Impact of the empirical therapy timing on the clinical progress of septic shock patients

AIM

To evaluate the effect of timing of antimicrobial therapy on clinical progress of patients with septic shock.

MATERIALS AND METHOD

We included 204 adult patients diagnosed with septic shock according to Sepsis-3 criteria between March 2016 and April 2021. One-month survival was evaluated using univariate and logistic regression analysis.

RESULTS

Antibiotic treatment was initiated within 1 h of the vasopressors in 26.4 % of patients. One-month mortality did not differ significantly between patients with and without empirical therapy coverage on etiological agents. Univariate factors that significantly affected one-month survival were starting antibiotics at the first hour, the unit where the case was diagnosed with septic shock, SOFA scores, qSOFA scores, and lactate level. In multivariate analysis, diagnosis of septic shock in the Emergency Service, SOFA score ≥11, qSOFA score of three and lactate level ≥4 were significantly associated with one-month mortality.

CONCLUSION

Training programs should be designed to increase the awareness of septic shock diagnosis and treatment in the Emergency Service and other hospital units. Additionally, electronic patient files should have warning systems for earlier diagnosis and consultation.

Understanding clinical outcomes and factors influencing mortality in intensive care unit patients with COVID-19-associated candidemia

BACKGROUND

During the COVID pandemic, research has shown an increase in candidemia cases following severe COVID infection and the identification of risk factors associated with candidemia. However, there is a lack of studies that specifically explore clinical outcomes and mortality rates related to candidemia after COVID infection.

OBJECTIVES

The aim of this international study was to evaluate the clinical outcomes and identify factors influencing mortality in patients who developed candidemia during their COVID infection.

PATIENTS/METHODS

This study included adult patients (18 years of age or older) admitted to the intensive care unit (ICU) and diagnosed with COVID-associated candidemia (CAC). The research was conducted through ID-IRI network and in collaboration with 34 medical centres across 18 countries retrospectively, spanning from the beginning of the COVID pandemic until December 2021.

RESULTS

A total of 293 patients diagnosed with CAC were included. The median age of the patients was 67, and 63% of them were male. The most common Candida species detected was C. albicans. The crude 30-day mortality rate was recorded at 62.4%. The logistic regression analysis identified several factors significantly impacting mortality, including age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07, p < .0005), SOFA score (OR 1.307, 95% CI 1.17-1.45, p < .0005), invasive mechanical ventilation (OR 7.95, 95% CI 1.44-43.83, p < .017) and duration of mechanical ventilation (OR 0.98, 95% CI 0.96-0.99, p < .020).

CONCLUSIONS

By recognising these prognostic factors, medical professionals can customise their treatment approaches to offer more targeted care, leading to improved patient outcomes and higher survival rates for individuals with COVID-associated candidemia.

European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults

SCOPE

These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended for clinicians involved in diagnosis and treatment of brain abscess in children and adults.

METHODS

Key questions were developed, and a systematic review was carried out of all studies published since 1 January 1996, using the search terms 'brain abscess' OR 'cerebral abscess' as Mesh terms or text in electronic databases of PubMed, Embase, and the Cochrane registry. The search was updated on 29 September 2022. Exclusion criteria were a sample size <10 patients or publication in non-English language. Extracted data was summarized as narrative reviews and tables. Meta-analysis was carried out using a random effects model and heterogeneity was examined by I2 tests as well as funnel and Galbraith plots. Risk of bias was assessed using Risk Of Bias in Non-randomised Studies - of Interventions (ROBINS-I) (observational studies) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (diagnostic studies). The Grading of Recommendations Assessment, Development and Evaluation approach was applied to classify strength of recommendations (strong or conditional) and quality of evidence (high, moderate, low, or very low).

QUESTIONS ADDRESSED BY THE GUIDELINES AND RECOMMENDATIONS

Magnetic resonance imaging is recommended for diagnosis of brain abscess (strong and high). Antimicrobials may be withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time, preferably within 24 hours (conditional and low). Molecular-based diagnostics are recommended, if available, in patients with negative cultures (conditional and moderate). Aspiration or excision of brain abscess is recommended whenever feasible, except for cases with toxoplasmosis (strong and low). Recommended empirical antimicrobial treatment for community-acquired brain abscess in immuno-competent individuals is a 3rd-generation cephalosporin and metronidazole (strong and moderate) with the addition of trimethoprim-sulfamethoxazole and voriconazole in patients with severe immuno-compromise (conditional and low). Recommended empirical treatment of post-neurosurgical brain abscess is a carbapenem combined with vancomycin or linezolid (conditional and low). The recommended duration of antimicrobial treatment is 6-8 weeks (conditional and low). No recommendation is offered for early transition to oral antimicrobials because of a lack of data, and oral consolidation treatment after ≥6 weeks of intravenous antimicrobials is not routinely recommended (conditional and very low). Adjunctive glucocorticoid treatment is recommended for treatment of severe symptoms because of perifocal oedema or impending herniation (strong and low). Primary prophylaxis with antiepileptics is not recommended (conditional and very low). Research needs are addressed.

Ertapenem plus meropenem combination treatment in carbapenem-resistant Klebsiella pneumoniae bacteremia: an analysis of 53 cases

Herein, we aimed to describe the outcomes of patients with blood stream infections due to carbapenem-resistant Klebsiella pneumoniae (CR-Kp) who received ertapenem plus meropenem combination treatment (EMCT). A total of 53 patients with culture proven CR-Kp bacteremia treated with ertapenem + meropenem were included. The patients with secondary bacteremia due to urinary tract infection exhibited a significantly lower 1-month mortality (OMM), particularly in those with microbiological eradication and those with end-of-treatment success. Salvage EMCT resulted in 49% 1-month survival.

249. Evaluation of 99 Radiologically-proven Osteomyelitis Cases

Background

Herein we aimed to evaluate osteomyelitis cases in our setting.

Methods

We evaluated the hospital records of patients with osteomyelitis between January 2013 and December 2020 retrospectively. Osteomyelitis was confirmed by direct radiography or magnetic resonance imaging or pathology. Demographic features, risk factors, clinical/laboratory findings, treatment response and mortality rates were evaluated. Clinical response was defined as (resolution of clinical signs including fever and purulent discharge and other symptoms) and/or negative culture at the end of antimicrobial therapy.

Results

Patients were 33 female, aged 29–85 years (mean 59±12.6). Fourty nine of the patients were diabetic foot infection, 30 were spondylodiscitis, eight were primary, seven were post-traumatic, and five were post-surgical osteomyelitis. Overall 62 patients had diabetes mellitus and 16 patients had chronic renal failure. Peripheral arterial disease, neuropathy, diabetic retinopathy and venous insufficiency rate in the DM subgroup is shown in table. Fever was present in 24.2% of the cohort. İncreasing of CRP was in 95,9%, erythrocyte sedimentation rate in 83,9%, and leukocytosis in 37.3%. The radiological findings of osteomyelitis were detected via magnetic resonance imaging in 73 patients. Etiology in biopsy cultures were elucidated in 59.5% and the most common pathogen was S. aureus (30%) Table1. The most common empirical treatment regimens were tigecycline in 27 patients, ampicillin/sulbactam in 19 patients and ceftriaxone+teicoplanin in 12 cases. Duration of treatment was 36,2±17.3 days (range 6-104 days). Overall, clinical response was obtained in 91.9%. Fifty patients were performed surgical procedure + antibacterial treatment, clinical response was 96% (p:0.091). Surgical debridement could be performed in 22 patients, clinical response was obtained in all (p:0.193). Thirteen patients developed recurrence within one year. Sixty-seven patients received oral consecutive treatment after discharge. In hospital mortality rate was 2/99 (2,02%).

Conclusion

Despite surgical debridement and/or developed antimicrobial treatment, approximately 1/5 of osteomyelitis cases required further treatment Further interventions seem to be needed to reach better outcomes.

