A Prognostic Marker in COVID-19 Disease Severity and Mortality: D-Dimer/Platelet Ratio

INTRODUCTION

We aimed to examine the D-dimer/platelet ratio (DPR), which includes the combination of D-dimer and platelet measurements, which are two important markers in predicting prognosis, considering that it will show clinical progression.

METHODS

After ranking the patients from high to low according to DPR level, they were divided into three equal groups. Demographic, clinical, and laboratory parameters between groups were compared according to DPR level. The consistency of DPR with other coronavirus disease 2019 (COVID-19) biomarkers in the literature in terms of hospitalization and mortality in the intensive care unit was examined.

RESULTS

Complications such as renal failure, pulmonary thromboembolism (PTE), and stroke of the patients increased as the DPR increased. Patients in the third group with high DPR had higher oxygen demands from symptom onset, such as reservoir masks, high-flow oxygen, and mechanical ventilation. The first hospitalization location in the third group was determined as the intensive care unit. Mortality increased as the DPR value increased, and the time to death in patients in the third group was significantly shorter than the patients in the other two groups. While most of the patients in the first two groups recovered, 42% of the patients in the third group died. While the area under the curve was 80.6% in predicting DPR admission to the intensive care unit, the cut-off value was determined as 1.606. When the effect of DPR on predicting mortality was examined, the area under the curve for DPR was 82.6% and the cut-off value was determined as 2.284.

CONCLUSION

DPR is successful in predicting the severity, ICU admission, and mortality of COVID-19 patients.

Factors associated with development of an acute ischemic event during hospitalization for COVID-19 in cancer and non-cancer patients

BACKGROUND

COVID-19 and solid cancer are both associated with an increased risk of thromboembolism.

OBJECTIVES

Assess whether solid cancer is a risk factor for acute ischemic event development among patients with COVID-19.

DESIGN

Retrospective cohort SETTING: A tertiary training and research hospital PATIENTS AND METHODS: Patients who were hospitalized for COVID-19 for ≥3 days between 15 March 2020 and 30 March 2021 at Antalya Training and Research Hospital, Antalya, Turkiye. were included in the study. Independent predictors of the development of acute ischemic events during hospitalization were determined using multivariable logistic regression analysis.

MAIN OUTCOME MEASURES

Risk factors for acute ischemic event development.

SAMPLE SIZE

538 patients.

RESULTS

Patients diagnosed with solid cancer comprised 11.3% of the cohort (n=61). Forty-one (7.6%) developed an acute ischemic event at a median of 3 (range, 1-15) days after hospitalization. The presence of a solid cancer (OR 3.80, 95% CI 1.20-12.03, P=.023) along with length of hospital stay (OR 1.05 per day, 95% CI 1.01-1.09, P=.025) were independent predictors of acute ischemic event development during the course of COVID-19. Mortality was reported in 200 (37%) patients at a median of 5 (range, 3-10) days after hospitalization. The presence of solid tumor increased mortality 5.83 times (95% CI 3.19-10.63, P<.001) while this ratio was 4.59 (95% CI 2.29-9.23, P<.001) for patients who experienced an acute ischemic event.

CONCLUSION

Patients with active cancer carry a significant risk for acute ischemic event development during the course of COVID-19 and such patients may require particular attention in terms of anticoagulation therapy.

LIMITATIONS

Retrospective design and small sample size.

CONFLICT OF INTEREST

None.

Vaccine hesitancy and refusal among parents: An international ID-IRI survey

INTRODUCTION

Although vaccines are the safest and most effective means to prevent and control infectious diseases, the increasing rate of vaccine hesitancy and refusal (VHR) has become a worldwide concern. We aimed to find opinions of parents on vaccinating their children and contribute to available literature in order to support the fight against vaccine refusal by investigating the reasons for VHR on a global scale.

METHODOLOGY

In this international cross-sectional multicenter study conducted by the Infectious Diseases International Research Initiative (ID-IRI), a questionnaire consisting of 20 questions was used to determine parents' attitudes towards vaccination of their children.

RESULTS

Four thousand and twenty-nine (4,029) parents were included in the study and 2,863 (78.1%) were females. The overall VHR rate of the parents was found to be 13.7%. Nineteen-point three percent (19.3%) of the parents did not fully comply with the vaccination programs. The VHR rate was higher in high-income (HI) countries. Our study has shown that parents with disabled children and immunocompromised children, with low education levels, and those who use social media networks as sources of information for childhood immunizations had higher VHR rates (p < 0.05 for all).

CONCLUSIONS

Seemingly all factors leading to VHR are related to training of the community and the sources of training. Thus, it is necessary to develop strategies at a global level and provide reliable knowledge to combat VHR.

