Portraying infective endocarditis: results of multinational ID-IRI study

Infective endocarditis is a growing problem with many shifts due to ever-increasing comorbid illnesses, invasive procedures, and increase in the elderly. We performed this multinational study to depict definite infective endocarditis. Adult patients with definite endocarditis hospitalized between January 1, 2015, and October 1, 2018, were included from 41 hospitals in 13 countries. We included microbiological features, types and severity of the disease, complications, but excluded therapeutic parameters. A total of 867 patients were included. A total of 631 (72.8%) patients had native valve endocarditis (NVE), 214 (24.7%) patients had prosthetic valve endocarditis (PVE), 21 (2.4%) patients had pacemaker lead endocarditis, and 1 patient had catheter port endocarditis. Eighteen percent of NVE patients were hospital-acquired. PVE patients were classified as early-onset in 24.9%. A total of 385 (44.4%) patients had major embolic events, most frequently to the brain (n = 227, 26.3%). Blood cultures yielded pathogens in 766 (88.4%). In 101 (11.6%) patients, blood cultures were negative. Molecular testing of vegetations disclosed pathogens in 65 cases. Overall, 795 (91.7%) endocarditis patients had any identified pathogen. Leading pathogens (Staphylococcus aureus (n = 267, 33.6%), Streptococcus viridans (n = 149, 18.7%), enterococci (n = 128, 16.1%), coagulase-negative staphylococci (n = 92, 11.6%)) displayed substantial resistance profiles. A total of 132 (15.2%) patients had cardiac abscesses; 693 (79.9%) patients had left-sided endocarditis. Aortic (n = 394, 45.4%) and mitral valves (n = 369, 42.5%) were most frequently involved. Mortality was more common in PVE than NVE (NVE (n = 101, 16%), PVE (n = 49, 22.9%), p = 0.042).

Brucellosis in pregnancy: results of multicenter ID-IRI study

Brucellosis in pregnant women is reported to be associated with obstetric complications (OCs), and adequate data for human brucellosis during pregnancy are largely lacking. We performed this multicenter retrospective cross-sectional study to evaluate the epidemiology, clinical course, treatment responses, and outcomes of brucellosis among pregnant women. The study period comprised a 14-year period from January 2002 to December 2015. All consecutive pregnant women diagnosed with brucellosis in 23 participating hospitals were included. Epidemiological, clinical, laboratory, therapeutic, and outcome data along with the assessment data of the neonate were collected using a standardized questionnaire. Data of 242 patients were analyzed. The OC rate was 14.0% (34/242) in the cohort. Of the 242 women, 219 (90.5%) delivered at term, 3 (1.2%) had preterm delivery, 15 (6.2%) aborted, and 5 (2.1%) had intrauterine fetal demise. Seventeen (7.0%) of the newborns were considered as low birth weight. Spontaneous abortion (6.1%) was the commonest complication. There were no maternal or neonatal deaths and pertinent sequelae or complications were not detected in the newborns. Splenomegaly (p = 0.019), nausea and/or vomiting (p < 0.001), vaginal bleeding (p < 0.001), anemia (blood hemoglobin < 11 g/dL; p < 0.001), high level of serum aspartate aminotransferase (> 41 IU/L; p = 0.025), oligohydramnios on ultrasonography (p = 0.0002), history of taking medication other than Brucella treatment during pregnancy (p = 0.027), and Brucella bacteremia (p = 0.029) were the significant factors associated with OCs. We recommend that pregnant women with OC or with fever should be investigated for brucellosis if they live in or have traveled to an endemic area.

Hepatitis C testing among adults born between 1945 and 1965 in Turkey: a multicentre study

OBJECTIVE

Hepatitis C virus (HCV) infection is a major public health problem and affects large populations all over the world. Serum anti-HCV level is a valuable marker to determine HCV infection. Anti-HCV testing has been recommended for high-risk population. The Center for Disease Control (CDC) and Prevention in the United States proposed a new high-risk population group - adults born between 1945-1965. Under this perspective, we designed a multicentre retrospective study to determine the seropositivity of anti-HCV among adults born between 1945 and 1965 and adults born after 1965 in Turkey. With the data collected, we aimed to determine whether there was a need for anti-HCV testing especially in people born between 1945 and 1965.

