BLOODSTREAM INFECTIONS ASSOCIATED WITH INTENSIVE CARE UNIT AT A MULTIPROFILE HOSPITAL, TBILISI, GEORGIA.

Bloodstream infections (BSIs) are associated with a high mortality rate, additional hospital days and excess hospital costs. Intensive Care Unit (ICU) patients are at high risk of nosocomial BSIs because of their weakened condition caused by underlying disease, frequent invasive diagnostic and therapeutic procedures. Catheterization is the most common cause of hospital-acquired BSIs. The major causes of catheter-related BSI (CRBSI) are microorganisms from the patient's and medical personnel's skin and contamination of the catheter hub. From July 1, 2015 through June 30, 2016, were collected blood cultures from patients fulfilling the criteria for systemic inflammatory response syndrome in a tertiary care hospital ICU in Tbilisi. Blood culturing procedures and techniques and antimicrobial susceptibility testing, following methods set out by EUCAST. From microbiologically studied 84 blood samples 21 (25%) were positive for growth, 19 (90.5%) samples were monomicrobial, whereas 2 (9.5%) samples were polymicrobial. On the basis of microbiological, clinical and epidemiological data 21 patients were diagnosed as ICU associated BSI. Among them 16 (76.2%) patients were diagnosed primary BSI and CLABSI, four (23.8%) patients - secondary BSI; three of them were caused with ventilator-associated pneumonia, one - with catheter-associated urinary tract infection. The most common microorganism isolated from ICU associated BSI cases were Coagulase-negative staphylococci (30,4%), A. baumannii (21.7%) and K. pneumoniae (17.4%). Preventing BSIs should be a priority for hospitals and for this they must be introduced to modern methods infection prevention and control.

EPIDEMIOLOGY OF CARBAPENEM-RESISTANT KLEBSIELLA PNEUMONIAE IN INTENSIVE CARE UNITS OF MULTIPROFILE HOSPITALS IN TBILISI, GEORGIA.

Klebsiella pneumoniae is one of the most frequent cause of health care associated infections. Dissemination of carbapenem-resistant (CR) K. pneumoniae infections significantly trend toward patient morbidity, length of stay and mortality. The aim of this research was to study prevalence and risk-factors of CR K. pneumoniae in Georgia. To identify risk factors for hospital-acquired carbapenem-resistant (CR) K. pneumoniae, from January 1, 2017 through February 28, 2018, an observational case-control study was performed in the ICUs of two tertiary-care hospitals in Tbilisi (High Medical Technology Centre and Ghudushauri National Medical Centre). All isolated K. pneumoniae cultures were tested on antibiotic susceptibility tests (AST). AST was performed by disk diffusion methods and E-test for MIC detection. For the first time CR K. pneumoniae isolates were screened for the presence of KPC, VIM, IMP, NDM and OXA carbapenemase in a PCR. Totally, 46 cultures of K. pneumoniae were isolated. Among them 20 (43.5%) were resistant to carbapenems. Most frequently CR K. pneumoniae cultures were isolated in patients with ventilator associated pneumonia (75%). Main risk factors of carbapenem-resistant from invasive procedures were: mechanical ventilation (OR 30.4, 95% CI 3.504-263.752, p=0.0003), nasogastric tube (OR 17.0, 95% CI 3.202-90.257, p=0.0002), central venous catheter (OR 10.06, 95% CI 1.152-87.849, p=0.028) and previous use of antibiotics (OR 10.059, 95% CI 1.152-87.849, p=0.028), especially carbapenem and 3rd generation cephalosporin. Predominant is OXA-producing K. pneumoniae, NDM-producing K. pneumoniae is relatively rare. To control dissemination of CR K. pneumoniae infection prevention and control should be toughened in medical facilities, and screening for early detection of patients with CR K. pneumoniae should be done.

EFFECTIVE TREATMENT OF CHRONIC HEPATITIS C VIRUS INFECTIONS WITH DIRECT ACTING ANTIVIRALS IN PRISONS SYSTEM.

Hepatitis C is a widespread infectious disorder, accounting for chronic hepatic inflammatory condition - hepatitis, hepatic cirrhosis and hepatocellular carcinoma throughout the world. In Georgia, where the incidence of HCV infection in population is highest among eastern European countries, hepatitis C represents one the most actual problems of healthcare system. The aim of the study was to identify the efficacy of antiviral therapy and management of side effects in HCV infected patients. In the patients under observation with type I genotype, the rapid viral response (RVR) was negative in 100%. End of treatment response (EOT) was negative in 100%, and stable viral response (SVR) was negative in 99.3%. In patients with type II genotype the rapid viral response (RVR) was negative in 100%, end of treatment response (EOT) was negative in 100% and stable viral response (SVR) was negative in 100%. In patients with type III genotype: the rapid viral response (RVR) was negative in 100%. End of treatment response (EOT) was negative in 100% and stable viral response (SVR) was negative in 97%. Thus, HCV infection is widespread in correction department institutions. According to our study results, the final outcomes of antiviral treatment completed within the frames of this program, side effects developed during the course of treatment and their management are not significantly different from the results of antiviral treatment conducted in other population. Regardless of different psychological setting present in this type of institutions, this program is ongoing successfully and the observed results indicate on the importance of its continuation.

