Deep Tracheal Aspirate Research Articles

Bacterial and Fungal Infections Among COVID-19 Patients in Intensive Care Unit

Aim: Secondary infections caused by bacteria or fungi are dangerous because they increase death rates, particularly in patients with COVID-19 who are receiving intensive care. In this study, hospital-associated secondary infections resulting from bacteria and fungi amid COVID-19 patients treated in intensive care units, as well as their distribution according to microbial agents, were investigated. Material and Method: The study comprised 134 COVID-19 patients who were being treated in the Mersin City Hospital of the Ministry of Health intensive care unit between January 1, 2021, and April 30, 2021. The patients’ demographics and clinical records, as well as bacterial and fungal infections in the blood, urine and deep tracheal aspirate samples, were analyzed retrospectively. Results: The rate of secondary infection was found to be quite high in patients hospitalized in intensive care units for over 72 hours (91.4%). The majority of secondary infections were detected in blood samples (n=103, 15%). Secondary infection was detected in 61 (8.9%) deep tracheal aspirate specimens and 59 (8.5%) urine samples. The most common secondary infectious agents were Candida spp. (22.3%), Acinetobacter baumannii (16.8%). In addition, it was determined that ≥60 years and ≥3 days of mechanical ventilation independently increased the probability of developing secondary infection. Conclusion: Our findings are emphasized that the concern of secondary infection due to Candida spp., Acinetobacter baumanii and Stahylococcus epidermidis agents. Evaluation of bacterial superinfections during the later waves of the pandemic may be critical, especially given the changes in the management of these patients, such as the routine use of corticosteroids and the raise of the different variants of the SARS-CoV-2.

Solunumsal Yoğun Bakım Ünitesinde İzole Edilen Mikroorganizmalar ve Antibiyotik Direnç Durumlarının Yıllara Göre Değişimi ve Mortaliteye Etkisi

BACKGROUND: Intensive care units (ICU) are multidisciplinary departments where patients with life-threatening diseases, major surgical interventions, respiratory failure, coma condition, hemodynamic insufficiency, and ≥1 organ failure are admitted for relevant diagnoses and treatment. AIM: The present study sought to investigate pathogens causing infections in patients admitted to our respiratory ICU and their antibiotic resistance patterns. MATERİALS and METHOD: The antibiogram results and clinical data of all patient samples submitted between January 1, 2008, and December 31, 2010, were retrospectively reviewed. RESULT: In total, 248 patients with 561 culture results were included in the study. Microbial growth was detected in the following samples: blood, 336 (59.9%); deep tracheal aspirate, 104 (18.6%); urine, 89 (15.9%); wound drain, 12 (2.1%); central venous catheter liquid, 7 (1.3%); phlegm, 10 (1.8%); Foley tip liquid, 1 (0.2%); and pleural effusion, and 1 (0.2%). Rapid growth was most frequently noted in the cultures of coagulase-negative staphylococci (25.3%), Acinetobacter spp. (23.1%), and Escherichia coli (12.6%). STATISTICAL ANALYSIS Descriptive statistics for continuous variables were expressed as means and standard deviations. The intermittent variables were converted into cross-tables and analyzed using Fisher’s exact and Pearson’s chi-square tests. The normal distribution of the study data was assessed using Kolmogorov–Smirnov test. The mean values of the variables were analyzed using Student’s t-test. Bidirectional hypotheses were used, and a p-value of <0.05 was considered statistically significant. The IBM Statistical Package for the Social Sciences Ver. 18.0 for Windows (SPSS Inc., Chicago, IL, USA) software was used for statistical analyses. IN CONCLUSION, the present study revealed microorganisms’ resistance profiles similar to those of other relevant studies. The study provides important insights into the selection of empiric antibiotic therapy for patients admitted in intensive care unit. Keywords: respiratory intensive care unit, intensive care infections, antibiotic resistance, antibiotic susceptibility

Epidemiology and resistance profiles of Enterobacterales in a tertiary care hospital in Lebanon: a 4-year retrospective study.