Clinical Features of Post-Operative Nosocomial Meningitis in Adults and Evaluation of Efficiency of Intrathecal Treatment

Background: Post-operative nosocomial meningitis is a critical complication that develops in patients after neurosurgical interventions and operations. Patients and Methods: Data were collected for 65 patients who were diagnosed as having nosocomial meningitis after neurosurgery. The agent profile, clinical and biochemical differences in gram-negative and gram-positive meningitis, and the effectiveness of intrathecal antibiotic administration in cases with carbapenem-resistant gram-negative agents were evaluated. Results: Gram-negative bacteria were isolated in 52.3% of patients. In gram-negative cases of post-operative nosocomial meningitis, white blood cell count (p = 0.015), C-reactive protein (p = 0.001), cerebrospinal fluid leukocyte count (p = 0.0001), and protein (p = 0.0001) were higher, and glucose (p = 0.002) was lower. Concurrent bacteremia (p = 0.041), 14-day mortality (p = 0.022), and 30-day mortality (p = 0.023) were higher in gram-negative cases. Empirical treatment was appropriate in 78.5% of the patients. Seventeen patients (26.2%) received intrathecal antibiotic agents in addition to intravenous antibiotic treatment because of carbapenem-resistant gram-negative bacteria. Nine (53%) of the patients receiving intrathecal therapy had Acinetobacter baumannii as the agent, six had Klebsiella pneumoniae (35.4%), one had Pseudomonas aeruginosa (5.8%), and one had Providencia rettgeri (5.8%). The mean intravenous treatment duration was 21.4 ± 10.6 (4-60) days, and the mean intrathecal treatment duration was 17.6 ± 14.0 (1-51) days. Eleven patients received colistimethate sodium intrathecally (1 × 10 mg/d), three patients received amikacin intrathecally (1 × 10 mg/d), and three patients received gentamicin intrathecally (1 × 10 mg/d). Clinical and microbiologic treatment success was achieved in nine patients (53%). Conclusions: In cases of meningitis caused by carbapenem-resistant agents, intrathecal administration of antibiotic agents such as gentamicin, amikacin, and colistin with limited blood-brain barrier transition in intravenous administration will increase survival. Therefore, intrathecal antibiotic administration should be considered as a part of routine of nosocomial meningitis.

Managing adult patients with infectious diseases in emergency departments: international ID-IRI study

We aimed to explore factors for optimizing antimicrobial treatment in emergency departments. A single-day point prevalence survey was conducted on January 18, 2020, in 53 referral/tertiary hospitals in 22 countries. 1957 (17%) of 11557 patients presenting to EDs had infections. The mean qSOFA score was 0.37 ± 0.74. Sepsis (qSOFA ≥ 2) was recorded in 218 (11.1%) patients. The mean qSOFA score was significantly higher in low-middle (1.48 ± 0.963) compared to upper-middle (0.17 ± 0.482) and high-income (0.36 ± 0.714) countries (P < 0.001). Eight (3.7%) patients with sepsis were treated as outpatients. The most common diagnoses were upper-respiratory (n = 877, 43.3%), lower-respiratory (n = 316, 16.1%), and lower-urinary (n = 201, 10.3%) infections. 1085 (55.4%) patients received antibiotics. The most-commonly used antibiotics were beta-lactam (BL) and BL inhibitors (n = 307, 15.7%), third-generation cephalosporins (n = 251, 12.8%), and quinolones (n = 204, 10.5%). Irrational antibiotic use and inappropriate hospitalization decisions seemed possible. Patients were more septic in countries with limited resources. Hence, a better organizational scheme is required.

Risk factors for fecal carriage of extended-spectrum beta-lactamase-producing and carbapenem-resistant Escherichia coli and Klebsiella pneumoniae strains among patients at hospital admission

AIM

Extended-spectrum beta-lactamase (ESBL)-producing and carbapenem-resistant (CR) Enterobacteriaceae are substantial problems in hospital-acquired infections worldwide. We analyzed the risk factors for fecal carriage of ESBL-positive and/or CR E. coli and K. pneumoniae (EcKp) strains in a hospital in Turkey, an endemic country for both resistances.

MATERIALS AND METHODS

A prospective cross-sectional study including the rectal swab samples of 168 patients, obtained at the day of admission, was conducted. ESBL-producing and CR EcKp were investigated with phenotypic tests and PCR, and the clonal relatedness of isolates was studied. Risk analysis was performed with logistic regression method.