Disclosures

All Authors: No reported disclosures

268. Methicillin Sensitive Versus Methicillin Resistant Staphylococcus aureus Nosocomial Meningitis

Background

Herein, we aimed to analyze the outcomes of the methicillin sensitive (MS) versus methicillin resistant (MR) culture-proven Staphylococcus spp. nosocomial meningitis (S-NM) in our setting.

Methods

We extracted data and outcomes for all adult patients (age &gt;18 years) consulted by the Infectious Diseases Consultants and diagnosed NM (developed at a compatible time according to CDC nosocomial meningitis definitions) between January 2006 and 2021 and fulfilled the following study inclusion criteria: (a) Age ≥18-year-old; (b) CSF culture is positive for Staphylococcus spp. (c) Presence of at least two of three clinical/laboratory criteria as meningitis findings: (i) Body temperature &gt;38oC; (ii) CSF finding; &gt;250 leucocytes/mm3; (iii) at least one of the following clinical findings, ie. impairment of consciousness, neck stiffness, nausea/vomiting. Identification of the infecting bacteria and determination of antimicrobial susceptibility were performed using the VITEK 2 automated system (BioMerieux Inc, Mercy L’etoil, France) and conventional methods. Resistance to methicillin was tested by E-test (bioMérieux). Antibacterial susceptibility tests were evaluated according to Clinical Laboratory Standards Institute (CLSI) criteria until 2014 and EUCAST between 2015 and 2021. Chi-square and Student T tests were used for statistical comparison.

Results

A total of 9 patients in MSS-NM, 41 patients in MRS-NM group fulfilled the study inclusion criteria. Age, gender, and CSF findings (except CSF glucose was significantly lower in MSS-NM) were similar in both groups (Table 1). Besides, EOT clinical success and overall success (EOT success followed by one-month survival without relapse or reinfection) rates were similar (Table 1). Relapse and reinfection rates during post-treatment one month period were 0%-0% and 0%-6.6% in MSS/MRS-NM, respectively. In MRS-NM group reinfection pathogens were Acinetobacter baumannii and Pseudomonas aeruginosa after 12 and 30 days end of treatment.

Characteristics of NM

Conclusion

Overall success in MSS-NM was acceptable while it was non-significantly lower in MRS-NM. The medical community should seek better infection control measures from NM.

Disclosures

All Authors: No reported disclosures

691. Infective Endocarditis with an Indication for Cardiac Surgery in a Tertiary Care Educational Hospital: Does Cardiac Surgery Improve Outcomes?

Background

In this retrospective cohort study, it was aimed to compare the clinical characteristics and outcomes of IE cases without and with an indication for cardiac surgery in terms of whether they have been operated or not, in a tertiary-care educational hospital.

Methods

Patients that were followed up for definite IE (diagnosed according to modified Duke criteria between March 2007 and November 2020) with an indication for cardiac surgery according to European Society of Cardiology Guidelines, comprised the study group. Subjects were evaluated in terms of whether these cases have been operated or not, demographic features, underlying diseases, risk factors, clinical and laboratory findings, therapy responses, complications, and mortality. The timing of surgery is defined as emergency; surgery performed within 24 hours, urgent; within a few days, elective; after at least one-two weeks of antibiotic therapy. Statistical analysis was performed via Chi square and Student T tests and a p value < 0.05 was considered significant.

Results

A total of 90 patients with an indication for surgery, 33.3% patients in underwent surgery, 66.6% patients in not underwent surgery group fulfilled the study criteria. The most frequently seen complaints in patients were fever (91.1%), cold-shiver (56.6%), weight-loss (27.7%), dyspnea (25.5%), and tachycardia (20%). Heart murmur was detected during cardiac auscultation of 44 patients. Mean blood leukocyte count, C-reactive protein and erythrocyte sedimentation rate were 12324 ± 6558/mm³ (1408-30330), 11.46 ± 8.38 mg/dl (0.18-34.6) and 61.43 ± 33.4 mm/h (2-130), respectively. There was no significant difference between two groups in terms of cardiac/non-cardiac risk factors, age, gender, etiologic agents, laboratory findings, septic embolisms and complaints (Table 1). In total IE with an indication for surgery mortality was 27.7%. Mortality rate was significantly less and heart murmur was significantly higher in cases who underwent surgery than those did not undergo surgery (p: 0.0447).

Table 1. Comparison of basic characteristics of patients in the two operated / unoperated cohorts.

Conclusion

These data support the importance of the guidelines’ criteria for cardiac surgery in the management of IE. Assuming that only 1/3 of the surgery needing cases received surgery, more interventions are needed to decrease the barriers against surgery.

Disclosures

All Authors: No reported disclosures

The deep impact of the COVID-19 pandemic on medical students: An online cross-sectional study evaluating Turkish students' anxiety

AIM

Coronavirus Disease 2019 (COVID-19) changed the delivery of medical education in Turkey by moving to an emergency remote teaching system and led to many challenges for future doctors. In this study, we aimed to explore the impact of the COVID-19 pandemic on medical students, to assess their anxiety level and their main anxiety sources related to this pandemic.

METHODS

A Google Form was distributed to medical students using the virtual snowball sampling method. The form included the Beck Anxiety Inventory and additional 19 questions on sociodemographic characteristics, perceived level of knowledge about the epidemic, self-risk perceptions of COVID-19 and their anxiety levels about some other topics related to COVID-19.

RESULTS

Overall, 3105 medical students with a mean age of 22.37 ± 2.46, took the survey. Amongst the participants, only 32% of the students defined their knowledge about the precautions that should be taken during an epidemic disease as acceptable. Students reported highest anxiety level for the continuing spread of COVID-19 in Turkey and transmitting coronavirus to another person. Clinically significant anxiety prevalence was 23.2%. Regression analysis revealed that factors that increased the risk of being anxious included being female, being other than a 5th-year student, thinking that being a medical student would increase the risk of coronavirus transmission or being uncertain about it, being exposed to a patient with COVID-19 or being uncertain about it, being anxious about the continuing spread of COVID-19 in Turkey, being anxious about acquiring COVID-19, being anxious for graduating and being on active duty, being anxious about a medical training interruption.

CONCLUSION

Our results suggest that anxiety is prevalent amongst Turkish medical students during the COVID-19 pandemic and they have a weak preparedness for a pandemic such as COVID-19. Based on our results, new strategies should be implemented for medical education and for alleviating students' anxiety levels.

Daptomycin versus teicoplanin in the treatment of osteomyelitis: Results of the Göztepe retrospective cohort study

OBJECTIVES

Daptomycin is highly effective against Gram-positive multidrug-resistant bacteria. Publications on daptomycin in osteomyelitis treatment are limited.

PATIENTS AND METHODS

In this multicenter retrospective cohort study, the aim was to evaluate the outcomes of osteomyelitis cases having received daptomycin or teicoplanin. This multicenter retrospective cohort study gathered data from seven centers located in five cities of Turkey. Study inclusion criteria were as follows: (a) magnetic resonance imaging and/or direct X-ray revealed osteomyelitis or biopsy pathologic examination results concomitant with osteomyelitis. Chi-squareand Student t-tests were used for statistical comparison.

RESULTS

A total of 72 patients, 38 cases in the daptomycin group and 34 cases in the teicoplanin group diagnosed with osteomyelitis fulfilling the study inclusion criteria, were included in the study. Clinical success at the end of induction therapy was achieved in 32/38 cases in the daptomycin cohort vs. 30/34 cases in the teicoplanin cohort (p: 0.73).

CONCLUSION

Although this is a limited experience in a small but well-defined cohort, our data suggest that daptomycin may be a safe alternative to glycopeptides in osteomyelitis treatment. A randomized controlled clinical study involving larger cohorts may increase the available evidence.

Tigecycline versus INR increase; more than expected?

