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Abstract Background Herein, we analyzed the efficacy of main antibiotic therapy regimens in the treatment of healthcare-associated meningitis (HCAM). Materials/methods This retrospective cohort study was conducted in 18 tertiary-care academic hospitals Turkey, India, Egypt and Romania. We extracted data and outcomes of all patients with post-neurosurgical meningitis cases fulfilling the study inclusion criteria and treated with empirical therapy between December 2006-September 2018. Results Twenty patients in the cefepime + vancomycin-(CV) group, 31 patients in the ceftazidime + vancomycin-(CFV) group, and 119 patients in the meropenem + vancomycin-(MV) group met the inclusion criteria. The MV subgroup had a significantly higher mean Glasgow Coma Score, a higher rate of admission to the intensive care unit within the previous month, and a higher rate of antibiot herapy within the previous month before the meningitis episode (p 0.05) among the three cohorts. No regimen was effective against carbapenem-resistant bacteria, and vancomycin resulted in an EOT clinical success rate of 60.6% in the methicillin-resistant staphylococci or ampicillin-resistant enterococci subgroup (n = 34). Conclusions Our study showed no significant difference in terms of clinical success and mortality among the three treatment options. All regimens were ineffective against carbapenem-resistant bacteria. Vancomycin was unsuccessful in approximately 40% of cases involving methicillin-resistant staphylococci or ampicillin-resistant enterococci.

Introduction: Data on the relationship between Coronavirus disease-2019 (COVID-19) and acute pancreatitis are limited. This study aimed to investigate the possible role of COVID-19 in the etiology of acute pancreatitis in a tertiary-care educational university hospital by retrospectively evaluating the incidence of acute pancreatitis in adult hospitalized patients with COVID-19. Materials and Methods: Severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) polymerase chain reaction (PCR)-positive adult inpatients from March 15, 2020, to February 1, 2021, constituted the study group in our hospital. This cohort was analyzed for acute pancreatitis criteria, including acute abdominal pain, increased amylase and/or lipase more than three times the normal value, and radiological finding supporting the disease. Patients who met at least two of the acute pancreatitis diagnostic criteria were determined, and those who met the criteria during or after SARS-CoV-2 PCR positivity detection were included in the study. These patients were further analyzed for COVID-19-related data and pancreatitis severity status. Results: Our hospital had 1227 inpatients with COVID-19 diagnosis in one year. A total of four cases met the inclusion criteria. Acute pancreatitis rates were detected at 0.3% and 1.07% for all cohorts (n=1227) and the pancreatic enzyme-tested group (n=372), respectively. Of these four patients, two (50%) were females (50%) and the mean age was 70.7 (range: 64-79) years. There was no correlation between COVID-19 pneumonia and pancreatitis severity scores, including Ranson, Acute Physiologic Assessment and Chronic Health Evaluation 2, and modified computed tomography severity scores. Conclusion: COVID-19 is a rare risk factor for acute pancreatitis and did not affect the pancreatitis severity or mortality in our cohort.

Introduction: Ventilator-associated pneumonia (VAP) is one of the major hospital-acquired infections in the intensive care unit (ICU). The Centers for Disease Control and Prevention (CDC) made changes in the definitions of VAP. In this study, we aimed to prospectively evaluate patients in the tertiary-level chest diseases ICU between December 2016 and May 2017 in terms of ventilator-related events using the new surveillance criteria for patients requiring invasive mechanical ventilation. Materials and Methods: Patients in the chest diseases ICU were prospectively evaluated in terms of VAP development, and the incidence was calculated according to the old and new CDC criteria. Results: A total of 82 patients (31 women, 51 men) were followed up in the chest diseases ICU. Twenty-four patients who met the new surveillance criteria (survived >4 days) with 1632 patient-days and 601 ventilator days were included in the study. The incidences of VAP according to the old and new criteria were 31.6 and 1.6 per 1000 ventilator days, respectively. Conclusion: Our data suggest that new CDC definitions underdiagnose pneumonia in the daily practice. We may conclude that it does not seem rational to switch to the newer VAP definitions in the daily practice from the elder CDC definitions.