METHODS

We requested data from ten different medical centres in ten different provinces. Each medical centre collected the anti-HCV test results of adult patients for five-year period between 2009 and 2014 from hospital records.

RESULTS

A total of 974,449 anti-HCV test results were included in this study. When the seropositivity rates in the two groups of adults were compared, anti-HCV seropositivity rates were higher in nine medical centres out of ten. Anti-HCV seropositivity in adults born between 1945-1965 was significantly higher than in adults born after 1965 (p < 0.05).

CONCLUSIONS

We determined that the anti-HCV seropositivity rate is significantly higher in adults born between 1945-1965 compared to the younger adults as indicated in the literature. According to data from this study together with the WHO and CDC suggestions, we believe that it is appropriate to offer anti-HCV serology testing for people over 50 years of age since the anti- HCV seroprevalence in this age group is relatively high.

The relationship between mortality and microbiological parameters in febrile neutropenic patients with hematological malignancies

Objectives:

To determine effective risk factors on mortality in febrile neutropenic cases with hematologic malignancy. Patients with hematologic diseases are more prone to infections and those are frequent causes of mortality.

Methods:

This retrospective study was performed using data of 164 febrile neutropenic cases with hematologic malignancies who were followed up in a hematology clinic of a tertiary health care center between 2011-2015. The relationship between descriptive and clinical parameters rates and rates of mortality on the 7^th and the 21^st days were investigated.

Results:

Patients with absolute neutrophil count<100/mm³, duration of neutropenia longer than 7 days, pneumonia or gastrointestinal foci of infection, central catheterization (p=0.025), isolation of Gram (-) bacteria in culture, carbapenem resistance, septic shock, and bacterial growth during intravenous administration of antibiotic treatment were under more risk for mortality on both the 7^th and the 21^st days. The final multivariate logistic regression results showed that pneumonia (p<0.0001), septic shock (p=0.004) and isolation of Gram-negative bacteria (p=0.032) were statistically significant risk factors.

Conclusion:

Early diagnosis and appropriate treatment of serious infections, which are important causes of morbidity and mortality, are crucial in patients with febrile neutropenia. Thus, each center should closely follow up causes of infection and establish their empirical antibiotherapy protocols to accomplish better results in the management of febrile neutropenia.

Risk factors for recurrences in patients with hepatitis C virus after achieving a sustained virological response: a multicentre study from Turkey

In this study, we aimed to determine the late relapse rate in hepatitis C patients with sustained virological response after interferon-based regimens, and evaluated the predictors of late relapse while comparing the real-life data of our country with that of others. A multicenter retrospective study was performed to investigate the data of patients infected with HCV who obtained sustained virological response after classical or pegylated interferon alpha (PegIFNα) and ribavirin (RBV) for 48 weeks. Sustained virological response was based on negative HCV RNA level by PCR at the end of six months after the therapy. The information of patients enrolled in the study was retrieved from the hospital computer operating system and outpatient follow-up archives. We evaluated the age, gender, HCV RNA levels, HCV genotype, six-month and further follow-up of patients with sustained virologic response, presence of cirrhosis, steatosis and relapse. In all, 606 out of 629 chronic hepatitis C patients (mean age was 53±12 years; 57.6% of them were female) with sustained virological response were evaluated. We excluded 23 patients who relapsed within six months after the end of treatment (EOT). The mean follow-up period of the patients was 71 months (range: 6-136) after therapy. Late relapse rate was 1.8% (n=11) in all patients. Univariate Cox proportional hazard regression models identified that cirrhosis and steatosis were associated with the late relapse [(p = 0.027; Hazard Ratio (HR) 2.328; 95% confidence interval (CI): 1.309-80.418), (p = 0.021; HR 1.446; 95% CI: 1.243-14.510, respectively]. In multivariable Cox regression analysis, steatosis was the only independent risk factor for late relapse (p = 0.03; HR 3.953; 95% CI: 1.146-13.635). Although the late relapse rate was approximately 2% in our study, clinicians should consider that pretreatment steatosis may be an important risk factor for late relapse.