Objectives: The aim of the study was to investigate the frequency of tigecycline-associated INR abnormality.Methods: Patients who were hospitalized between June and September 2016 and treated with tigecycline including therapy were extracted from hospital database and retrospectively reviewed. INR values at the beginning and end of treatment were compared.Results: A total of 79 patients who received tigecycline were identified by analyzing the hospital database. Nineteen patients were excluded from the study since INR was not measured at the beginning and/or end of treatment. In 55 of the 60 patients, INR levels were within normal limits (0.9-1.2) at the beginning of treatment while 19 of these 55 (34,5%) had prolonged INR after treatment. Prolongation was found to be mild (1.01-1.25 x ULN-upper limit of normal) in 12 of 19 patients, moderate (1.26-1.5 x ULN) in six and severe (1.51-3.0 x ULN) in one. In 10 of 19 patients, tigecycline was stopped, and the INR values normalized. There was no difference in INR abnormality rate between tigecycline monotherapy versus combination therapy receiving cases (19/27-33% vs. 10/33-30% p:1).Conclusion: These data show that INR prolongation may develop as common as 34.6% during tigecycline therapy. Regular INR follow-up may be beneficial in cases receiving tigecycline.

Retrospective evaluation of the patients with urinary tract infections due to carbapenemase producing Enterobacteriaceae

In this study, we aimed to investigate retrospectively the patients with carbapenem-resistant Enterobacteriaceae urinary tract infections (UTIs) in the terms of demographic findings, antibiotic sensitivity patterns and clinical features along with the treatment options. This study was performed at a tertiary-care educational university hospital. Adult (>18 years old) patients diagnosed with culture proven UTI due to carbapenem-resistant Klebsiella pneumoniae (between December 2016 to December 2017) were included in the study. Antimicrobial susceptibility testing of the isolates was performed with the VITEK 2 system (bioMérieux). Resistance to imipenem, ertapenem, and meropenem was tested by E-test (bioMérieux). The results were interpreted according to the EUCAST criteria. A total number of 100 patients (34% female, mean age 61.69 ± 1.65 years) were included in this study. One month all-cause mortality rate was 19%. Microbiologic eradication rate was 88.7% while it was significantly higher in combination therapy (65/70 vs. 14/19, p = 0.019) and carbapenem long-lasting (4 h) infusion subgroups (54/56 vs. 2/56, p = 0.005). Relapse and reinfection rates were 61.7 and 29.7%, respectively. Logistic regression analysis for mortality risk factors resulted as history of ertapenem usage (OR: 4.74, 95% CI: 0.678-33.201, p = 0.117), lack of microbiologic eradication (OR: 21.7, 95% CI: 1.906-247.375, p = 0.013) and ICU stay (OR: 54.8, 95% CI: 4.145-726.324, p = 0.002). Combination, carbapenem long-lasting infusion and double carbapenem therapies seem to result in higher microbiologic eradication rates and thus may effect the mortality rates of these group of patients. Randomized-controlled studies should be performed in this critical patient group to confirm these results.

618. Fluconazole-Resistant Candida albicans Vaginitis with Cross-Resistance to Azoles: A Case Report

Background

Local and systemic use of azole derivatives are common in the treatment of vulvovaginal candidiasis. However, there are cases unresponsive to these agents. Herein, we present treatment and follow-up of a patient with fluconazole–itraconazole and voriconazole-resistant recurrent vaginal candidiasis.

Methods

A 37-year-old woman with no comorbidity used topical and oral antifungal/antibacterial medications (including fluconazole and itraconazole) in the treatment of recurrent vulvovaginitis, was hospitalized due to continuous complaints. Intense, white-colored, odorless vaginal discharge was observed on physical examination. Urine and vaginal swab samples were taken for mycological and bacteriological culture. Metronidazole (500 mg 3x1 i.v.) and high dose fluconazole (600 mg/day i.v.) were initiated empirically for the possibility of dose-dependent resistant Candida infection, but there was no clinical response.

Results

Candida albicans was isolated in vaginal swab culture, but response to systemic fluconazole treatment for one week was inadequate. Antifungal susceptibility test was performed by microdilution method according to CLSI M27A3 guidelines and MIC values were reported respectively; fluconazole 4 µg/mL (SDD), itraconazole 1 µg/mL (R), posaconazole 0.06 µg/mL (WT), voriconazole 0.25 µg/mL (SDD), anidulafungin ≤ 0.015 µg/mL (S), amphotericin B 0.06 µg/mL (WT). For the resistance mechanism, point mutation in the ERG11 gene and MDR1 and MDR2 from efflux pumps were investigated and only the G464S mutation was detected in the ERG11 gene. Treatment was switched to IV anidulafungin (200 mg on day 1 followed by 100 mg/day). Clinical response was achieved in the patient whose complaints were reduced, and there was no Candida in the repeated vaginal swab culture taken on day 3 of treatment. The patient was discharged after 2 weeks of treatment. She had no recurrence after 2 years follow-up.

Conclusion

It should be kept in mind that resistant strains may be responsible for recurrent and unresponsive vulvovaginal candidiasis cases. Although there is no case report in which anidulafungin is used for treatment and it should be kept in mind that the anidulafungin is also in the treatment as it is summarized.

Disclosures

All authors: No reported disclosures.

219. Is the modified quick SOFA scale superior to quick SOFA in patients with diagnosed septic shock?

Background

In this study it was aimed to compare the effects of qSOFA (Quick Sequential Organ Failure Assessment) score with modified qSOFA score (PLoS One. 2018 Sep 26;13(9):e0204608) for predicting one month survival in patients with diagnosed septic shock (SS) in a tertiary-care educational university hospital in a developing country.

Methods

Modified qSOFA was created by adding age factor (>50 years=1 point) to patients with qSOFA scale 1 or 2 or 3 who had SS (sepsis+hypotension+adrenergic agent) and consulted by Infectious Diseases consultants between December 2013-December 2018. Arterial lactate level of >2 mmol/L criterion was added as an including criteria for SS according to 3^rd International Sepsis and Septic Shock Consensus Statement after 23^rd February 2016. Statistical analysis was performed via Chi-square test and a p-value <0.05 was considered significant.

Results

The number of patients with qSOFA score of 1 or 2 or 3 from 527 patients are in Table1 [some of the cases were diagnosed as septic shock according to elder definition (without lactate criterion) and there was a subgroup with qSOFA score 1]. Among the >50-year aged group, the 30-day survival rate was lower in patients with qSOFA3 vs. qSOFA 2 vs. qSOFA 1 (Table1, 3x2 Chi Square test, P = 0.0057). Among the <50 years group, the qSOFA one month survival rate was lower in patients with qSOFA 3 vs. qSOFA 2 vs. qSOFA 1 (Table, 3x2 Chi Square Test, P = 0.0052). According to modified qSOFA, there was a significant difference for one month survival among SS cases with scores of 1, 2, 3 and 4 (12/21 57% vs. Fifty/126 40% vs. 78/269 29% vs. 22/111 20%, 4x2 Chi-square test, P = 0.0003). On the other hand, there was no significant difference in terms of one month survival when we performed subgroup analysis in qSOFA score 1, 2, or 3 subgroups, as ≤50 years vs. >50 years (table, Chi-square test, 12/21 vs. 39/97 P = 0.224, 11/29 vs. 75/244 P = 0.526, 3/25 vs. 22/111 P = 0.572).

Conclusion

In terms of survival at one month, there was a significant difference between qSOFA score 1, 2, 3 and 4 subgroups. In patients with qSOFA score of 1 or 2 or 3, being under 50 years did not have a significant effect on one-month survival. Modified qSOFA may be beneficial to foresee the probable mortality but these findings need to be validated in larger cohorts

Disclosures

All authors: No reported disclosures.