RESULTS

A total of 67 (39.8%) and 21 (12.5%) patient samples tested positive for ESBL-producing and CR EcKp, respectively. CTX-M (n = 27) and OXA-48 (n = 12) were the dominant ESBL and carbapenemase types, and 4.5%-10.7% of the isolates were clonally-related. Among 15 potential risk factors studied, longer lengths of hospital stay and antimicrobial use, and receiving total parenteral nutrition in the last 6 months were determined as independent risk factors for fecal carriage of ESBL-producing and/or CR EcKp, while prior antimicrobial treatment was only a risk factor for ESBL producers.

CONCLUSION

Certain conditions in patients' medical backgrounds may be associated with increased likelihood of resistant bacterial colonization. Notably, questioning these situations at admission can help to identify potential carriers and proactively administer appropriate infection control measures.

A rare case of raoultella planticola peritonitis in a chronic ambulatory peritoneal dialysis patient and review of the literature

Peritonitis is a common and serious complication of peritoneal dialysis and often primary factor of change over to hemodialysis treatment. Raoultella planticola is known as as environmental bacterium and rarely causes infections in humans. We present a case of peritoneal dialysis related peritonitis due to Raoultella planticola and review the clinical manifestations and treatment options of this microorganism. As far as we know, this is the third case of Raoultella planticola peritonitis in the literature.

Comparison of steam technology and a two-step cleaning (water/detergent) and disinfecting (1,000 resp. 5,000 ppm hypochlorite) method using microfiber cloth for environmental control of multidrug-resistant organisms in an intensive care unit

Aim: The aim of this prospective observational study was to evaluate the impact of two cleaning and disinfecting methods and the use of steam against methicillin-resistant Staphyl ococcus aureus, vancomycin-resistant Enterococcus faecalis, carbapenem-resistant Pseudomonas aeruginosa and multidrug-resistant (MDR) Acinetobacter baumannii in a tertiary referral hospital. Methods: McFarland 0.5 suspensions (content 1.5 x 10⁸ cfu/ml) of four challenge bacterial species were prepared and used to inoculate different sites in three ICU rooms. One of the following methods was used in each room: steam technology (Tecnovap Evo 304) resp. cleaning with microfiber cloths, soaked with detergent and water, thereafter disinfection with 1,000 ppm hypochlorite or the same procedure with 5,000 ppm hypochlorite. Qualitative microbiology and ATP bioluminescence were performed before and after cleaning with each method. The Wilcoxon test was used for paired samples to check for ordinal variables. The cost of each cleaning method was analyzed. Results: Environmental cleaning with steam technology was found to be as effective against MDR microorganisms as a two-step cleaning process (water/detergent and disinfecting with 1,000 resp. 5,000 ppm hypochlorite) in ICUs. No bacterial growth was detected after any of the three cleaning methods. Steam technology was 76% and 91% cheaper than using 5,000 ppm and 1,000 ppm hypochlorite, respectively. Conclusions: When compared to, steam technology was found to have an advantage over the 2-step procedure with cleaning and disinfection, because it avoids the use of chemicals, reduces water consumption, labor time and costs for cleaning.

Seroprevalence of hepatitis B and C virus in patients who undergo hemodialysis in Antalya province, Turkey

Background

Chronic hepatitis B (HBV) and C virus (HCV) infections are important causes of morbidity and mortality in patients who undergo hemodialysis (HD).

Objectives

To define seroprevalence of HBV and HCV in patients who underwent HD in Antalya province, Turkey.

Methods

We included 1347 patients with end-stage renal failure who underwent HD at one of the 23 centers in Antalya province from January 01 to March 31, 2014 in this retrospective cross-sectional study. Hepatitis B surface antigen (HBsAg) and anti-HCV seropositivity were assessed clinically using a third-generation enzyme-linked immunosorbent assay. HBV DNA and HCV RNA were determined in HBsAg positive and anti- HCV positive HD patients respectively.

Results

Of the patients included, 805 (59.8%) were male. Mean age (± standard deviation) of the patients was 53.9 ± 17.0 (range 17–89) years. The sera of 2.4% patients was positive for HBsAg, and the sera of 5.5% of the patients was positive for anti-HCV. The sera of 56% of patients positive for HBsAg was also positive for HBV DNA, and the sera of 43% of patients positive for anti-HCV was also positive for HCV RNA. Coexistence of HBsAg and anti-HCV was 1.02%.