The impact of economic and social factors on the prevalence of hepatitis B in Turkey

Background

Viral Hepatitis is one of the major global health problems, affecting millions of people every year. Limited information is available on the impact of social and economic factors on the prevalence of Hepatitis B virus (HBV) in Turkey. This study, contrary to other studies in the literature, was undertaken with the aim of examining the Majority of the excluded data come from the volunteers.

Methods

There are medical and the social-economic factors affecting the prevalence of HBV. This research, while taking medical factors as control variables, clarify the social and economic factors affecting the prevalence of HBV by utilising clinical data with the use of the Binary Probit Model (BPM). The BPM estimation is a powerful tool to determine not only the factors but explain also the exact impacts of each factor.

Results

The estimations of the BPM shows that economic and social variables such as age, gender, migration, education, awareness, social welfare, occupation are very important factors for determining HBV prevalence. Compared to the youngest population, the 46 to 66+ age group has a higher prevalence of HBV. The male respondents were 5% more likely to develop HBV compared to females. When region-specific differences are taken into account, migrating from the poorest parts of the country such as the eastern and south-eastern regions of Turkey are approximately 16% more likely to be infected. The welfare indicators such as a higher number of rooms in the respondent’s house or flat decreases the probability of having HBV and, relatively higher income groups are less likely to develop HBV compared to labourers. The Self-employed/Business owner/Public sector worker category are approximately 10% less likely to develop HBV. When people are aware of the methods of prevention of HBV, they are 6% less likely to be infected. Previous HBV infection history increases the probability of having HBV again B by 17%.

Conclusions

These findings strongly suggest that the impact of social and economic factors on the prevalence of HBV is vital. Any improvements in these factors are likely to reduce prevalence of HBV.

Changes in acute viral hepatitis epidemiology in the Turkish adult population: A multicenter study

BACKGROUND/AIMS

The present study aimed to determine the changes in the epidemiology of hepatitis in recent years in an adult Turkish population.

MATERIALS AND METHODS

Overall, 852 patients with acute viral hepatitis from 17 centers were included in this study. Their sociodemographic characteristics, clinical courses, treatments, and laboratory findings were retrospectively analyzed.

RESULTS

The most commonly found microorganisms were the hepatitis B virus (55.2%) and hepatitis A virus (37.6%), and the types of acute viral hepatitis differed significantly according to the age group (p≤0.001). The most frequently reported symptom was fatigue (73.7%), and the most common complications were cholecystitis (0.4%) and fulminant hepatitis (0.4%). The median hospital stay was 9 days (range 1-373). In total, 40.8% patients with acute hepatitis B virus developed immunity.

CONCLUSION

In Turkey, there are significantly large adolescent and adult populations susceptible to acute viral hepatitis. Therefore, larger vaccination programs covering these age groups should be implemented.