COMBINED ANTIVIRAL TREATMENT OF HEPATITIS C VIRUS INFECTION WITH PEGYLATED INTERFERON (PEG-IFN) Α-2A (PEGFERON) AND RIBAVIRIN (COPEGUS) IN INMATES.

The aim of the study was to assess the impact of combined antiviral therapy in prisoners with HCV. In total, 210 patients with chronic C hepatitis have been observed. The patients were divided into 3 groups according to HCV genotype: Group I: - 70 patients infected with genotype 1a/1b; Group II: - 70 patients infected with genotype 2a/2b; Group III: - 70 patients infected with genotype 3a. As for the patients with genotype I: RVR - rapid virological response was negative in 100%; EVR - early virological response was negative in 99%; EOT - end of treatment results was negative in 94% and SVR- sustained virologic response was negative in 91%. In patients with genotype II: RVR - rapid virological response was negative in 100%, EVR - early virological response was negative in 99%, EOT - end of treatment results was negative in 96% and SVR-sustained virologic response was negative in 91%. In patients with genotype III: RVR - rapid virological response was negative in 100%, EVR - early virological response was negative in 94%, EOT - end of treatment results was negative in 94% and SVR- sustained virologic response was negative in 93%. According to our observations, side effects and their management, do not differ significantly from the antiviral therapy in other populations. Despite the differences in psychological conditions, which is common for this type of institutions, the program is having beneficial effects and the obtained results justify expedience of continuation as it will not only improve quality of life in prisoners but also reduce medical costs related to disease progression and prevent further dissemination of hepatitis C as inside of penal institutions/prisons as well as throughout the country.

EPIDEMIOLOGY OF CLINICALLY MANIFESTED ACUTE HEPATITIS C CASES IN GEORGIA.

Hepatitis C virus is responsible for the majority of persistent viral infections of the liver, chronic hepatitis, liver cirrhosis and/ or hepatocellular carcinoma. Two strategies are important to curtailing the rising prevalence of disease: efficient diagnosis of acute hepatitis and identification of the likely mode of transmission. The aim of this study was to identify the clinical and epidemiological hallmarks of acute hepatitis C. During 2013-2015, 31 patients were hospitalized with a diagnosis of acute C hepatitis. According to epidemiological data, the primary mode of transmission is during medical procedures, responsible for 14 (45.16%) of cases, followed by injection drug use 3 (9.7%) of cases and sexual transmission - 2 (6.43%) of cases. However, in 12 (38.71%) of cases the infected individual was unable identify the likely source of infection. Given that nearly half of all cases arise from nosocomial infection, it is imperative that infection control practices be reviewed and resources provided to prepare a sterile environment for patients and health care providers.

EPIDEMIOLOGY, CLINICAL AND LABORATORY FEATURES OF CRIMEAN-CONGO HEMORRHAGIC FEVER IN GEORGIA.

Crimean-Congo hemorrhagic fever virus transmitted to humans by Hyalomma ticks or by direct contact with the blood of infected humans or domestic animals. The most common clinical signs of CCHF are fever, nausea, headache, diarrhea, myalgia, petechial rash, and bleeding. CCHF is a severe disease in humans with a fatality rate up to 15-85%. This study was undertaken to determine the predictors of fatality among patients with CCHF based on epidemiological, clinical, and laboratory findings. 34 patients were enrolled in the study, aged 4 to 77; 17 - male and 17 female. 3 of them were fatal cases. All of them were from Shua Kartli: Khashuri, Gori and Kaspi districts, involved in farming/handling livestock and the history of tick bite was present in most of patients. Evaluation of the epidemiological characteristics of this cases showed that the female to male ratio was nearly similar. The disease is common in the rural areas of the region, mostly in the actively working age group and almost all patients were farmers. The results of our study show that the most cardinal clinical and laboratory features of Crimean-Congo hemorrhagic fever are - acute beginning of disease, high fever, intoxication and hemorrhagic symptoms, thrombocytopenia, high level of aminotransferases and creatine. Predictors of fatality are: an altered mental status, in early stage of disease dramatic decreased thrombocytes count and significantly high level of aspartate aminotransferase, also longer the mean prothrombin time and INR.