Introduction: Hand hygiene is one of the most cost-effective infection control measures. In this multicenter study we analyzed the hand hygiene compliance observation results of 15 hospitals in Turkey. Materials and Methods: This study was performed in the intensive care units of 15 hospitals (eight tertiary-care educational hospitals, six state hospitals, and one private hospital) from 11 cities located in six regions of Turkey. The observations were made by infection control practitioners according to the World Health Organization (WHO) - Five Moments for Hand Hygiene (WHO-5) indications rule for hand hygiene and overall compliance rates were calculated. Observations were unblinded (healthcare professionals knew that they were observed). The study period included 2015 and 2016 calendar years. Results: There was a statistically significant increase in hand hygiene compliance rates in 2016 versus 2015. The overall number of hand hygiene opportunities and instances of compliance in 2015 and 2016 were 60071/78116 (76.9%) and 66551/83607 (79.6%) (p=0.0001), respectively. Nurses were the most compliant group in both years. The highest compliance was after body fluid exposure (88.2% in 2015 and 91.4% in 2016), while the lowest compliance was before patient contact (61.3% in 2015 and 65% in 2016). Conclusion: The presented data suggest that under unblinded observations, hand hygiene compliance seems to be in relatively acceptable rates in Turkey. Centers with compliance rates below the 50th percentile in any of the five moments should increase efforts to enhance compliance for that indication.

Introduction: Hand hygiene is one of the most effective infection control measures to prevent the spread of healthcare-associated infections (HCAI). Water, soap, paper towel and hand disinfectant must be available and adequate in terms of effective hand hygiene. The adequacy of hand hygiene products or keeping water-soap and paper towel is still a problem for many developing countries like Turkey. In this multicenter study, we analyzed the adequacy in number and availability of hand hygiene products. Materials and Methods: This study was performed in all intensive care units (ICUs) of 41 hospitals (27 tertiary-care educational, 10 state and four private hospitals) from 22 cities located in seven geographical regions of Turkey. We analyzed water, soap, paper towel and alcohol-based hand disinfectant adequacy on four different days, two of which were in summer during the vacation time (August, 27th and 31st 2016) and two in autumn (October, 12th and 15th 2016). Results: The total number of ICUs and intensive care beds in 41 participating centers were 214 and 2357, respectively. Overall, there was no soap in 3-11% of sinks and no paper towel in 10-18% of sinks while there was no alcohol-based hand disinfectant in 1-4.7% of hand disinfectant units on the observation days. When we compared the number of sinks with soap and/or paper towel on weekdays vs. weekends, there was no significant difference in summer. However, on autumn weekdays, the number of sinks with soap and paper towel was significantly lower on weekend days (p

Introduction: In this multicenter study, we analysed the magnitude of healthcare worker (HCW) [infection control practitioner (ICP), nurses and others] workforce in hospitals participated in the study. Materials and Methods: This study was performed in 41 hospitals (with intensive care units-ICU) located in 22 cities from seven regions of Turkey. We analysed the ICP workforce, nursing and auxiliary HCW (AHCW) workforce in ICUs, number of ICU beds and occupied beds in four different days [two of which were in summer during the vacation time (August 27 and 31, 2016) and two others in autumn (October 12 and 15, 2016)]. The Turkish Ministry of Health (TMOH) requires two patients per nurse in level 3 ICUs, three patients per nurse in level 2 ICUs and five patients per nurse in level 1 ICUs. There is no standardization for the number of AHCW in ICUs. Finally, one ICP per 150 hospital beds is required by TMOH. Results: The total number of ICUs, ICU beds and ICPs were 214, 2377 and 111, respectively in he 41 participated centers. The number ICPs was adequate only in 12 hospitals. The percentage of nurses whose working experience was 2. The number of patients per other HCW was minimum 3.75 and maximum 4.89 on weekdays and on day shift while it was minimum 5.02 and maximum 7.7 on weekends or on night shift. When we compared the number of level 1, 2 and 3 ICUs with adequate nursing workforce vs inadequate nursing workforce, the p value was