Tetanus in adults: results of the multicenter ID-IRI study

Tetanus is an acute, severe infection caused by a neurotoxin secreting bacterium. Various prognostic factors affecting mortality in tetanus patients have been described in the literature. In this study, we aimed to analyze the factors affecting mortality in hospitalized tetanus patients in a large case series. This retrospective multicenter study pooled data of tetanus patients from 25 medical centers. The hospitals participating in this study were the collaborating centers of the Infectious Diseases International Research Initiative (ID-IRI). Only adult patients over the age of 15 years with tetanus were included. The diagnosis of tetanus was made by the clinicians at the participant centers. Izmir Bozyaka Education and Research Hospital's Review Board approved the study. Prognostic factors were analyzed by using the multivariate regression analysis method. In this study, 117 adult patients with tetanus were included. Of these, 79 (67.5%) patients survived and 38 (32.5%) patients died. Most of the deaths were observed in patients >60 years of age (60.5%). Generalized type of tetanus, presence of pain at the wound area, presence of generalized spasms, leukocytosis, high alanine aminotransferase (ALT) and C-reactive protein (CRP) values on admission, and the use of equine immunoglobulins in the treatment were found to be statistically associated with mortality (p < 0.05 for all). Here, we describe the prognostic factors for mortality in tetanus. Immunization seems to be the most critical point, considering the advanced age of our patients. A combination of laboratory and clinical parameters indicates mortality. Moreover, human immunoglobulins should be preferred over equine sera to increase survival.

Quality of life and related factors among chronic hepatitis B-infected patients: a multi-center study, Turkey

BACKGROUND

The aim of this study was to assess health-related quality of life (HRQOL) among chronic hepatitis B (CHB) patients in Turkey and to study related factors.

METHODS

This multicenter study was carried out between January 01 and April 15, 2015 in Turkey in 57 centers. Adults were enrolled and studied in three groups. Group 1: Inactive HBsAg carriers, Group 2: CHB patients receiving antiviral therapy, Group 3: CHB patients who were neither receiving antiviral therapy nor were inactive HBsAg carriers. Study data was collected by face-to-face interviews using a standardized questionnaire, Short Form-36 (SF-36) and Hepatitis B Quality of Life (HBQOL). Values equivalent to p < 0.05 in analyses were accepted as statistically significant.

RESULTS

Four thousand two hundred fifty-seven patients with CHB were included in the study. Two thousand five hundred fifty-nine (60.1 %) of the patients were males. Groups 1, 2 and 3, consisted of 1529 (35.9 %), 1721 (40.4 %) and 1007 (23.7 %) patients, respectively. The highest value of HRQOL was found in inactive HBsAg carriers. We found that total HBQOL score increased when antiviral treatment was used. However, HRQOL of CHB patients varied according to their socio-demographic properties. Regarding total HBQOL score, a higher significant level of HRQOL was determined in inactive HBV patients when matched controls with the associated factors were provided.

CONCLUSIONS

The HRQOL score of CHB patients was higher than expected and it can be worsen when the disease becomes active. Use of an antiviral therapy can contribute to increasing HRQOL of patients.

Causative pathogens and antibiotic resistance in diabetic foot infections: A prospective multi-center study

AIM

Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials.

METHODS

The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate (NCT02026830).

RESULTS

A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group.

CONCLUSIONS

Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.

Cranial imaging findings in neurobrucellosis: results of Istanbul-3 study

OBJECTIVE

Neuroimaging abnormalities in central nervous system (CNS) brucellosis are not well documented. The purpose of this study was to evaluate the prevalence of imaging abnormalities in neurobrucellosis and to identify factors associated with leptomeningeal and basal enhancement, which frequently results in unfavorable outcomes.

METHODS

Istanbul-3 study evaluated 263 adult patients with CNS brucellosis from 26 referral centers and reviewed their 242 magnetic resonance imaging (MRI) and 226 computerized tomography (CT) scans of the brain.

RESULTS

A normal CT or MRI scan was seen in 143 of 263 patients (54.3 %). Abnormal imaging findings were grouped into the following four categories: (a) inflammatory findings: leptomeningeal involvements (44), basal meningeal enhancements (30), cranial nerve involvements (14), spinal nerve roots enhancement (8), brain abscesses (7), granulomas (6), and arachnoiditis (4). (b) White-matter involvement: white-matter involvement (32) with or without demyelinating lesions (7). (c) Vascular involvement: vascular involvement (42) mostly with chronic cerebral ischemic changes (37). (d) Hydrocephalus/cerebral edema: hydrocephalus (20) and brain edema (40). On multivariate logistic regression analysis duration of symptoms since the onset (OR 1.007; 95 % CI 1-28, p = 0.01), polyneuropathy and radiculopathy (OR 5.4; 95 % CI 1.002-1.013, p = 0.044), cerebrospinal fluid (CSF)/serum glucose rate (OR 0.001; 95 % CI 000-0.067, p = 0.001), and CSF protein (OR 2.5; 95 % CI 2.3-2.7, p = 0.0001) were associated with diffuse inflammation.