Systematic review of Lyme disease in Turkey

A systematic review was conducted with the aim of describing the demographical data, features and outcomes of patients with Lyme disease (LD), reported from Turkey. Three international database (electronic PubMed, Web of Science and Scopus) and two national database (Ulakbim and Turkmedline) searches were performed using the following keywords (['Lyme' or 'Borrelia burgdorferi' or 'Borrelia' or 'Borreliosis'] and 'Turkey [and/country]'). National Notifiable Diseases Surveillance System (NNNDS) of Centers for Disease Control and Prevention (CDC) criteria were used for classification. A PRISMA-based algorithm was used for systematic review. There were a total of 75 LD cases in 36 different reports. Studies related to LD are confined to case reports. We believe that LD is an important healthcare problem in Turkey and to our knowledge this is the first systematic review from this country.

Pooled analysis of 1270 infective endocarditis cases in Turkey

INTRODUCTION

Despite developments in medicine, infective endocarditis (IE) is still associated with significant morbidity and mortality. In this study it was aimed to systematically review the infective endocarditis literature published or presented from Turkey.

METHODS

To find the published series, one national database (Ulakbim), and three international databases (Scopus, Pubmed and Sci-e) were searched between 31 October-3 November 2014. also, abstracts of congresses by three national congresses were searched for studies regarding infective endocarditis.

RESULTS

Data for 1270 patients (38.3% female, mean age 46.2, 28% prosthetic valve endocarditis) with a diagnosis of infective endocarditis were obtained from 21 reports (18 published articles and three congress abstracts). Of the 18 articles, four were in peer-reviewed medical journals indexed in national databases and 14 were in international databases. There was an underlying heart disease in 51.9% and history of dental procedure was 6.7%. Fever, heart murmur and fatigue were present in 94%, 71.4% and 69% respectively. most commonly involved site was mitral valve (43.3%), followed by aortic (33.8%) and tricuspid valve (6.4%). Staphylococcus aureus, coagulase-negative staphylococci and enterococci comprised the 22.8%, 9.7% and 7.5% of the cases while 31.1% were culture-negative. Overall mortality was 23.4%. When we compared series related to years 2008 and before and 2009 and after, the mortality rates were (24.1%-224/931) vs (20.1%-32/159), respectively (p = 0,31).

CONCLUSION

Infective endocarditis is still associated with significant mortality. S. aureus seems to be the most common etiologic agent. There was a slight decrease in the recent years in mortality.

Correction to: Prediction of unfavorable outcomes in cryptococcal meningitis: results of the multicenter infectious Diseases International Research Initiative (ID-IRI) cryptococcal meningitis study

In the original version of this article, Mustafa Sunbul was not included in the list of authors for this article. The name has been added accordingly.

[Investigation of bacterial and viral etiology in community acquired central nervous system infections with molecular methods]

In this multicenter prospective cohort study, it was aimed to evaluate the bacterial and viral etiology in community-acquired central nervous system infections by standart bacteriological culture and multiplex polymerase chain reaction (PCR) methods. Patients hospitalized with central nervous system infections between April 2012 and February 2014 were enrolled in the study. Demographic and clinical information of the patients were collected prospectively. Cerebrospinal fluid (CSF) samples of the patients were examined by standart bacteriological culture methods, bacterial multiplex PCR (Seeplex meningitis-B ACE Detection (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes, Group B streptococci) and viral multiplex PCR (Seeplex meningitis-V1 ACE Detection kits herpes simplex virus-1 (HSV1), herpes simplex virus-2 (HSV2), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein Barr virus (EBV) and human herpes virus 6 (HHV6)) (Seeplex meningitis-V2 ACE Detection kit (enteroviruses)). Patients were classified as purulent meningitis, aseptic meningitis and encephalitis according to their clinical, CSF (leukocyte level, predominant cell type, protein and glucose (blood/CSF) levels) and cranial imaging results. Patients who were infected with a pathogen other than the detection of the kit or diagnosed as chronic meningitis and other diseases during the follow up, were excluded from the study. A total of 79 patients (28 female, 51 male, aged 42.1 ± 18.5) fulfilled the study inclusion criteria. A total of 46 patients were classified in purulent meningitis group whereas 33 were in aseptic meningitis/encephalitis group. Pathogens were detected by multiplex PCR in 41 patients. CSF cultures were positive in 10 (21.7%) patients (nine S.pneumoniae, one H.influenzae) and PCR were positive for 27 (58.6%) patients in purulent meningitis group. In this group one type of bacteria were detected in 18 patients (14 S.pneumoniae, two N.meningitidis, one H.influenzae, one L.monocytogenes). Besides, it is noteworthy that multiple pathogens were detected such as bacteria-virus combination in eight patients and two different bacteria in one patient. In the aseptic meningitis/encephalitis group, pathogens were detected in 14 out of 33 patients; single type of viruses in 11 patients (seven enterovirus, two HSV1, one HSV2, one VZV) and two different viruses were determined in three patients. These data suggest that multiplex PCR methods may increase the isolation rate of pathogens in central nervous system infections. Existence of mixed pathogen growth is remarkable in our study. Further studies are needed for the clinical relevance of this result.

Tigecycline-based prolonged salvage therapy in patients presenting with complex bone and joint infection

OBJECTIVES

To assess the clinical experience of tigecycline-based salvage therapy in patients presenting with Bone and Joint Infections (BJI).

PATIENTS AND METHODS

Multicenter retrospective cohort study in France and Turkey (2007-2014).

RESULTS

Thirty-six patients (age 58.2±17.8 years; 21 men) were included. The most frequently isolated bacteria were Enterobacteriaceae and staphylococci. Tigecycline (50mg BID, mainly in combination (69.4%), mean duration of 58 days) was indicated for multidrug resistance (90.6%) and/or previous antibiotic intolerance (36.1%), and/or as second- or third-line therapy (69.4%). Six patients (16.7%) experienced early treatment discontinuation for adverse event (4 severe vomiting, 1 pancreatitis, 1 asymptomatic lipase increase). Clinical success was observed in 23 of 30 assessable patients who completed the tigecycline therapy (mean follow-up: 54.1±57.7 weeks).

CONCLUSION

Prolonged tigecycline-based therapy could be an alternative in patients presenting with BJI requiring salvage therapy, especially if multidrug-resistant Enterobacteriaceae and/or staphylococci are involved.

Antibacterial resistance patterns and incidence of hospital-acquired Staphylococcus aureus bacteremia in a tertiary care educational hospital in Turkey: a perspective from 2001 to 2013

Background/aim: Staphylococcus aureus is an important nosocomial pathogen and a successful antimicrobial-resistance developer. In this study we retrospectively evaluated the resistance patterns and incidence of microbiologically confirmed nosocomial bacteremia (MCNB) related S. aureus strains between 2001 and 2013. Materials and methods: Any patient in whom S. aureus was isolated in at least one set of blood cultures (sent to the bacteriology laboratory 72 h after hospital admission) was considered to have MCNB. Results: The methicillin-resistant S. aureus (MRSA) rate in 2001 was 73.8% whereas it was 36.2% in 2013. When the 2001-2003 and 2011?2013 periods were compared, resistance to oxacillin, levofloxacin, gentamicin, erythromycin, and clindamycin decreased significantly (P < 0.05). When we evaluated the total S. aureus, MRSA, and methicillin-sensitive S. aureus (MSSA) bacteremia rates per 1000 days and 1000 patients, there was an increase in the 2004?2005 period, which was followed by a slight decrease until 2013 (P < 0.05). There was a plateau in MCNB-related S. aureus rates between 2008 and 2011. Conclusion: There was a decrease in overall S. aureus and MRSA bacteremia incidence as well as MRSA rates except for a plateau between 2008 and 2011. This steady decrease in the resistance rates is most probably due to the 2003 budget application and application of antimicrobial stewardship.