Introduction: Transrectal prostate biopsy (TPB) is currently a commonly used invasive procedure for the diagnosis of prostatic diseases. Due to increasing infectious complications after TPBs in our institute, it was decided to change antimicrobial prophylaxis regimens and pre-intervention measures. The aim of this study was to evaluate the effects of shorter antimicrobial prophylaxis, intestinal cleansing and single use sterile gels on infections developing after TPBs in our tertiary-care educational hospital. Materials and Methods: Infections developing in the last six months after TPB were evaluated retrospectively by using records of microbiology, radiology and urology departments. Sterilization and disinfection, antimicrobial prophylaxis regimens, intestinal decontamination procedures and routine biopsy procedures were reevaluated in cooperation with the corresponding clinics. Afterwards, it was decided to implement three changes in the TPB practice: 1) Shortening the antimicrobial prophylaxis, 2) Intestinal cleansing one day before the intervention by using enema, and 3) Using sterile gel (single patient use only) during biopsy. Patients were diagnosed as clinical or microbiologically confirmed healthcare-associated infection according to the "Centers for Disease Control and Prevention" criteria. The preintervention period was 2007 July-December and the intervention period was 2008 January-July. Results: Overall infection/infectious complication rate (10.5% vs. 3.8%; p=0.007), overall clinically defined infection rate (4.8% vs. 1.1%; p=0.028) and overall microbiologically defined infection rate (5.8% vs. 2.7%; p=0.002) decreased significantly in the post intervention period. Conclusions: Our findings suggest that shorter antimicrobial prophylaxis regimens, using sterile gels and intestinal cleansing may be useful in the control of infections developing after TPB.

Introduction: World population is ageing. Accordingly, the prevalence of health problems and diseases are also increasing. Aging is associated with a growing demand for acute and primary healthcare. Urinary tract infections (UTIs) are among the most common infectious diseases associated causes of hospitalization. When considering the fact that complicating factors are encountered more often in elderly patients, it is very important to find out these factors and start the appropriate treatment for the management of these patients in order to prevent untoward consequences. In this study, we aimed to evaluate the patients diagnosed with UTI in two different age groups and analyze the differences in advanced ages. Materials and Methods: We retrospectively evaluated demographic characteristics, complaints, underlying diseases and the results of physical examination and laboratory analyses in patients with diagnosis of UTI in our clinic. We divided the subjects into two groups: ≥65 years of age and

Middle East respiratory syndrome coronavirus (MERS-CoV) which was first described in 2012, belongs to the CoV family. Coronaviruses may cause global outbreaks with high mortality. Although there is no definite evidence, it is thought that bats are reservoir hosts and one-humped camels are intermediate hosts. According to the World Health Organization data, 1,698 MERS-CoV cases were identified as of March, 23th, 2016 with 609 (36%) deaths. Most of the cases were seen in Saudi Arabia. South Korea is the country following Saudi Arabia where most of the cases developed through in-hospital spread. There is no reported case from Turkey except a Turkish patient returning from Saudi Arabia. In Saudi Arabia, there was a marked peak in new cases during April 2014 and May 2014. Although there was no spesific symptom or laboratory finding that belongs to MERS-CoV, pneumonia, acute respiratory distress syndrome and acute renal failure were the most common clinical conditions. Diabetes mellitus, hypertension, congestive hearth failure and chronic renal failure were usually the main predisposing diseases. Real-time polymerase chain reaction is the gold standard for diagnosis and lower respiratory samples are preferred because of high viral load. There is no spesific treatment for MERS-CoV but there are reports showing decreased viral load with ribavirin-interferon combination. Strict and correct personal protective equipment use is the most important factor for preventing the spread of the disease.

