A review of the current place of glycopeptides in turkish medical practice

BACKGROUND

Glycopeptide antibiotics are considered by many investigators to be the last resort in the treatment of gram-positive bacterial infections.

OBJECTIVE

The aim of this review was to assess the place of glycopeptides in the treatment of common gram-positive bacteria in accordance with the current epidemiologic data in Turkey.

METHODS

A search of both the English- and Turkish-language literature indexed on MEDLINE, Ulakbim (Turkey), and Pleksus (Turkey) was performed using the terms: vancomycin, teicoplanin, and glycopeptides, or their Turkish-language counterparts. The complete texts of the articles found in these databases were obtained from the electronic library of Gulhane Medical Academy, Ankara, Turkey. Articles from regional journals, without the support of an electronic format, were obtained by direct communication. Articles of interest were those based on studies occurring in Turkish populations, with special consideration given to publications in press after 2002.

RESULTS

Staphylococci were the most frequent gram-positive pathogens encountered in Turkish hospitals. Studies have found that ∼74% of strains were Staphylococcus aureus and the remaining strains were coagulase-negative staphylococci (CoNS). Overall methicillin resistance in staphylococci was reported as ∼60%. In Turkey, S aureus was one of the most common infectious agents found inside hospitals and is deemed a growing threat in the community. While the rate of methicillin resistance in community-acquired isolates is ∼4%, the data from hospitals suggest that reduced resistance comprises most of the isolates. In the studies reviewed, older quinolones like ciprofloxacin and ofloxacin seem to be ineffective in nearly half of the S aureus isolates. Alternatives like rifampicin, gentamicin, tetracycline, trimethoprim/sulfamethoxazole (TMP/SMX), clindamycin, and erythromycin have had substantial resistance profiles in >50% of the strains. In recent Turkish studies, in vitro profiles of linezolid, quinupristin/dalfopristin (QD), and daptomycin have had positive results. As in the S aureus isolates, resistance trends have been observed in the CoNS group of pathogens. The possible use of β-lactams seems restricted, and alternative approaches have become necessary. Quinolones, gentamicin, tetracycline, TMP/SMX, clindamycin, and erythromycin have resistance profiles of >50%. Although glycopeptide resistance was not detected, the frequency of heterogenous vancomycin-intermediate S aureus, a precursor to future resistance, was 13% in 1 study. Current studies in Turkey have found that Enterococcus faecalis comprises three quarters of enterococci while the rest are comprised of Enterococcus faecium. Initial studies performed with linezolid, QD, and daptomycin suggest that these drugs might be effective alternatives for future enterococcal infections that may have high glycopeptide resistance. Approximately 8% of the Streptococcus pneumoniae strains had high-level resistance in Turkey. However, 10 million units of crystallized penicillin or 3 g of oral amoxicillin maintains the optimum treatment of pneumococcal infections outside the central nervous system (CNS). Resistance profiles in third-generation cephalosporins in Turkey range between 2% and 2.5%.

CONCLUSIONS

In Turkey, a review of the existing literature found that the current use of glycopeptides in pneumococcal infections is restricted to CNS infections facing therapeutic failure in due course. However, the belief that these drugs are the last resort, either in staphylococcal or enterococcal infections, is no longer valid. If a patient has a critical status due to probable gram-positive microorganisms, clinicians should consider the empiric use of glycopeptides. However, new molecules such as linezolid, QD, and daptomycin, offered for use in the treatment of gram-positive bacterial diseases, should be reserved for the future, when glycopeptides eventually become obsolete.