Clinical and epidemiological peculiarities of hemorrhagic colitis complicated by hemolytic-uremic syndrome.

The aim of the research: identification of etiological structure of acute diarrheas and hemorrhagic colitis in Georgia, manifestation of clinical peculiarities and predictors of hemorrhagic colitis complicated by HUS ( Hemolytic-Uremic syndrome). In 2011-2013 we studied 274 hospitalized patients at the Center of Infectious Diseases, AIDS and Clinical Immunology (160 hemorrhagic colitis and 114 non-bloody diarrhea). Causative agents of hemorrhagic colitis (160 patients) were determined in 110 (69%) cases; etiology of the non-bloody diarrhea (114 patients) was established in 46 (40%) cases. Enteronterohaemorrhagic E. coli (EHEC) strains are major causes of hemorrhagic colitis. For the confirmation of STEC infection by the bacteriological investigation some significant additional methods were used: serologic examination of feces on shiga- toxin molecular markers by ImmunoCard STAT and PCR methods. Thus, these above mentioned investigations contribute to diagnosis STEC infection at the early stage of the disease. Based on our findings we were able to reveal predictors of complications of hemorrhagic colitis by HUS. They include: Delayed hospitalization, rural residents, premorbid background, onset of the disease with low-grade fever accompanied with abdominal cramps, manifestation of bloody diarrhea on the 2-3-rd days of the disease, frequent bowl movement (>20 times a day), development of oliguria and edema on the following days, leucocytosis in hemogram, elevation of LDH, creatinine and urea, hypoalbuminemia and development of ascites.

[Insulin resistance disturbances in patients with HCV infection].

The aim of investigation was to study the impact of insulin resistance in patients with HCV infection. 130 patients were investigated: 20 with acute hepatitis C; 38 with chronic hepatitis C; 72 with cirrhosis. The study demonstrated, that the serum level of C-peptide and Insulin in patients with liver cirrhosis is higher, than in patients with acute and chronic HCV infection. This is necessary the monitoring of patients with insulin resistance, which will contribute to the prevention of complications and can improve patients' quality of life.

The role of interleukin-10 in patients with HCV infection.

The aim of investigation was to study cytokine-producing ability of blood immune cells in type of viral hepatitis C, correlation with the degree of hepatic lesion and liver cirrhosis. 130 patients were investigated: 72 with cirrhosis: among them 10 - with stage A, 14 - with stage B and 48 - with stage C. The study demonstrates significant changes of cytokine-producing ability of blood immune cells type of viral hepatitis C, correlation with the degree of hepatic lesion and liver cirrhosis. The results showed that various types of chronic viral hepatitis C and stages of cirrhosis were associated with misbalance in production of anti-inflammatory cytokine, i.e. a significant rise of interleukin-10 concentration, which were the most prominent in cases of severe hepatic lesion.

[HOMA-IR in patients with chronic hepatitis C].

The aim of investigation was to study the frequency of IR in type of viral hepatitis C, correlation with the degree of hepatic lesion and liver cirrhosis. 130 patients were investigated: 20 with acute hepatitis C; 38 with chronic hepatitis C; 72 with cirrhosis: among them 10 with Stage A, 14 with Stage B and 48 with Stage C. Also we used 30 healthy people as the controls. The study demonstrates significant changes of insulin, glucose, HOMA-IR type of viral hepatitis C, correlation with the degree of hepatic lesion and liver cirrhosis. In patients with liver cirrhosis levels of HOMA-IR is higher than in patients with chronic hepatitis C. In patients with acute hepatitis C levels of HOMA-IR was normal as in the control group. The results showed that various types of chronic viral hepatitis C and stages of cirrhosis set to increase HOMA-IR versus the controls., which were the most prominent in cases of severe hepatic lesion, which indicates that insulin resistance is a frequent companion of CHC.

The serum level of interleukin-12 among patients with HCV infection.

The aim of investigation was to study cytokine-producing ability of blood immune cells in type of viral hepatitis C, correlation with the degree of hepatic lesion and liver cirrhosis. 130 patients were investigated: 20 with acute hepatitis C; 38 with chronic hepatitis C; 72 with cirrhosis: among them 10 with Stage A, 14 with Stage B and 48 with Stage C. Also we used 30 healthy people as the controls. The study demonstrates significant changes of cytokine-producing ability of blood immune cells type of viral hepatitis C, correlation with the degree of hepatic lesion and liver cirrhosis. The serum contents of IL-12 in chronic HCV patients is higher than in patients with acute HCV infection and in patients with liver cirrhosis The results showed that various types of acute, chronic viral hepatitis C and stages of cirrhosis were associated with misbalance in production of proinflammatory cytokine, i. e. a rise of interleukin-12 concentration versus the controls., which were the most prominent in cases of severe hepatic lesion.