Introduction: Hydatid disease is a zoonotic infection caused by the cestode Echinococcus spp. It is transmitted by ingestion of infectious cestode eggs, especially through dog feces. The two organs most commonly affected are the liver and the lung. In this paper, a series of 15 cases with symptomatic hydatid cysts hospitalized in our clinic and evaluated via consultations are presented. Materials and Methods: Patients, who were treated with hydatid disease between April 2006 and June 2015, were included in the study. Demographic characteristics, symptoms (fever, abdominal pain, pruritus, weakness, icterus, cough, sputum, nausea-vomiting), signs (hepatomegaly, splenomegaly), radiological-laboratory findings, complications, involvements of other body parts and treatment modalities were evaluated retrospectively. Results: Ten (66.7%) of the patients were female. The mean age of the patients was 52.3±18.3 year. Twelve (80%) patients had at least one cystic lesion in the liver. Four cases were complicated with a lung cyst, three with spondylodiscitis, three with splenic cyst, two with renal cyst, two with amoebic liver abscess, one with intraabdominal dissemination and one case was complicated with anaphylactic shock. Seven patients (46.7%) had leukocytosis and three (20%) had eosinophilia. All patients received treatment with albendazole p.o 2x400 mg tablets. The mean duration of treatment was 27.4±18.5 weeks. Conclusion: Hydatid cyst is an infectious disease that may cause severe organ involvement. Patients with hydatid cyst in any part of the body should be checked carefully for other system involvement, including the liver, abdominal and/or retroperitoneal organs.

Introduction: The prevalence of hospital-acquired or healthcare-associated infections (HAI) varies from country to country even between different units of the same hospital. By the help of prevalence studies, HAI rates can be demonstrated in a wider perspective and, based on these data; infection control measures may be reevaluated. In this study, we investigated the HAI prevalence in hospitalized patients on 23 December 2013 at our tertiary-care educational hospital. Materials and Methods: On 23 December 2013, patients diagnosed with HAI (by using Centers for Disease Control and Prevention criteria) by infectious diseases and clinical microbiology specialists in our 1850-bedded (including 1.516 adult, 334 pediatric and a total of 328 intensive care unit beds) tertiary-care hospital, were evaluated in terms of underlying disease, risk factors, implementation initiatives, focus of infection and causative microorganisms. Results: The number of patients hospitalized on 23 December 2014 was 1.470, the prevalence of HAI was found to be 7.21%. The most common type of HAI was pneumonia followed by urinary tract infection, bacteremia, surgical site infections and intra-abdominal infections. Conclusion: We conclude that repeated HAI prevalence studies at appropriate intervals are very useful for taking effective infection control measures and follow-up of HAI in large hospitals like our tertiary care hospital where active surveillance could not be done in all clinics.

Listeria monocytogenes are gram-positive bacilli causing epidemics through contagious food. It may lead to infections in the elderly and immunocompromised host. Although in vitro efficacy of levofloxacin is promising, published experience is limited. Acatheter-related L. monocytogenes bacteremia cleared microbiologically under levofloxacin is presented in this paper. A patient, diagnosed with metastatic breast carcinoma, was hospitalized for palliative care in medical oncology clinic with the recurrent need of paracentesis and impaired oral in take caused by severe nausea and vomiting. On the second and fourth days of hospitalization,the patient developed recurrent fever. Patient’s cultures were performed and empirical levofloxacin 500 mg/per day was started. Cultures (on the second and fourth days of hospitalization) yielded growth of L. monocytogenes. Under levofloxacin, the patient had no fever again and cultures drawn on the third and eighth days of antibiotherapy did not yield any pathogen. The patient died due to sudden respiratory failure, which was thought to be related to pulmonary embolism on the fifteenth day of hospitalization. Blood cultures, performed on the day the patient died, did not yield any pathogen. To our knowledge, this is the first case of L. monocytogenes bacteremia treated successfully with levofloxacin. The case suggests that levofloxacin (although not as monotherapy) may be a good option for combinations in the salvage therapy of L. monocytogenes bacteremia.