Kikuchi-Fujimoto Disease: analysis of 244 cases

Kikuchi-Fujimoto Disease (KFD) was first described in Japan in 1972. The disease frequently mimics tuberculous lymphadenitis, malign lymphoma, and many other benign and malignant conditions. To our knowledge, there is no previous study comparing the clinical and laboratory characteristics of patients from different geographical parts of the world. We searched literature records beginning from 1991 and analyzed epidemiological, clinical, and laboratory data of 244 patients (including cases diagnosed in our institution) reported in 181 publications. Of the 244 cases, 33% were male and 77% were female. Mean age was 25 (1-64) and 70% was younger than 30. Most of the cases were reported from Taiwan (36%), USA (6.6%), and Spain (6.3%). Fever (35%), fatigue (7%) and joint pain (7%) were the most frequent symptoms, while lymphadenomegaly (100%), erythematous rashes (10%), arthritis (5%), hepatosplenomegaly (3%), leucopenia (43%), high erythrocyte sedimentation rate (40%), and anemia (23%) being the most common findings. KFD was associated with SLE (32 cases), non-infectious inflammatory diseases (24 cases), and viral infections (17 cases). SLE was more frequent in cases from Asia than Europe (28 and 9%, respectively). The disease was self-limiting in 156 (64%) and corticosteroid treatment was necessary in 16 (16%) of the cases. The mortality rate was 2.1%. Early diagnosis is crucial as the clinical and laboratory presentation generally imitates situations needing lengthy and costly diagnostic and therapeutic interventions. Additionally, association with SLE needs further investigation.

Tuberculous meningitis with multiple intracranial tuberculomas mimicking neurocysticercosis clinical and radiological findings

Central nervous system (CNS) tuberculosis (TB), the most dangerous form of TB, remains a public health problem, particularly in developing countries. In the differential diagnosis of intracranial tuberculomas (ICTs), images on radiological findings should be differentiated from other causes of space-occupying lesions. These lesions include malignant diseases such as glioma or lymphoma, pyogenic abscess, toxoplasmosis, neurocysticercosis (NC), sarcoidosis, hydatidosis and late syphilitic involvement of CNS. We present a case with multiple ICTs mimicking NC with similar clinical and imaging manifestations in a young immunocompetent patient. The diagnosis was based on brain magnetic resonance imaging findings. The definitive diagnosis was confirmed mycobacteriologically in cerebrospinal fluid and sputum specimens. Adequate response to anti-TB chemotherapy was achieved while multiple ICTs in the brain disappeared slowly. In the absence of appropriate therapy, these pathologies might be fatal; the possibilities of differential diagnosis would be of great clinical importance, particularly because of the different treatment protocols required for the NC and ICTs.

Comparison of silver-coated dressing (Acticoat), chlorhexidine acetate 0.5% (Bactigrass), and fusidic acid 2% (Fucidin) for topical antibacterial effect in methicillin-resistant Staphylococci-contaminated, full-skin thickness rat burn wounds

Acticoat, chlorhexidine acetate 0.5%, and fusidic acid 2% were compared to assess the antibacterial effect of an application on experimental 15% BSA, full-thickness burn wounds in rats swabbed 24 h earlier with a 10(8) standard strain of methicillin-resistant Staphylococci. The swabbed organism was recovered from the eschar of all groups except the fusidic acid group. While there were significant differences between treatment groups and control group, the mean eschar concentrations did not differ significantly between the Acticoat and chlorhexidine acetate groups, but there were significant differences between the fusidic acid group and the other treatment groups. There were no statistically significant differences between treatment groups, and between control group and the chlorhexidine acetate group regarding recovery of the seeded organism from muscle, but there were significant differences between the control group and Acticoat group, and between control the group and the fusidic acid group. While no systemic spread was seen in the treatment groups, it was seen in six animals in the control group. The animal data suggest that fusidic acid is the most effective agent in the treatment of methicillin-resistant Staphylococcus aureus-contaminated burn wounds, and Acticoat is a choice of treatment with the particular advantage of limiting the frequency of replacement of the dressing.

Effects of a major earthquake on blood donor types and infectious diseases marker rates

This observational study attempted to identify the effect of a natural disaster on the safety of blood supply and donor types with the influx of donors after a severe earthquake. Blood donation rate, blood discard rate and safety of blood donations responding to the earthquake, as projected from the infectious disease marker rate, were evaluated in blood donated immediately before (1 July-17 August) and after 17 August 1999 (17 August-21 August). These were compared with the results from the corresponding periods in 1998 and 2000 for donations at a university medical centre and two regional blood centres. 8055 units of allogeneic blood were collected at two regional blood centres, and 450 units were collected at a university medical centre during 4 days. Viral marker rates were nearly the same at the former but were slightly lower at the latter. The blood discard rate was nearly twice the comparative periods at the former, but it remained unchanged at the latter. Voluntary donors replaced the replacement donors during 4 days. This analysis highlights the size of the pool of potential donors that are available as a national resource that can be motivated to give blood with the right motivation.