Conclusions

The present study showed that the prevalence of chronic HBV and HCV infection in patients who underwent HD in Antalya province was moderate-to-low for Turkey. Compliance of HD centers with infection control rules, isolation of HBsAg positive patients, isolation of the equipment used for HBV susceptible patients, and active surveillance of the HD patients may have resulted in lower prevalence rates.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Soluble TRAIL levels decreased in chronic hepatitis C treatment with pegylated interferon α plus ribavirin: association with viral responses

The molecular mechanisms and pathogenesis of chronic hepatitis C (CHC) infection are unclear. Innate immune cells such as natural killer (NK) cells and dendritic cells are responsible from molecular mechanism of CHC. NK cell cytotoxicity such as TRAIL expression is important pathway for viral clearance. The aim of this study was to evaluate the relationship between HCV RNA and sTRAIL levels during the first 12 weeks of Peg-IFNα and ribavirin treatment. Twelve treatment naive patients with CHC treated with Peg-INFα and ribavirin were included in this study. Circulating sTRAIL and HCV RNA levels were measured at baseline, 4th and 12th week of treatment and their correlation was investigated. sTRAIL and HCV RNA levels decreased gradually with Peg-INFα plus ribavirin treatment. The differences were significant between day 0, 4th week and 12th week of treatment. The expression of sTRAIL was correlated with HCV RNA level at baseline, at 4th and 12th week of treatment (P = 0.021 P = 0.012, P = 0.001 respectively). IFN binds to its receptor on the infected hepatocyte surface during Peg-IFNα and ribavirin treatment. So the polarized phenotype of NK cell is not displayed and NK cell cytotoxicity such as TRAIL expression is blocked. We suggest that the decreased level of circulating sTRAIL may reflect increased binding to its ligand expressed on hepatocyte and decreased TRAIL production under the influence of Peg-IFNα plus ribavirin treatment. Therefore TRAIL may be probably a immunologically predictive factor such as HCV RNA during treatment.

Weekly chlorhexidine douche: does it reduce healthcare-associated bloodstream infections?

BACKGROUND

Daily chlorhexidine (CHG) bathing has been used as a precaution to reduce the rate of healthcare-associated bloodstream infections (HA-BSI). The application frequency of CHG bathing remains unclear, this procedure has been implemented daily by this time. The aim of this study was to determine the efficacy of weekly whole-body douche with CHG shower gel on rates of HA-BSI.

METHODS

We conducted a prospective intervention trial in medical, surgical, and anesthesiology intensive care units (ICUs) in a tertiary teaching hospital from June 2011 to November 2012. This study included three periods. During the first period, patients received a daily bed bath by wiping with water and soap. In the second period patients were given a weekly douche with water and soap; in the third period patients were given a weekly douche with CHG shower gel. The rates of HA-BSI were compared between the three periods using Poisson regression analysis.

RESULTS

The central line-associated bloodstream infection rates did not decline significantly between periods (p = 0.76). The laboratory-confirmed bloodstream infection (LCBSI) rates in the first, second, and third periods were 7.1, 4, and 1.7, respectively. The LCBSI rates were reduced 43.7% from the first period to the second period (p = 0.03). In addition, there was a 57.5% reduction in LCBSI rates between the second and third periods (p < 0.001). Interestingly, the major decline (76.1%) was determined from the first to the third period (p < 0.002).

CONCLUSIONS

Weekly douche with CHG shower gel significantly reduced LCBSI rates. Further studies are needed to validate the clinical impact of different intervals of CHG bathing.

Effect of steroid and cyclosporine in membranous nephropathy that is resistant to steroid and/or cytotoxic treatment

Membranous Nephropathy (MN) is a glomerular disease characterized by proteinuria. The etiology is unknown in many cases, while in some patients MN may be secondary to infection, to other diseases, or to exposure to drugs and toxic substances. The prognosis of the disease is variable, 1/3 of patients can have spontaneous remission; patients with nephrotic proteinuria, those with advanced tubulointerstitial changes and those with increased serum creatinine at presentation have a poorer prognosis. Although MN is one of the most common causes of adult-onset Nephrotic Syndrome (NS), its management is still controversial. Corticosteroids have been used for many years as the basic treatment, though with controversial results. Controversial results have been obtained with cytotoxic agents. Cyclosporine has been shown to be effective in the treatment of this disease. We have evaluated the results of 23 patients (14 males, 9 females aged between 26-53) diagnosed with Idiopathic MN (IMN) who have received cyclosporine because of the relapse or persistence after steroid and/or cytotoxic treatment. At the end of a 12-month follow-up, 8 patients had (34.8%) complete remission, 8 (34.8%) had partial remission, 2 (8.7%) had persistent proteinuria and 5 patients (21.7%) had no response to the treatment. There was a significant decrease in proteinuria throughout the study. There was no significant difference in total protein, albumin and creatinine levels between before and after the treatment. Our results indicate that patients with MN who do not respond well or have-relapse after steroid and/or cytotoxic therapy, should be offered cyclosporine. We think that in the future; long-term studies which are prospective and randomized with an extensive number of patients will be effective on the treatment of MN.