The burden and epidemiology of community-acquired central nervous system infections: a multinational study

Risk assessment of central nervous system (CNS) infection patients is of key importance in predicting likely pathogens. However, data are lacking on the epidemiology globally. We performed a multicenter study to understand the burden of community-acquired CNS (CA-CNS) infections between 2012 and 2014. A total of 2583 patients with CA-CNS infections were included from 37 referral centers in 20 countries. Of these, 477 (18.5%) patients survived with sequelae and 227 (8.8%) died, and 1879 (72.7%) patients were discharged with complete cure. The most frequent infecting pathogens in this study were Streptococcus pneumoniae (n = 206, 8%) and Mycobacterium tuberculosis (n = 152, 5.9%). Varicella zoster virus and Listeria were other common pathogens in the elderly. Although staphylococci and Listeria resulted in frequent infections in immunocompromised patients, cryptococci were leading pathogens in human immunodeficiency virus (HIV)-positive individuals. Among the patients with any proven etiology, 96 (8.9%) patients presented with clinical features of a chronic CNS disease. Neurosyphilis, neurobrucellosis, neuroborreliosis, and CNS tuberculosis had a predilection to present chronic courses. Listeria monocytogenes, Staphylococcus aureus, M. tuberculosis, and S. pneumoniae were the most fatal forms, while sequelae were significantly higher for herpes simplex virus type 1 (p < 0.05 for all). Tackling the high burden of CNS infections globally can only be achieved with effective pneumococcal immunization and strategies to eliminate tuberculosis, and more must be done to improve diagnostic capacity.

Pooled analysis of 899 nosocomial meningitis episodes from Turkey

BACKGROUND/AIM

Healthcare-associated meningitis (HCAM) is a relatively rare entity with significant morbidity and mortality. The aim of this study was to systematically review the Turkish medical literature for acute nosocomial meningitis.

MATERIALS AND METHODS

One national (ULAKBİM) and two international (www.scopus.com and www.pubmed.com) databases were searched. In addition, abstracts of four national congresses held between 2004 and 2013 were searched for reports for HCAM meningitis.

RESULTS

Data for 899 HCAM meningitis episodes were obtained from 24 reports. In terms of clinical findings, 177 of 216 (81.9%) had fever (>38 °C), 55 of 64 (85.9%) had high CRP levels, 105 of 132 had leukocytosis (>10,000/mm³), and 241 of 759 had shunt infection. Cerebrospinal fluid culture yielded a pathogen in 689 of 872 nosocomial meningitis episodes. The most common pathogen was Acinetobacter spp. (30.7%), followed by coagulase-negative staphylococci (21.2%) and Staphylococcus aureus (19%). Carbapenem resistance was reported in 18 of 48 (37.5%) Acinetobacter spp. Overall mortality was 160/593 (27%). Pathogen-specific mortality was 55.5% (30/54) for A. baumannii whereas it was 18.9% (7/37) for S. aureus and 2/17 (11,7%) for MRSA.

CONCLUSION

Nosocomial meningitis is still a serious and highly fatal disease. More preventive measures should be sought to further decrease HCAM meningitis and the mortality/morbidity related to it.

Managing atypical and typical herpetic central nervous system infections: results of a multinational study

There have been many studies pertaining to the management of herpetic meningoencephalitis (HME), but the majority of them have focussed on virologically unconfirmed cases or included only small sample sizes. We have conducted a multicentre study aimed at providing management strategies for HME. Overall, 501 adult patients with PCR-proven HME were included retrospectively from 35 referral centres in 10 countries; 496 patients were found to be eligible for the analysis. Cerebrospinal fluid (CSF) analysis using a PCR assay yielded herpes simplex virus (HSV)-1 DNA in 351 patients (70.8%), HSV-2 DNA in 83 patients (16.7%) and undefined HSV DNA type in 62 patients (12.5%). A total of 379 patients (76.4%) had at least one of the specified characteristics of encephalitis, and we placed these patients into the encephalitis presentation group. The remaining 117 patients (23.6%) had none of these findings, and these patients were placed in the nonencephalitis presentation group. Abnormalities suggestive of encephalitis were detected in magnetic resonance imaging (MRI) in 83.9% of the patients and in electroencephalography (EEG) in 91.0% of patients in the encephalitis presentation group. In the nonencephalitis presentation group, MRI and EEG data were suggestive of encephalitis in 33.3 and 61.9% of patients, respectively. However, the concomitant use of MRI and EEG indicated encephalitis in 96.3 and 87.5% of the cases with and without encephalitic clinical presentation, respectively. Considering the subtle nature of HME, CSF HSV PCR, EEG and MRI data should be collected for all patients with a central nervous system infection.

Infections in travellers returning to Turkey from the Arabian peninsula: a retrospective cross-sectional multicenter study

Mass gatherings pooling people from different parts of the world—the largest of which is to Mecca, Saudi Arabia, for Hajj—may impose risks for acquisition and dissemination of infectious diseases. A substantial number of pilgrims to Hajj and Umrah are Turkish citizens (456,000 in 2014) but data are lacking on scale of the problem. We did a retrospective cross-sectional multicenter study in Turkey to explore the range of infections among inpatients who had recently returned from the Arabian Peninsula. Our inclusion criteria were patients who had acquired an infection during their trip to an Arabian Peninsula country, or who became symptomatic within 1 week of their return. The data were collected retrospectively for January 1, 2013 and March 1, 2015. 185 Turkish patients were recruited to the study across 15 referral centers with travel associated infectious diseases after returning from Arabian Peninsula countries (predominantly Saudi Arabia 163 [88.1 %] for religious purposes 162 [87.5 %]). Seventy four (40.0 %) of them were ≥ 65 years old with numerous comorbidities including diabetes (24.3 %) and COPD (14.1 %). The most common clinical diagnosis was respiratory tract infections (169 [91.5 %]), followed by diarrheal diseases (13 [7 %]), and there was one case of MERS-CoV. Patients spent a median of 5 (3–7) days as hospital inpatients and overall mortality was 1.1 %. Returning travellers from the Arabian Peninsula present as inpatients with a broad range of infectious diseases similar to common community acquired infections frequently seen in daily medical practices in Turkey.

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.

[Publication rates of Turkish medical specialty and doctorate theses on Medical Microbiology, Clinical Microbiology and Infectious Diseases disciplines in international journals]

Writing a thesis is mandatory for getting a postgraduate medical degree in Turkey. Publication of the results of the thesis in an indexed journal makes the results available to researchers, however publication rate is usually low. The aim of this retrospective observational study was to investigate the publication rate of Turkish Infectious Diseases and Clinical Microbiology, Medical Microbiology specialty theses and Microbiology doctorate theses in international peer-review journals. On August 17th 2007, the thesis database of the Council of Higher Education of the Republic of Turkey (YOK) where all specialization and doctorate theses are recorded obligatorily, was searched for Infectious Diseases and Clinical Microbiology and Medical Microbiology specialty and Microbiology doctorate theses. Assuming that publication of a thesis would last at least six months, theses dated to February 2007 and after were excluded. The publication rate of those theses was found out by searching Science Citation Index-Expanded database for thesis author and supervisor between August 17-September 12, 2007. Chi-square test was used for statistical analysis. Our search yielded a total of 834 theses dated from 1997 to 2007, however 10 of them were excluded, since they were dated to February 2007 or after. It was found that the overall publication rate was 11.4% (94/824). The publication rates for Microbiology doctorate, Medical Microbiology and Infectious Diseases and Clinical Microbiology specialty theses were 13.7% (34/249), 10.7% (33/309) and 10.2% (27/266), respectively, with no statistical significance (p> 0.05). It was determined that nine (9.6%) of the 94 published theses belonged to 1997-2001 period, whereas 85 (80.4%) were in 2002-2007 period (p< 0.05). The probable reason for this increase was thought to be related with the updated criteria of YOK carried out in 2000 for academic promotions, nevertheless the publication rate of the investigated theses in international peer-review journals was still low. Thesis is an important part of specialty and doctorate education and necessitates intense work. The created knowledge usually contains important data about the country and the world. Publication of the theses supplies dissemination of new knowledge and completes the process of a scientific study. Solutions must be generated to promote the publication of specialty and doctorate theses.

