent University, Training and Research Hospital in Adana, Turkey, between November 2000 and August 2002. Patients were observed from the time of admission until 48 hours after discharge from the hospital. RESULTS: In this study, 618 (2.1%) nosocomial infections (NIs) were detected in 29778 patients. One hundred and fifteen of these infections were NP and investigated with surveillance prospectively. The most frequently isolated microorganisms in NP were methicillin-resistant Staphylococcus aureus (MRSA) 32.8%, Pseudomonas species 21.5%, methicillin-sensitive Staphylococcus aureus (MSSA) 10.2%, Klebsiella species (9.1%) and Acinetobacter species 5.9%, E. coli; 5.4% (10/186), Streptococcus species; 4.8% (9/186), Candida species; 4.8% (9/186), Enterobacter species; 2.7% (5/186) and the other bacteria; 2.7%. The predominant pathogens isolated in this study were MRSA (33.8%), Pseudomonas species (16.9%) and MSSA (16.9%) in early-onset pneumonias and MRSA (32.2%), Pseudomonas species (24.0%), and Klebsiella species (10.7%) in late-onset pneumonias. CONCLUSION: This study demonstrated that the possibility of developing NP, significantly increases with such risk factors as decreased level of consciousness, respiratory failure, mechanical ventilation and tracheostomy. Each center should know its patients' profile, the factors that increase the infection, the antibiotic resistance patterns of microorganisms, and the distribution of hospital infections in every department. Strategies to prevent both development of antibiotic resistance and spread of resistant organisms are necessary.

[Falciparum malaria originating in foreign country: four cases]. / Yurtdisi kökenli Plasmodium falciparum sitmasi: dört olgu sunumu.

Malaria has been commonly determined in tropical and subtropical regions and the Plasmadium (P.) vivax generally occurs in our country, Turkey. However, in the people who have been travelling abroad from Turkey P. falciparum and P. malaria were also detected. The diagnosis was confirmed by microscopy of Giemsa stained thin and thick blood slides in four cases, at a magnification of 1000. The diagnosis of four cases was made by seeing the gametocytes of P.falciparum in thin blood films. The cases were found in Hatay region and the patients are those working abroad. The cases are presented in order to emphasize on the necessity of giving education on public health and taking the precautions for the prevention of the disease and in order to draw attention to malaria diseases caused by different species from abroad and to the fact that it can be seen in local cases as well.

Epidemiologic, clinical, and imaging findings in brucellosis patients with osteoarticular involvement.

OBJECTIVE: The aim of this study was to assess the epidemiologic and clinical features, complications, imaging findings, and outcomes for brucellosis patients with osteoarticular involvement. SUBJECTS AND METHODS: This prospective study was performed over 4 years (December 2000-December 2004). The subjects were 251 Turkish patients (age range, 2-77 years) who were diagnosed with brucellosis during that period. Joint sonography, radiography, radionuclide bone scintigraphy, and MRI were performed in all patients with osteoarticular and spinal manifestations. RESULTS: The disease was acute in 92 patients (36.7%), subacute in 48 patients (19.1%), and chronic in 111 patients (44.2%). Sonography of the joints showed bursitis in 13 patients (5.2%). Radiography, MRI, and scintigraphy revealed 71 patients (28.3%) with sacroiliitis, 26 (10.4%) with spondylodiskitis, three (1.2%) with acute osteomyelitis, and one (0.4%) with avascular necrosis of the femoral head. All patients received combinations of either two or three antibiotics. Surgery was performed in three patients with spinal instability or radiculopathy. CONCLUSION: Brucellosis is endemic to some regions. MRI is the method of choice for diagnosing osteoarticular and spinal complications of human brucellosis, especially during the early phase. It is important to differentiate tuberculous spondylodiskitis from brucellar spondylodiskitis because proper treatment for each of these diseases can prevent complications. The radiologic findings for these two forms of spondylodiskitis are similar, so serologic testing for brucellosis is necessary in such cases.

Clinical pattern and abdominal sonographic findings in 251 cases of brucellosis in southern Turkey.

OBJECTIVE: The aim of this study was to report the clinical features, complications, abdominal sonographic findings, and treatment outcomes for a series of brucellosis cases in southern Turkey. SUBJECTS AND METHODS: This prospective study involved 251 patients (age range, 2-77 years) who were hospitalized with brucellosis during a 4-year period. Patients were classified as having acute (< 3 months), subacute (3-12 months), or chronic (> 12 months) disease. Physical, laboratory, and abdominal sonographic findings were analyzed. RESULTS: The disease was acute in 92 cases (36.7%), subacute in 48 (19.1%), and chronic in 111 (44.2%). Sonographic examination of the abdomen showed enlarged periportal lymph nodes in 23 patients (9.2%), splenomegaly in 21 (8.4%), hepatomegaly in 15 (6%), pleural effusion in 7 (2.8%), splenic abscesses in 4 (1.6%), splenic cysts in 2 (0.8%), acute appendicitis in 2 (0.8%), and acute acalculous cholecystitis in 1 patient (0.4%). The main hematologic and biochemical manifestations were anemia, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and elevated transaminase levels. All patients were treated with combinations of either two or three antibiotics. Surgery was performed in the patients with acute appendicitis, acute cholecystitis, and multiple splenic cysts. CONCLUSION: Brucellosis is endemic to Turkey. Sonographic examination is the method of choice for diagnosing abdominal complications of human brucellosis. This disease should be included in the differential diagnosis for any patient with enlarged periportal lymph nodes. The specific treatment regimen and duration of therapy should be based on sites of organ involvement and complications.