Antimicrobial resistance (AMR) is a worldwide problem that threatens treatment effectiveness against the most serious bacterial infections. AMR in Enterobacterales is highly prevalent in Lebanon. However, recent reports regarding the distribution of Enterobacterales and related antimicrobial susceptibility are scarce. In this retrospective study at the Lebanese Hospital Geitaoui Medical Center in Lebanon, all data regarding culture specimens from urine, blood, sputum, deep tracheal aspirate, broncho-alveolar lavage, wounds, surgical sites, tissue, body fluids, and central venous catheter that were positive for at least one of the 4 bacterial isolates (Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae and Proteus mirabilis) were collected. All susceptibility testing was performed according to the Clinical and Laboratory Standards Institute guidelines. A total of 4283 non-duplicate Enterobacterales were isolated during the study period (January 2017 to December 2020). Urine was the most common site of infection. E. coli was the most detected isolate as well as the leading pathogen in urine, wounds and surgical sites, and blood. Regarding antimicrobial susceptibility, the mean susceptibility to third generation cephalosporins was 55.53% and a mean extended-spectrum β-lactamases production of 31.2% was measured in E. coli. Mean carbapenem susceptibility was the lowest in K. pneumoniae and E. cloacae. The lowest mean susceptibility to fluoroquinolones was detected in E. coli isolates. This study identified the predominance of E. coli among Enterobacterales in Lebanese patients, with the urinary tract being the most common site of infection and underlined the high rates of AMR in Enterobacterales in Lebanon.

Incidence of cereblon protein in intensive care patients: a cross-sectional study.

Sepsis remains a common cause of death. The cereblon (CRBN) protein, which is involved in important cellular processes, plays a role in sepsis. This cross-sectional study aimed to show the CRBN protein expression and its effects on patients in the intensive care unit. Samples were taken by deep tracheal aspiration from patients. The presence of CRBN was pathologically investigated using immunohistochemical tests and polyclonal antibodies against CRBN. The relationship between gender, sepsis, steroid, survival and the presence of CRBN was examined. Respiratory and neurologic diseases were the most common reasons for admission. Acinetobacter was the most frequent microorganism. In patients with more than normal inflammatory cells, a negative correlation was observed between CRBN expression and leukocyte rate (p=0.031). In patients with CRBN, there was no correlation between steroid and mortality, APACHE/Glasgow score, hospital stay length, and ICU. Although the prognosis for sepsis is better in CRBN-deficiency animals, the presence of CRBN in humans does not affect it. In our study, CRBN decreased as inflammatory cells increased in the patient's aspiration material. The response to steroids, an immunomodulator, did not change with the presence of the immunomodulator target molecule, CRBN. Therefore, using immunomodulators in the treatment of sepsis should be reconsidered.

Evaluation of hospital acquired infections in intensive care unit

Aim: Hospital acquired infections are a serious problem in inpatients in terms of mortality and cost. The aim of this study is to present hospital acquired infections and risk factors, causative pathogens, antibiotic resistance status, and mortality relationship in a public hospital intensive care unit (ICU) over the scope of 5-years.Methods: Hospital acquired infections developed between January 2016 and December 2020 in Bolu İzzet Baysal State Hospital Adult ICUs were investigated retrospectively. Samples taken from areas such as central venous catheter, deep tracheal aspirate, urinary catheter and wound area were studied. Hospital acquired infections was diagnosed based on Centers for Disease and Control (CDC) criteria.Results: A total of 3587 patients were admitted to the ICUs between January 2016 and December 2020, and 309 (8.6%) patients were diagnosed with hospital acquired infections. When considered as comorbidity, neurological disorders were the most common, while sepsis was the most common hospitalization diagnosis in patients with hospital infection. The most common hospital acquired infections was ventilator associated pneumonia (VAP) with 38.8% (n=120) of the patients. Examining the culture isolate results, the most isolated agent as hospital acquired infections was Acinetobacter spp. (32.6%, n=101). Acinetobacter spp. and Klebsiella spp. It was resistant to all antibiotics with 4.9%.Conclusion: Hospital acquired infections rates may vary in intensive care units due to reasons such as awareness, physical conditions, education of working personnel, etc. Knowing the risk factors well, early culture isolate monitoring in suspected cases and selecting the appropriate antibiotic are effective in patient treatment and may reduce mortality.