CONCLUSIONS

In this study, 45 % of neurobrucellosis patients had abnormal neuroimaging findings. The duration of symptoms, polyneuropathy and radiculopathy, high CSF protein level, and low CSF/serum glucose rate were associated with inflammatory findings on imaging analyses.

A persistently low HBV DNA level is a predictor of spontaneous HBsAg clearance in patients with chronic hepatitis B

BACKGROUND/AIM

The incidence and predictors of spontaneous hepatitis B surface-antigen (HBsAg) seroclearance in patients with chronic hepatitis B virus (HBV) were evaluated.

MATERIALS AND METHODS

A total of 1427 patients with chronic HBV infection, who were followed between 1994 and 2013, were investigated in this retrospective study. All data were extracted from patient files.

RESULTS

Spontaneous HBsAg seroclearance occurred in 84 patients during 8798 person-years of follow-up. The patients were categorized into 3 groups at follow-up based on HBV DNA features as continuously <100 copies/mL (Group A), 0-10,000 copies/mL (Group B), and 0 to >10,000 copies/mL (Group C). Alanine aminotransferase features in the 2 groups were categorized as continuously normal (<40 U/L) and 0 to >40 U/L. Spontaneous HBsAg seroclearance was seen primarily in patients with Group A HBV DNA features, and continuously low HBV DNA values were the main predictor of HBsAg seroclearance (P < 0.001).

CONCLUSION

These results suggest that a continuously low viral load is the most important factor affecting spontaneous HBsAg seroclearance.

Tuberculous and brucellosis meningitis differential diagnosis

BACKGROUND

The Thwaites and Lancet scoring systems have been used in the rapid diagnosis of tuberculous meningitis (TBM). However, brucellar meningoencephalitis (BME) has similar characteristics with TBM. The ultimate aim of this study is to infer data to see if BME should be included in the differential diagnosis of TBM when these two systems suggest the presence of TBM.

METHOD

BME and TBM patients from 35 tertiary hospitals were included in this study. Overall 294 adult patients with BME and 190 patients with TBM were enrolled. All patients involved in the study had microbiological confirmation for either TBM or BME. Finally, the Thwaites and Lancet scoring systems were assessed in both groups.

RESULTS

The Thwaites scoring system more frequently predicted BME cases (n = 292, 99.3%) compared to the TBM group (n = 182, 95.8%) (P = 0.017). According to the Lancet scoring system, the mean scores for BME and TBM were 9.43 ± 1.71 and 11.45 ± 3.01, respectively (P < 0.001). In addition, TBM cases were classified into "probable" category more significantly compared to BME cases, and BME cases were categorized into the "possible" category more frequently.

CONCLUSIONS

When the Thwaites or Lancet scoring systems indicate TBM, brucellar etiology should also be taken into consideration particularly in endemic countries.

Predictors of response to pegylated interferon treatment in HBeAg-negative patients with chronic hepatitis B

INTRODUCTION

Although pegylated interferons (pegIFNs) alpha-2a and alpha-2b have been used in chronic hepatitis B (CHB) treatment for many years, there are few studies concerning predictors of sustained virologic response (SVR) to pegIFN therapy. In this study, we aimed to investigate the predictors of response to pegIFN treatment in cases with HBeAg-negative CHB infection.