Bacterial and viral etiology in hospitalized community acquired pneumonia with molecular methods and clinical evaluation

Introduction: Polymerase chain reaction (PCR) method has improved the diagnosis rates for patients with community-acquired pneumonia (CAP). We aimed to evaluate the bacterial and viral etiology of hospitalized CAP cases and compare clinical and laboratory findings of patients with pure bacterial and bacterial and viral (mixed) infections. Methodology: A total of 55 patients hospitalized with CAP were enrolled into the prospective study between February 2010 and December 2010. Clinical and laboratory follow-up were performed on days 0, 7 and 14. Deep tracheal aspiration samples were examined for bacterial and viral pathogens by multiplex PCR, and standard bacteriological culture method. Results: The etiological identification rate in 50 patients for bacteria, viruses and mixed virus–bacteria combination by PCR were 62%, 4%, 32%, respectively and 60% in 55 patients by bacterial culture method. Streptococcus pneumoniae concomitant with Haemophilus influenzae (36%) and rhinovirus (16%) was very common, whereas atypical pathogens (only Mycoplasma pneumoniae) were rare (6%). Rhinovirus was the most common viral agent (20%). Recently identified viruses, human coronavirus HKU1 and human bocavirus were not detected except for human metapneumovirus (one case). There was no significant difference in terms of mean age, immune status, leukocyte count, C-reactive protein (CRP) values, hospitalization duration and CURB-65 score between bacterial and mixed viral-bacterial detections. Advanced age (p < 0.01) and higher CURB-65 score (p = 0.01) were found to be associated with increased mortality. Conclusion: Concomitance of bacterial and viral agents is frequent and resemble with bacterial infections alone. Further studies are needed for the clinical significance of mixed detections.

Piperacillin/tazobactam vs. cefoperazone/sulbactam in adult low-risk febrile neutropenia cases

AIM

The aim of this study was to compare the efficacy of piperacillin/tazobactam (P/T) and cefoperazone/sulbactam (C/S) in the empirical treatment of adult neutropenic fever.

METHODS

Data and outcomes of low-risk adult cases with neutropenic fever and treated with P/T (4.5 g q6h) or C/S (2 g q8h) between 2005 and 2011 June were extracted from our database. Risk evaluation was made according to criteria of Multinational Association for Supportive Care in Cancer (MASCC) and a score of ≥ 21 was considered as low risk. Data were collected prospectively by daily visits and evaluated retrospectively. Primary outcome was - fever defervescence at 72 h in combination with success without modification (referring to episodes where the patient recovered from fever with disappearance of signs of infection without modification to initial empirical treatment). All-cause mortality referred to death resulting from a documented or presumed infection or unidentified reason during the treatment and 30-day follow-up period.

RESULTS

A total of 172 patients (113 cases P/T and 59 cases C/S) fulfilled the study inclusion criteria. Persistent response in P/T arm was 73.5%, whereas it was 64.5% in C/S arm (p > 0.05). Rates of any modification were also similar in both treatment arms. All-cause mortality during the treatment and 30-day follow-up period was not significantly different (P/T: 4/113 vs. C/S: 2/59, p > 0.05). There was no severe adverse effect requiring antibiotic cessation in both cohorts.

CONCLUSION

In conclusion, our data suggest that C/S may be a safe alternative to P/T in the empirical treatment of adult low-risk febrile neutropenia cases.

[Risk factors for gastrointestinal colonization by ESBL-producing Klebsiella pneumoniae and Escherichia coli in anaesthesiology and reanimation intensive care unit]

In this study it was aimed to investigate the risk factors for gastrointestinal colonization by extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae and Escherichia coli in intensive care unit (ICU) of anaesthesiology and reanimation, Ege University Faculty of Medicine, Izmir, Turkey. This study was performed prospectively on adult patients hospitalized in ICU of anaesthesiology and reanimation and rectal swab cultures were performed in all patients in the first 48 hours of hospitalization and every one week until discharge or death. Samples were transported to the laboratory in Stuart transport medium and were cultured on two EMB agar plates (one including 4 mg/L ceftazidime) and incubated for 48 hours. E.coli and K.pneumoniae isolates were identified by conventional methods. Antibiotic susceptibility tests were performed by disc diffusion method on Mueller Hinton agar and interpreted according to CLSI guidelines. ESBL was confirmed by double disc synergy test. A total of 140 patients (49 female 91 male; age range: 18-83 years, mean age: 56.3 years) were evaluated, and 41 (29.3%) of the patients were found to be colonized with ESBL positive E.coli (n= 39) or K.pneumoniae (n= 2). The mean time for colonization was 11.15 ± 10.91 (range between 2-39) days. Age and gender of the patients and antibiotic consumption before or during the stay in ICU of anaesthesiology and reanimation were not found to be associated with colonization (p> 0.05). However length of ICU of anaesthesiology and reanimation stay in colonized patients was longer than non-colonized patients (27.59 ± 22.52 vs. 17.78 ± 11.74 days; p< 0.05). Infectious episodes developed in 22% (9/41) of the colonized cases and three of the nine strains were isolated from the blood cultures, five from the urine cultures and one from both blood and bronchoalveolar lavage cultures. ESBL-positive E.coli or K.pneumoniae colonization was found as an independent risk factor for the development of infection (9/41 vs. 4/99 cases; p= 0.002). Forward logistic regression analysis revealed that diabetes mellitus, immunosuppresive drug use and length of intubation were associated with ESBL-positive E.coli or K.pneumoniae colonization (p< 0.05). The results of this study indicated that the risk of development of infection was significantly high in intensive care patients colonized by ESBL positive E.coli and K.pneumoniae and the identification of the related risk factors was critically important for the establishment of effective control measures.

[Co-occurence of visceral leishmaniasis and lymphoma]

Clinicians have usually considered malignancies during follow up of patients who have infectious diseases as a pre-diagnosis. However, malignancy and an infectious disease are seen together more rarely, with the exception of immunosuppressed patients. This presentation is a case report followed up for fever of unknown origin. The patient was admitted to the hospital with the symptoms of fever, weight loss, abdominal pain and weakness. Anemia and hypergamaglobulinemia by biochemical analyses and splenomegaly by total body computed tomography were detected. Amastigotes were seen in bone marrow aspiration smears and promastigotes were isolated in NNN medium. At the end of the Liposomal Amphotericin B treatment, control bone marrow aspiration was applied. Leishmania amastigotes were not seen, while patient was diagnosed as diffuse B cell lymphoma pathologically.

[Mucormycosis: retrospective evaluation of 12 cases]

Mucormycosis is a rare and often fatal invasive fungal infection. Disseminated or pulmonary forms are common in patients with immune deficiency while rhinocerebral form is common in diabetes mellitus. The aim of this study was to evaluate retrospectively the adult mucormycosis cases which were followed up in our hospital between 2007-2010. The cases were evaluated in terms of demographic characteristics, underlying diseases, laboratory, clinical and treatment results. A total of 12 mucormycosis cases (6 were male; age range: 18-74 years; mean age: 50.83 ± 18.27 years) were evaluated. Ten of the 12 cases had definitive diagnosis of invasive fungal infection according to EORTC/MSG (European Organization for Research and Treatment of Cancer/Mycoses Study Group) criteria whereas two had possible mucormycosis. Six cases had rhinoorbital, four had rhinocerabral, one had pulmonary and one had rhinocerebral and pulmonary mucormycosis. Fever (n= 10; 83%), edema in face (n= 8; 67%) and eyes (n= 6; 50%) were the most common symptoms and findings. Mycologic culture was performed in ten cases and was found positive in five cases (four cases had Rhizopus spp. one case had Mucor). In two cases direct microscopy revealed mycelium but culture did not yield any pathogen. Two cases had concomitant Aspergillus spp. growth. Overall mortality rate was determined as 50% (6/12). All of the cases received antifungal therapy (liposomal amphotericin B and posaconazole or itraconazole), however, surgical intervention was applied to five cases. Mean duration of antifungal treatment was 60.8 ± 47.4 days. Mortality rate was lower in cases who received concomitant surgical therapy, but the difference was not found statistically significant (2/5 vs. 4/7, p> 0.05). Hematologic diseases (n= 6) and diabetes mellitus (n= 3) were the most common underlying diseases in mucormycosis cases. Voriconazole prophylaxis applied to three cases with hematologic diseases was detected as a risk factor. Development of mucormycosis in those cases who were under voriconazole prophylaxis, deserves attention. Since this is the largest 3-years series of adult mucormycosis cases reported from a single center and includes the first cases treated with posaconazole, the results of this evaluation may aid to the management of patients with mucormycosis.