Splenic complications in malaria: report of two cases from Turkey

Malaria is still a major health problem in Turkey, where Plasmodium vivax malaria is endemic. Spontaneous rupture of the spleen is an important and life-threatening complication and occurs in up to an estimated 2 % of cases. Hence the small number of case reports suggests under-reporting or underdiagnosis. Review articles have reported only 18 malaria cases with spontaneous splenic rupture in the English language literature since 1960. Two cases of P. vivax malaria with splenic complications are reported here. One of them showed signs and symptoms of acute abdominal pain, then splenic rupture occurred.

A Case of Recurrent Subcutaneous Emphysema as a Complication of Endotracheal Intubation

We describe a case of subcutaneous cervicofacial emphysema in a 21-year-old man who had undergone endotracheal intubation while under general anesthesia 2 months earlier. The emphysema had arisen on the right side of the face and neck and extended to the right shoulder and the cubital fossa. The patient was hospitalized and treated with parenteral antibiotics and hyperbaric oxygen. On hospital day 10, he had improved sufficiently to warrant discharge on the next day. Two months later, the patient presented at a follow-up visit with a recurrence, and he was readmitted. By hospital day 28, his condition had improved and he was scheduled for discharge. However, he experienced another recurrence just before he was to leave the hospital. The circumstances of this second recurrence led us to suspect that the patient was able to produce these signs and symptoms on his own. He was referred for psychiatric evaluation, and findings were negative. He was then sent to the Ear, Nose, and Throat Service, where we confirmed that his subcutaneous emphysema could be brought on by Valsalva's maneuver. We performed suspension laryngoscopy and detected two orifices of fistular tracts next to the right vallecula and three at the root of the epiglottis. We repaired the injured mucosa and the orifices of the fistulae with absorbable sutures and cauterized the area. The swelling resolved completely within 4 days, and findings on a radiographic examination of the chest and neck 1 week later were normal. The patient was then lost to follow-up. The presence of air in the retropharyngeal and cervical subcutaneous spaces of the neck and shoulder without pneumomediastinum is an uncommon complication of endotracheal intubation. We discuss the clinical and radiographic findings associated with this complication, and we review diagnostic considerations and management.

A case of recurrent subcutaneous emphysema as a complication of endotracheal intubation

We describe a case of subcutaneous cervicofacial emphysema in a 21-year-old man who had undergone endotracheal intubation while under general anesthesia 2 months earlier. The emphysema had arisen on the right side of the face and neck and extended to the right shoulder and the cubital fossa. The patient was hospitalized and treated with parenteral antibiotics and hyperbaric oxygen. On hospital day 10, he had improved sufficiently to warrant discharge on the next day. Two months later, the patient presented at a follow-up visit with a recurrence, and he was readmitted. By hospital day 28, his condition had improved and he was scheduled for discharge. However; he experienced another recurrence just before he was to leave the hospital. The circumstances of this second recurrence led us to suspect that the patient was able to produce these signs and symptoms on his own. He was referred for psychiatric evaluation, and findings were negative. He was then sent to the Ear Nose, and Throat Service, where we confirmed that his subcutaneous emphysema could be brought on by Valsalva's maneuver. We performed suspension laryngoscopy and detected two orifices of fistular tracts next to the right vallecula and three at the root of the epiglottis. We repaired the injured mucosa and the orifices of the fistulae with absorbable sutures and cauterized the area. The swelling resolved completely within 4 days, and findings on a radiographic examination of the chest and neck 1 week later were normal. The patient was then lost to follow-up. The presence of air in the retropharyngeal and cervical subcutaneous spaces of the neck and shoulder without pneumomediastinum is an uncommon complication of endotracheal intubation. We discuss the clinical and radiographic findings associated with this complication, and we review diagnostic considerations and management.