METHODOLOGY

Seventeen tertiary care hospitals in Turkey were included in this study. Data from consecutively treated HBeAg-negative CHB patients, who received either pegIFN alpha-2a or alpha-2b, were collected retrospectively. SVR is defined as an HBV DNA concentration of less than 2,000 IU/mL six months after the completion of therapy

RESULTS

SVR was achieved in 40 (25%) of the 160 HBeAg-negative CHB patients. Viral loads in patients with SVR were lower compared to those with no SVR, beginning in the third month of treatment (p < 0.05). The number of cases with a decline of 1 log10 IU/mL in viral load after the first month of treatment and with a serum HBV DNA level under 2,000 IU/mL after the third month of treatment was higher in cases with SVR (p < 0.05). The number of patients who had undetectable HBV DNA levels at week 48 among responders was significantly greater than among post-treatment virological relapsers (p < 0.05).

CONCLUSIONS

Detection of a 1 log10 decline in serum HBV DNA level at the first month of treatment and a serum HBV DNA level < 2000 IU/mL at the third month of therapy may be predictors of SVR.

Liver involvement in patients with brucellosis: results of the Marmara study

Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system. But, the extent of liver damage in due course of the disease is unclear. This study included 325 brucellosis patients with significant hepatobiliary involvement identified with microbiological analyses from 30 centers between 2000 and 2013. The patients with ≥5 times of the upper limit of normal for aminotransferases, total bilirubin level ≥2 mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3 %) and cholestasis was detected in 215 (66.1 %) patients. Fatigue (91 %), fever (86 %), sweating (83 %), arthralgia (79 %), and lack of appetite (79 %) were the major symptoms. Laboratory tests showed anemia in 169 (52 %), thrombocytopenia in 117 (36 %), leukopenia in 81 (25 %), pancytopenia in 42 (13 %), and leukocytosis in 20 (6 %) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (n = 73), doxycycline plus rifampicin (n = 71), doxycycline plus rifampicin and an aminoglycoside (n = 27). The duration of ALT normalization differed significantly in three treatment groups (p < 0.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (p < 0.05). However, the length of hospital stay did not differ significantly between these three combinations (p > 0.05). During the follow-up, treatment failure occurred in four patients (1 %) and relapse was seen in three patients (0.9 %). Mortality was not observed. Hepatobiliary involvement in brucellosis has a benign course with suitable antibiotics and the use of doxycycline and an aminoglycoside regimen seems a better strategy in select patients.

The characteristics of patients with chronic hepatitis B in Turkey

AIM

To evaluate the characteristics of patients with hepatitis B virus (HBV) infection and summarize the treatment modalities.

METHODS

By September 30, 2011 the data of 7871 HBsAg (+) patients were complied and analysed according to demographic and medical records (age, sex, laboratory tests, treatment with antiviral agents) in thirty centres of Turkey.

RESULTS

Of the 7871 patients 3078 (39.1%) were females; mean (standard deviation) age was 35 (14) years, 3180 (40.4%) were HBsAg positive (+) after admission to a hospital, 1488 (18.9%) after blood donation and 967 (11.9%) were found during routine screening. The HBV prevalence among relatives of HBsAg (+) patients was 1764 (22.4%), and most frequently infected family members were siblings and mothers, 4961 (63.0%) and 2149 (27.3%), respectively). Anti-HDV was negative in 7407 94.1% of patients. Three-fourths of the patients 6383 (81.1%) were HBeAg negative (-). Mean (SD) ALT was 85.8 (266.4) U/L. Majority of patients, 5588 (71.0%) were chronic hepatitis-B patients under treatment, while 2283 (29.0%) were asymptomatic carriers without treatment and only 165 (2.1%) of patients were cirrhotic and 6612 (84.0%) of those were compensated. One-third of the patients 2983 (37.9%) were under a combined treatment, while others were under monotherapy. Lamivudine, entecavir and adefovir were the most frequently used oral therapies, used for 2583 (32.8%), 11.6% and 787 (10.0%) of patients, respectively), while 2975 (37.8%) of patients were under interferon treatment.

CONCLUSION

Hepatitis B is still a problem in our country. First task of the physicians and our state should be to prevent the development and spread of the disease with education and vaccination programs, safe blood transfusions, and control of barbers.