Enterohemorrhagic E. coli and hemolytic uremic syndrome in Georgia.

It is important to consider that between Jul-October 2009 in the pathologic center of infectious diseases (Tbilisi State Medical University Department of Infectious Diseases) among hospitalized patients with hemorrhagic colitis 25 patients developed HUS syndrome. Most of patients were rural residents 20 (80%), only 5 (20%) were urban. 11 (44%) patients were children, 14 (56%) were adults. Male and female rate was equal. All the patients related the onset of the disease with the consumption of notwashed raw fruits or vegetables, nonpasteurized dairy products, food from street vendors, soft cheeses made from raw milk and untreated water in areas lacking adequate chlorination. The onset of the disease was not acute: low grade fever (37,5-37,8(0)C), severe diffuse pain in abdomen accompanied with cramps, frequent bowel movement with loose, watery stools 5-6 times a day. On the 2-3rd days of disease condition was worsened by increased of intoxication and frequent bowel movement with bloody stools about 10-15-20 times a day. On the 3-4 rd days of the onset of the diarrhea developed oliguria, anuria, edema. Among other complications important were: polyserosit - 8 (32%), encephalopathy - 2 (8%), disseminated intravascular coagulation - 3 (14%), ileus -1 (4%,) acute reactive phsycosis - 1 (4)%. In 15 (60%) cases became necessary to carry out hemodialysis. died 5 patients, lethality is - 5 (20%). Treatment options included: pathogenetic and symptomatic. Thus, increased rate of patients in the recent years indicates to circulation of shiga-toxin producing E.Coli in Georgia.

[Side effects of the combined antiviral therapy in patients with chronic hepatitis C].

The aim of the study is to reveal and treat the side effects of the combined antiviral therapy - Peginterferon and Ribavirin in patients with chronic Hepatitis C. During 2004-2006 years, 40 patients in the ambulatory department of the Infectious Diseases Clinic of the State Medical University were investigated. All the patients were administered pegilated interferon and ribavirin after special procedures. The following side effects on the antiviral treatment were grouped: flu-like, cardiovascular, gastrointestinal, neuro-psychiatric, dermatological and hematological. Frequency, severity and duration of all unfavorable symptoms were independent of Hepatitis C genotype, though the adherence to the medications was better in younger age groups and the dose correction where required after the age 45.

Hemopoetic organs damage syndrome in patients with chronic viral hepatitis.

Liver cirrhosis and hepatocellular carcinoma are the most frequent and severe complications of chronic hepatitis C. Results of recent investigations indicate that HCV persists and replicates not only in hepatic tissue, but in the other organs as well. The goal of our investigation was to determine hematological disorders during chronic HCV and HCV+HBV hepatitis, to find correlation between activity of chronic hepatitis, stage of cirrhosis, and degree of hematological disorders. We have studied patients with chronic C and B+C hepatitis (36 persons) and 77 HCV-infected persons on the stage of cirrhosis. The erythrocytes morphology was investigated using light microscope. The osmotic resistance of erythrocytes was investigated using the method of Ianovski (modification of Ribiera); the thrombocytes' ability to adhere and aggregate was studied by Rite's method. The absolute number of thrombocytes was counted by means of phase-contrast microscope. Our investigation suggests that there is no absolute correlation between chronic hepatitis C activity and hematological disorders and often the degree of extrahepatocellular disorders is higher than the degree of liver damage.

[Immunologic aspects of acute viral hepatitis at different ages]. / Immunologicheskie aspekty ostrykh virusnykh gepatitov u bol'nykh razlichnogo vozrasta.

Patients of different age, among them 103 with viral hepatitis B and 120 with viral hepatitis A, were examined for immunoregulatory subpopulations of T lymphocytes and for the effects of HBsAg preparations and human liver-specific lipoprotein (LSL) on the blood E-RFC content. The patients of both mature and elderly age with viral hepatis A demonstrated insignificant, readily reversible alterations in cellular immunity. The patients with viral hepatitis B, particularly elderly ones, showed an evident tendency toward the predominance of the suppressor effects, which correlated with the disease gravity. During incubation of lymphocytes with HBsAg, the stimulating effect was mostly revealed. However, in elderly patients experiencing the stage of late convalescence, there was an increase in HBsAg-specific suppression depending on the disease gravity. The suppressive action of LSL was only recorded in single cases.