Seroprevalence of tetanus antibody in Turkish population and effectiveness of single-dose tetanus toxoid

The study presented here was performed to determine the rates of immunity to tetanus in a cross section of the Turkish population and to assess the impact of a single-dose tetanus toxoid in previously unvaccinated individuals. Among 18-year-old participants who received their last tetanus booster 4 years prior to the study and 22-year-old participants who received the booster 8 years previously, certain durable protective antibody (>1 IU/ml) was detected in 100%. However, only 3.3% of 20-year-old participants who did not know whether they had been vaccinated as children or young adults had a protective antibody level. After administering a single dose of tetanus vaccine to this group, the rate of protective antibody increased from 3.3% to 96.7%. For the prevention of tetanus, the optimal policy should focus on improving rates of complete primary immunization in adults and children and giving a single booster every 10 years, or at least at age 40 or 50 years.

Seroprevalences of hepatitis B and C among health care workers in Turkey

We determined the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) among health care workers (HCWs) at Gülhane Military Medical Academy, Haydarpasa Training Hospital in Istanbul, Turkey. Between April 1998 and September 2000, 702 HCWs were included in the study. The blood samples were tested for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs) and HCV antibody (anti-HCV) using third-generation tests, with confirmation by reverse transcriptase-polymerase chain reaction. Seroprevalence rates were compared with those detected in 5670 blood donors during the same period. HBsAg, anti-HBs and anti-HCV were detected in 21 (3.0%), in 480 (68.4%) and in 2 (0.3%) of 702 HCWs respectively. HBsAg and anti-HCV rates were 2.1 and 0.4% in blood donors, respectively. These data show that the prevalence rates of HBV and HCV were similar with prevalence rates detected in randomized blood donors showing that universal infection-control precautions and encouraging HBV vaccination reduces HCW infection with hepatotropic viruses.

Comparison of silver sulfadiazine 1%, mupirocin 2%, and fusidic acid 2% for topical antibacterial effect in methicillin-resistant staphylococci-infected, full-skin thickness rat burn wounds

Silver sulfadiazine 1%, mupirocin 2%, and fusidic acid 2% were compared to assess the antibacterial effect of a once-daily application on experimental rat 15% full-skin thickness burn wounds seeded 24 hours earlier with a 10 standard strain of methicillin-resistant staphylococci. The quantitative counts of seeded organism in burn eschar and subjacent muscle were determined at postburn day 7, beside the cultures of blood and lung biopsies. All tested topical agents were equally effective against methicillin-resistant in reducing local burn wound bacterial count and preventing systemic infection.

The evaluation of nosocomial infection during 1-year-period in the burn unit of a training hospital in Istanbul, Turkey

An analysis of the burned patients, admitted to our eight bed burn unit and treated between 1 January and 31 December 2000, was performed. Prevalence, etiologic agents, length of hospitalization, cost of treatment and mortality rates caused by nosocomial infections (NIs) were studied. The study included 63 patients. Eighteen of these (Group-A) had 24 NI episodes. The most common NI observed was burn-wound infection (58.3%), followed by bacteraemia-sepsis (16.7%). NIs were not detected in the rest at all (Group B). The mean length of hospitalization was 38.5+/-19.7 days in Group A, and 20.3+/-7.6 days in Group B. The mean total burned surface area (TBSA) was 43+/-21 in Group A and 29+/-18 in Group B, while the most important independent risk factor for NI was TBSA in burned patients (OR, 1.08; CI(95), 0.93-1.24). NI prolonged the mean hospital stay to 18 days and increased the cost of treatment by 502 US dollars. The most common bacteria isolated was Pseudomonas aeruginosa (41.7%) and the second was methicillin resistant Staphylococcus aureus (MRSA-25.0%). All of the NI-free patients survived, while, five (28.5%) patients with NI died (P<0.01). These findings emphasized the need for careful disinfection and conscientious contact control procedures in areas that serve immunosupressed individuals, such as burned patients.