Raoultella species are gram-negative, non-motile bacilli primarily considered to be environmental bacteria. R. planticola is a rare cause of human infections. Here in we report a case of complicated skin and soft tissue infection, necrotizing fasciitis with a rare etiologic agent R. planticola, treated with tigecycline. A 32-year-old male admitted to the emergency service with complaints of swelling in the neck, pain and a purulent wound on the mandible. He also had toothache for the last three weeks for which he was prescribed metronidazole and non-steroid anti-inflammatory drug by another doctor. He was internalized in the Plastic and Reconstructive Surgery clinic and debridement was performed and empirical antibiotic was started. Bacteriological culture revealed Acinetobacter baumannii and R. planticola. The case was successful treated with tigecycline. Necrotizing fasciitis may be fulminant and invasive in the diabetic host. To our knowledge this was the first R. planticola case treated successfully treated with tigecycline. In addition, it emphasizes once again the importance of bacteriological sampling in the management of necrotizing fasciitis and complicated soft tissue infection.

Introduction: Brucellosis is a systemic infection which in volves many organs including liver. In this study, it was aimed to review the hepatosplenic findings in allcases followed up in our clinic with the diagnosis of brucellosis. Materials and Methods: Allcases, we followed up in our clinic between July 2006 and October 2014 with the diagnosis of brucellosis, were reviewed retrospectively. Cases with microbiological culture confirmation and/or Wright agglutination test positivity with a titer of 1/160 or higher were considered brucellosis. Results: There were a total of 102 cases meeting the inclusion criteria (43 female (42.2%), 59 male (57.8%), aged 47.1 ± 16). Eighty-two (80.3%) patients had a titer of 1/160 or more Wright agglutination test positivity. Three patients had negative Wright agglutination test but had anti-humanglobulin test positivity. Seventeen (16.7%) patients were diagnosed with only blood culture. The most common three symptoms were fever (63.7%), weakness (48%) and back pain (48%). Hepatomegaly and splenomegaly were determined with ultrasonography in 16 (15.8%) and 19 (18.8%) cases, respectively. About 23.8%, 24.8%, 26.8%, 36.6%, and 12.9% of the patients had elevated levels of AST, ALT, ALP, GGT and total bilirubin, respectively. Forty-two (41.2%) patients had no remarkable pathology in the liver. Mean age of the cases without a remarkable liver pathology was 51.1 ± 14.9; whereas, mean age of the rest of the cases was 44.3 ± 16.3 (p= 0.035). Liver function tests improved in all cases with treatment. There was no severe adverse drug reaction during treatment. Conclusion: Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system, and may cause liver damage. Its response to treatment is high. However, there was no pathology in ultrasonography in majority of the cases. In a brucellosis endemic country such as Turkey, it must be kept in mind that the disease may present without significant liver involvement.

Streptococcus pneumoniae is the most frequently encountered microorganism in the etiology of community-acquired acute bacterial meningitis. In Turkey, third-generation cephalosporin resistance is extremely rare in S. pneumoniae. Third-generation cephalosporins are the most commonly used antimicrobial agents in the treatment of pneumococcal meningitis. In this paper, we report a meningitis case of S. pneumoniae with decreased susceptibility to third-generation cephalosporins. A 56-year-old man admitted to our clinic with headache, nausea-vomiting and fever in March 2012. In the physical examination, his Glasgow coma scale was 15 and his cooperation and orientation were normal. He did not have any meningeal irritation finding. His physical examination did not reveal any other pathology. Lumbar puncture revealed turbid cerebrospinal fluid (CSF) with a white cell count of > 1000 cells/mm3 with 80% polymorphonuclear leukocytes. CSF laboratory findings were as follows: glucose level < 2 g/dL and protein level 255 mg/dL. Gram staining of CSF revealed gram-positive diplococci. Ceftriaxone was started. Vancomycin was added after blood and CSF cultures yielded S. pneumoniae with intermediate susceptibility to cefotaxime. On the seventh day, rifampicin was added due to the persistence of fever. CSF findings were normal at the end of the treatment. The patient was discharged after 28 days of antibiotherapy. The patient did not develop any relapse after eight months of follow-up. To our knowledge, this is the first S. pneumoniae meningitis case from Turkey with intermediate susceptibility to cefotaxime who was treated successfully. The presented case emphasizes the importance of CSF sampling and penicillin and ceftriaxone minimum inhibitory concentration (MIC) evaluation in the management of meningitis.