Did the pandemic have an impact on influenza vaccination attitude? A survey among health care workers

Background

Health care workers' (HCWs) influenza vaccination attitude is known to be negative. The H1N1 epidemic had started in mid 2009 and made a peak in October-November in Turkey. A national vaccination campaign began on November 2^nd, 2009. Despite the diligent efforts of the Ministry of Health and NGOs, the attitudes of the media and politicians were mostly negative. The aim of this study was to evaluate whether HCWs' vaccination attitudes improved during the pandemic and to assess the related factors.

Methods

This cross-sectional survey was carried out at the largest university hospital of the Aegean Region-Turkey. A self-administered questionnaire with 12 structured questions was applied to 807 HCWs (sample coverage 91.3%) before the onset of the vaccination programme. Their final vaccination status was tracked one week afterwards, using immunization records. Factors influencing vaccination rates were analyzed using ANOVA, t-test, chi-square test and logistic regression.

Results

Among 807 participants, 363 (45.3%) were doctors and 293 (36.6%) nurses. A total of 153 (19.0%) had been vaccinated against seasonal influenza in the 2008-2009 season. Regarding H1N1 vaccination, 143 (17.7%) were willing to be vaccinated vs. 357 (44.2%) unwilling. The number of indecisive HCWs was 307 (38.0%) one week prior to vaccination. Only 53 (11.1%) stated that they would vaccinate their children. Possible side effects (78%, n = 519) and lack of comprehensive field evaluation before marketing (77%, n = 508) were the most common reasons underlying unwillingness or hesitation.

Among the 749 staff whose vaccination status could be tracked, 228 (30.4%) actually received the H1N1 vaccine. Some of the 'decided' staff members had changed their mind one week later. Only 82 (60%) of those willing, 108 (37%) of those indecisive and 38 (12%) of those unwilling were vaccinated.

Indecisive HCWs were significantly younger (p = 0.017). Females, nurses, and HCWs working in surgical departments were more likely to reject vaccination (p < 0.05). Doctors, HCWs working in medical departments, and HCWs previously vaccinated against seasonal influenza were more likely to accept vaccination (p < 0.05). Being younger than 50 and having been vaccinated in the previous season were important predictors of attitude towards pandemic influenza vaccination.

Conclusions

Vaccination rates increased substantially in comparison to the previous influenza season. However, vaccination rates could have been even higher since hesitation to be vaccinated increased dramatically within one week (only 60% of those willing and the minority of those indecisive were finally vaccinated). We speculate that this may be connected with negative media at the time.

Carbapenem versus fosfomycin tromethanol in the treatment of extended-spectrum beta-lactamase-producing Escherichia coli-related complicated lower urinary tract infection

The aim of this observational prospective study was to compare the effect of fosfomycin tromethanol (FT) and carbapenems (meropenem or imipenem cilastatin) in the treatment of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli-related complicated lower urinary tract infection (CLUTI). Inclusion criteria were: patients who were aged >18 yr with dysuria or problems with frequency or urgency in passing urine; those with >20 leukocytes/mm³ in urine microscopy and culture-proven ESBL-producing carbapenem or FT-sensitive E. coli in the urine (>10⁵ cfu/mm³); no leukocytosis or fever; and who were treated with ft (oral 3 g sachet x 1 every other night, three times) or carbapenems between march 2005 and January 2006 in our outpatient clinic and hospital. A total of 47 CLUTI attacks in 47 patients (27 FT group, 20 carbapenem group) were observed prospectively. Clinical and microbiological success in the carbapenem and ft groups was similar (19/20 vs 21/27 and 16/20 vs 16/27 p>0.05). Drug acquisition costs were significantly lower in the FT group (p<0.001). Although it is not a randomized controlled study, these data show that ft may be a suitable, effective and cheap alternative in the treatment of ESBL-producing E. coli-related CLUTI.

Nursing students' immunisation status and knowledge about viral hepatitis in Turkey: a multi-centre cross-sectional study

BACKGROUND

The aims of this multi-centre cross-sectional survey were to detect Turkish nursing students' level of knowledge on viral hepatitis, to evaluate their rates of exposure to blood and to find out their hepatitis A (HAV), hepatitis B (HBV) vaccination status.

METHODS

This multi-centre cross-sectional study was conducted in 14 nursing schools located in the seven geographical regions of Turkey. A questionnaire composed of 47 questions on socio-demographic factors, level of knowledge on HAV, HBV, hepatitis C (HCV) immunisation status, exposure history and attitudes was applied to the study group.

RESULTS

A total of 1491 third- and fourth-year nursing students participated with an 89% response rate. The mean age of the participating students was 21.4 ± 1.3. Their mean knowledge score was 23.7 ± 4.6 (71/100) and was significantly higher in fourth-year students than third-year students. There were significant differences in mean scores among nursing schools. Among the participants, 85.3% had received HBV vaccine and 9.1% had received HAV vaccine. The percentage of students who signify themselves at increased risk of acquiring viral hepatitis was 97.3%. Of the students, 28.1% had sustained a needle-stick injury and 5.4% had experienced conjunctival exposure to blood.

CONCLUSIONS

Curriculum differences among nursing schools have a significant effect on nursing students' level of knowledge. For this reason, nursing schools should organize HBV immunisation programmes for their students to increase vaccination coverage.

[A case of cerebral abscess due to methicillin-resistant Staphylococcus aureus which is treated with linezolid + rifampin combination]

Methicillin-resistant Staphylococcus aureus (MRSA) is a rare cause of cerebral abscesses, however it is a relatively more common etiologic agent in post-neurosurgical abscesses and the main antibacterial therapy option is vancomycin. In this report, a case of brain abscess due to MRSA which did not respond neither to moxifloxacin + vancomycin nor vancomycin + rifampin combination therapies, and merely treated by linezolid + rifampin combination, has been presented. Fifty-one years old female patient who was operated 40 days ago for subarachnoid bleeding and aneurysm in middle cerebral artery bifurcation, was hospitalized due to purulent leakage from the operation area. She did not have fever and her physical examination, including the neurologic system, was normal. Computerized tomography revealed an approximately 1 cm lesion compatible with subdural empyema and cerebral abscess in the right frontoparietal area in supratentorial sections. The patient was operated for wound revision and moxifloxacin was initiated. Since the operation materials revealed MRSA growth, vancomycin (4 x 500 mg, IV) was added to the treatment. The isolate was identified by conventional methods, and antibiotic susceptibility test performed by disk diffusion method showed that it was susceptible to levofloxacin, linezolid, rifampin, vancomycin and teicoplanin. Since no clinical response was obtained in two weeks, moxifloxacin was switched to rifampin (300 mg 1 x 2). On the 10th day of vancomycin + rifampin therapy, radiological findings showed development of cerebritis and therefore vancomycin was changed with linezolid (2 x 600 mg, IV). The control CT of the patient revealed regression of the brain lesion and linezolid + rifampin treatment continued for six weeks. The patient did not develop any hematological, liver or renal toxicity during the therapy and the radiological findings regressed. No relapse were detected in the one year follow-up period. This case suggested that linezolid might be a treatment alternative in the therapy of vancomycin-refractory MRSA brain abscess.