Filariasis in a child from southern Turkey: a case report.

Filariasis is a parasitic condition in which the lymphatic system is invaded by filarial nematodes. The initial signs are those of lymphangitis and lymphadenitis. The manifestations include edema in the extremities and elephantiasis due to lymphatic obstruction. Filariasis is endemic to most parts of the world, but occurs only sporadically in Turkey. This report describes a case of filariasis in a child who presented with fever and extensive lower-extremity edema.

[Strongyloides stercoralis in a patient complaining of chronic diarrhea]. / Kronik diyare yakinmasi olan bir hastada Strongyloides stercoralis.

In this study, a case of Strongyloides stercoralis infection in a 38-year-old patient with complaints of chronic diarrhea and stomach ache is presented. His history showed that the patient who has been a mechanic for 25 years is a farmer as well. S. stercoralis larvae were found during the parasitological examination of the patient's stool samples taken 3 times. The patient was given Albendazol (400 mg a day) for fifteen days. After the patient started to take Albendazol, there was a reduction in the number of parasites in the stool examined on the fifth day. In the stool examinations made on the tenth day, fifteenth day and after the treatment ended, no parasites were seen. When the treatment was completed, all the complaints of the patient disappeared. It was found that no investigation of parasitic infection had been made previously and he had been given different treatments. For this reason, it is important to investigate the possibility of parasitic infection in patients with chronic diarrhea.

An unusual case of ruptured distal anterior cerebral artery aneurysm associated with brucellosis.

Reports have noted aneurysmal dilatation of arteries in association with brucellosis, but involvement of intracranial vessels has not been documented to date. Sixty-one year old female patient who had been diagnosed with brucellosis 14 months earlier presented with symptoms of subarachnoid hemorrhage (SAH). Due to deterioration of the patient's clinical condition in spite of a two-drug antibiotic regimen, she was treated surgically and made a full recovery. It is important to identify this association promptly, as there are clinical implications for optimal management. The article also discusses the timing and duration of antibiotic therapy, indications for and considerations regarding surgery, and the use of other treatment modalities.

Scintigraphic findings in osteoarticular brucellosis.

AIMS: To describe the distribution of bone and joint involvement in 197 patients with brucellosis, and to detail a spectrum of findings on bone scintigraphy in 38 patients with brucellar spondylitis. METHODS: One hundred and ninety-seven patients (141 females, 56 males; age range, 5-77 years) with osteoarticular brucellosis were studied. Patients were classified into acute (62%) and chronic (38%) stages of the disease, and into age groups of less than 16 (1%), 16-30 (17%), 31-45 (29%), 46-60 (37%) and over 60 (16%) years. All patients were evaluated with Tc-methylene diphosphonate bone scanning. Quantification of sacroiliac joint uptake was performed to improve the sensitivity for the detection of sacroiliitis. Plain radiography and computed tomography (CT) or magnetic resonance imaging (MRI) were performed, when required, to evaluate the areas of the skeleton that showed abnormal uptake on the bone scan. MRI and single photon emission computed tomography (SPECT) were performed in all patients who had spinal lesions. RESULTS: The sites most commonly affected were the sacroiliac joints (53%) and spine (19%), followed by the shoulders (16%). Osteoarticular involvement was more common in females (72%) than in males (28%), and the acute stage (62%) was observed more than the chronic stage (38%). Bone and joint involvement occurred at any age, but the most common age group was 46-60 years. Eight scintigraphic patterns were identified in spinal involvement. CONCLUSION: Brucellosis may affect the musculoskeletal system at any site. Bone scan is a useful method to detect osteoarticular involvement in cases of relapse and progression. Spine involvement has the widest range of scintigraphic findings. A knowledge of the location and distribution of osteoarticular involvement as revealed on the bone scan of patients with brucellosis may be valuable in patient treatment and management.

Hydatid disease with atypical localization: 4 cases report.

Hydatid disease caused by Echinococcus often manifests as slowly growing cystic mass and mainly affects the liver or lung and rarely other parts of the body such as brain, heart, bone and muscle. Cyst may be single or multiple, uni-or multiloculated. In this paper 4 hydatic cases, multiple and atypically localized are presented. Of the 4 cases, 2 were known to suffer from hydatid disease, having had a hepatic cyst removal previously. Thus, when faced with a hydatid cyst in any part of the body, it is preferable to examine other parts of the body by radiological imaging methods.

Ticlopidine-induced marrow aplasia treated with cyclosporine.

A 50-year-old diabetic and hypertensive male patient is reported who had ticlopidine-induced marrow aplasia partially responsive to colony-stimulating factors and corticosteroids, but experienced complete recovery with cyclosporine. There is no consensus on the treatment of ticlopidine-induced marrow aplasia. Although many cases are reported to recover with colony-stimulating factors and corticosteroids, others are unresponsive or partially responsive. Our patient also did not completely respond to these medications, but was successfully treated with cyclosporine alone. Alone or in combination with corticosteroids, cyclosporine is an effective drug of choice for the resistant patients.