Among the hospital infections, hospital-acquired central nervous system infections are quite important due to the high mortality. The pathogens that cause hospital-acquired meningitis differ according to the immune system and underlying diseases. The most frequent pathogens are gram-negative bacilli, Staphylococcus aureus, and coagulase-negative staphylococci. There are difficulties in the treatment due to the problem of increasing resistance. Treatment options of the multiple-drug-resistant pathogens are limited. In this paper, the treatment options of the hospital-acquired and methicillin-resistant S. aureus meningitis are reviewed.

Transrectal prostate biopsy (TPB) is a commonly used invasive technique for the diagnosis of prostate cancer. Escherichia coli is a rare cause of adult meningitis. It can cause nosocomial meningitis after invasive procedures. In this paper, we present two cases of E. coli meningitis developing after TPB. The first case was a 65-year-old man who was admitted to the emergency service with fever and unconsciousness two days after TPB. He had neck stiffness, leukocytosis, and high C-reactive protein (CRP) levels. His cerebrospinal fluid (CSF) had turbid appearance, low glucose and high protein levels. More than 1000/mm3 leukocytes were seen on direct microscopy, and gram-negative bacilli were observed. Ceftriaxone 2 g q12h was started. CSF culture yielded E. coli susceptible to ceftriaxone. Concomitant urine and blood cultures were sterile. The second case was a 69-year-old man admitted with fever and unconsciousness six days after TPB. He had neck stiffness, leukocytosis and high CRP levels. His CSF had purulent appearance, low glucose and high protein levels. On microscopy, there were 800 leukocytes/mm3. Ceftriaxone 2 g q12h was started. CSF culture yielded extended spectrum beta-lactamase producer E. coli. Treatment was changed to meropenem 6 mg daily. Both patients were cured with the three-week antibiotic treatment. After TPB, resistant microorganisms can be involved in the etiology of severe bacterial infections; carbapenems can be used until culture results are available.

Ralstonia pickettii is an aerobic, nonfermentative gram-negative bacillus that can cause hospital-acquired infections by contaminated distilled water or chlorhexidine containing antiseptics. The two most common Ralstonia species in the clinical samples are R. pickettii and R. solanacearum. Infections caused by R. pickettii are very rare. These infections may appear as asymptomatic colonization or pseudo-bacteremia of respiratory system. The most common infections caused by R. pickettii are bacteremia and pneumonia. In the paper, a case of R. pickettii related deep incisional surgical site infectionis reported. A 63-year-old male patient with type-2 diabetes mellitus and coronary artery disease had coronary by-pass operation two-month ago. After the operation, patient had developed wound dehiscence and purulent discharge. Tissue biopsy culture performed in the setting revealed R. picketti. Patient was treated with 14 days of intravenous and 7 days of oral ciprofloxacin. His repeated cultures performed on the 14th day of ciprofloxacin did not yield any pathogen. To the knowledge, this is the first deep incisional surgical site infection caused by R. pickettii in the literature. The case is found to be of value because of emphasizing the importance of venture for diagnosis and rarity of R. pickettii in the etiology of soft tissue/surgical site infection.