[Evaluation of 694 tuberculous lymphadenitis cases reported from Turkey between 1997-2009 period by pooled analysis method]

Tuberculosis which mainly involves the lungs, can also cause infection in almost all other organs and tissues in the body. One of the most common forms of extrapulmonary tuberculosis is tuberculous lymphadenitis. In this study, tuberculous lymphadenitis cases reported from Turkey in national and international journals in the last 12 years, were reviewed systematically with pooled-analysis method. Related articles were retrieved by search of three national (Ulakbim Turkish Medical literature databases, http://www.turkishmedline.com, http://medline.pleksus.com.tr) and two international databases [PubMed and Science Citation Index (SCI)]. Between the years 1997-2009, tuberculous lymphadenitis cases have been published in a total of 44 articles (13 international, 31 national data base). These articles included a total of 694 tuberculous lymphadenitis cases (62.4% women, 37.6% men; mean age 37.5 years). The distribution of the lymph nodes involved was determined in 528 cases and the most commonly involved areas were cervical (61.4%), mediastinal (20.5%) and axillary (6.4%) areas. The most common complaints of patients were fever (15.8%), weight loss (14.5%), malaise-fatigue (13.1%) and sweating (12.4%). Tuberculous lymphadenitis was identified in 10.6% (51/479) of the cases by direct microscopical examination, in 15.9% (65/408) by culture and in 648 cases from whom biopsies were taken, by histopathological examination. Tuberculin skin test positivity was detected in 78.9% (377/478) cases. History of contact with active tuberculosis patients was determined in 24.2% (88/364) of the patients. Coexisting lung tuberculosis was detected in 7.8% (54/694) of the cases. The total number of cases that had died was four; two cases due to malignancy, one due to sepsis and one due to central nervous system tuberculosis that have developed four years following the diagnosis of tuberculous lymphadenitis. Since microbiological diagnosis is difficult in tuberculous lymphadenitis and not available in all centers, evaluation of the patients' history and clinical findings are of great importance. This pooled analysis which enabled the evaluation of a large number of tuberculous lymphadenitis cases, indicated that in countries where tuberculosis is widespread, careful evaluation of clinical findings and a good microbiological and histopathological investigation will provide valuable support for diagnosis and treatment of tuberculous lymphadenitis.

[Streptococcus equisimilis associated septic arthritis/prosthetic joint infection]

Group C streptococci are flora members of skin, nasopharynx, gastrointestinal and genitourinary systems. They are rare causes of human pharyngitis, arthritis, pneumonia, meningitis and bacteremia. In this report, a 71-years old male patient with Streptococcus equisimilis arthritis/prosthetic joint infection has been presented. The patient was admitted to the emergency service with the complaints of erythema, swelling and tenderness on right knee which had total knee prosthesis. Examination of synovial fluid punction sample yielded abundant amount of leukocytes (> 1000 cells/mm3). Empirical ampicillin-sulbactam (1 g q6h, parenterally) therapy was initiated. Bacteria which have been cultivated from synovial fluid specimen were identified as S. equisimilis. The isolate was found to be susceptible to penicilin, erythromycin and teicoplanin, and resistant to chloramphenicol and tetracycline. Although clinical presentation improved during the first ten days, symptoms recurred after the 10th day and the therapy was switched to teicoplanin. The recurrence was thought to be the result of antibiotic tolerence. The patient was treated successfully with teicoplanin, and no relapse or reinfection was observed during one year of follow-up. To our knowledge this is the first case of S. equisimilis arthritis reported from Turkey and first case of S. equisimilis associated prosthetic joint infection.

[A rare cause of catheter-related bacteremia: Rhizobium radiobacter]

Rhizobium spp. (R. radiobacter, R. rhizogenes, R. rubi, R. vitis) are aerobic, motile, non-spore forming, oxidase-positive, gram-negative bacilli. Although they are mostly plant pathogens, R. radiobacter may cause human infections. The aim of this report was to present a case of R. radiobacter bacteremia treated with levofloxacin. Twenty-seven year old male patient had fever after receiving chemotherapy due to osteosarcoma. The infection focus could not be detected in the initial physical examination. Blood cultures were obtained from peripheral veins and central catheter and levofloxacin (500 mg/day) was started as empirical therapy. His fever resolved on the next day. Meanwhile cultures of blood (Bact/Alert automated systems, bioMerieux, Durham, NC) obtained from peripheral veins and central catheters yielded bacteria which were identified as R. radiobacter by VITEK 2 (bioMerieux Inc, Mercy L'etoil, France). The strain was resistant to amikacin and sensitive to ceftazidime, ciprofloxacin, imipenem, meropenem and piperacillin/tazobactam. The patient was diagnosed as catheter-related bacteremia and the treatment was continued for 14 days. His catheter was not removed since subsequent cultures did not reveal any bacterial growth. In conclusion this case suggests that R. radiobacter may cause infections especially in immunocompromised patients with catheters or prosthetic devices. To our knowledge this is the first R. radiobacter case reported from Turkey and the first case of R. radiobacter bacteremia reported to be treated with levofloxacin in the literature.

[Extended-spectrum beta-lactamase production and antimicrobial resistance patterns of Klebsiella pneumoniae strains isolated from nosocomial bacteremic patients: evaluation of the results of 2001-2005 period]

Extended spectrum beta-lactamase (ESBL) producing Klebsiella pneumoniae is a global health problem. This study was aimed to retrospectively evaluate the resistance patterns of K. pneumoniae strains, microbiologically proven as agents of nosocomial bacteremia, between 2001-2005 and also to compare the 2001-2002 and 2004-2005 data to investigate the effect of 2003 budget application on antimicrobial resistance in our country. Data of antimicrobial resistance and hospital admission dates were extracted from the hospital patient record database. 2003 data was excluded to better evaluate the probable effect of governmental antibiotic restriction policy, which was started in March 2003. Blood cultures were performed on Bact/Alert (bioMerieux, Durham, NC) automated system and bacterial identifications were done by conventional methods. Double or more isolates during each episode were counted as one episode. Antibacterial susceptibility testing was done by disc diffusion method according to the recommendations of Clinical Laboratory Standards Institute. Resistance patterns in the 2001-2002 and 2004-2005 periods were compared by chi-square test. No resistance to carbapenems were detected in the strains. The comparison of 2001-2002 and 2004-2005 periods revealed that resistance to amikacin (30% and 19%, respectively), cefuroxime (55% and 37%, respectively), amoxycillin/clavulonate (59% and 46%, respectively), piperacillin/tazobactam (51% and 39%, respectively) and cotrimoxazole (53% and 35%, respectively) were decreased significantly (p < 0.05). The rate of ESBL K. pneumoniae strains was 49% in 2001-2002 period while it decreased to 35% in 2004-2005 period (p < 0.025). The decrease in the resistance rates after the 2003 budget application suggested that this success could be attributed to the evaluation of each patient to be given an extended spectrum antibiotic, by an infectious disease specialist and also more active use of the clinical microbiology laboratory.

[Ochrobactrum anthropi bacteremia developed after cholangiopancreatography]

Ochrobactrum anthropi (formerly Achromobacter spp.) is an aerobic, motile, oxidase positive and lactose negative gram negative bacillus which is widely distributed in the environment and water sources. In recent publications, O. anthropi has an increasing importance as a nosocomial infection agent. The aim of this report was to present a case of O. anthropi bacteremia developed after endoscopic retrograde cholangiopancreatography (ERCP). A 89-year old female patient presented with high fever one day after ERCP performed due to klatskin tumour. O. anthropi had been grown in blood culture (BacT/ALERT 3D, bioMérieux, Durham, USA), and the isolate was identified by automatized system (VITEK, bioMerieux, Marcy l'Etoile, France). Since there was no clinical response to empirical ceftriaxone therapy, it was switched to meropenem, which was found effective by VITEK antibiotic susceptibility detection system. The patient was treated successfully with meropenem therapy (3 x 1 gr/day, 10 days). As a result, in case of suspected post-ERCP bacteremia, unconventional microorganisms such as O. anthropi should be taken into consideration.