Exploring the antibiotic susceptibility of nosocomial infection causative Corynebacterium striatum strains

Introduction: Corynebacterium striatum (C. striatum) is one of the most frequently reported nosocomial infection agents among patients hospitalized in intensive care units following the COVID-19 pandemic. It may cause various opportunistic infections, such as ventilator-associated pneumonia and catheter-associated bloodstream infections, in such patients. The present study attempted to investigate the antibiotic susceptibility of 14 nosocomial infection agent C. striatum strains, isolated from deep tracheal aspirate and blood culture samples of hospitalized patients, for seven different antibiotics (benzylpenicillin, ciprofloxacin, clindamycin, rifampicin, linezolid, tetracycline, and vancomycin). Material and Method: Antibiotic susceptibility of the strains for the mentioned antibiotics was determined utilizing a disk diffusion test in line with the recommendations of the European Antibiotic Susceptibility Committee (EUCAST).Results: While all the isolated C. striatum strains (100%) were resistant to benzylpenicillin, tetracycline, rifampicin, ciprofloxacin, and clindamycin, we found none of them to be resistant to vancomycin and linezolid.Conclusion: Overall, uncovering the antibiotic susceptibility of C. striatum strains isolated from clinical specimens would guide clinicians in deciding on the empirical treatment of hospital-acquired infections led by this agent.

Microorganisms and Antibiotic Sensitivities Isolated from Deep Tracheal Aspirate Samples of Patients in the Intensive Care Unit of a Private Hospital

Amaç: Bu çalışmada, hastanemiz yoğun bakım ünitesi (YBÜ)’nde mekanik ventilasyon uygulanan hastalardan alınan derin trakeal aspirat (DTA) örneklerinde üretilen mikroorganizmaların dağılımı ve antibiyotik direnç oranlarının belirlenmesi amaçlanmıştır.Materyal ve Metot: Bu çalışmada Ocak 2019 – Ocak 2020 tarihleri arasında YBÜ’de yatan hastalardan alınan DTA örneklerinin mikrobiyolojik sonuçları geriye dönük olarak değerlendirilmiştir. DTA kültürlerinden izole edilen bakteriler konvansiyonel yöntemlerle tanımlanmıştır. Antibiyotik duyarlılık sonuçları Clinical and Laboratory Standards Institute kriterlerine göre değerlendirilmiştir.Bulgular: Çalışma periyodu boyunca 288 DTA örneği incelenmiş ve bunların 140’ında üreme saptanmıştır. En sık izole edilen etkenler %45 Acinetobacter spp, %21,4 Pseudomonas aeruginosa, %16,4 Klebsiella pneumoniae, %6,4 Enterobacter spp., %5 Staphylococcus aureus, %2,8 Escherichia coli ve %3 diğer patojenler idi. Acinetobacter suşlarında karbapenem direnci %87,3, K. pneumoniae’da %65,2, P. aeruginosa’da ise %40 olarak saptanmıştır.Sonuç: Acinetobacter spp. ve K. pneumoniae suşlarında yüksek oranda saptanan karbapenem direnci tedavi güçlüklerine yol açmaktadır. Her merkezin kendi mikroorganizma dağılımı ve direnç durumlarını belirleyerek tedavi protokolleri düzenlemesi gerekmektedir. Dirençli enfeksiyonların sürekli ve yakın takiplerinin yapılması, hızlı bir şekilde enfeksiyon kontrol önlemlerinin alınması, sağlık çalışanlarının eğitimi önemlidir.

Staphylococcus aureus Alpha-Toxin in Deep Tracheal Aspirates-Preliminary Evidence for Its Presence in the Lungs of Sepsis Patients.

The pore forming alpha-toxin (hemolysin A, Hla) of Staphylococcus aureus (S. aureus) is a major virulence factor with relevance for the pathogenicity of this bacterium, which is involved in many cases of pneumonia and sepsis in humans. Until now, the presence of Hla in the body fluids of potentially infected humans could only be shown indirectly, e.g., by the presence of antibodies against Hla in serum samples or by hemolysis testing on blood agar plates of bacterial culture supernatants of the clinical isolates. In addition, nothing was known about the concentrations of Hla actually reached in the body fluids of the infected hosts. Western blot analyses on 36 samples of deep tracheal aspirates (DTA) isolated from 22 hospitalized sepsis patients using primary antibodies against different epitopes of the Hla molecule resulted in the identification of six samples from five patients containing monomeric Hla (approx. 33 kDa). Two of these samples showed also signals at the molecular mass of heptameric Hla (232 kDa). Semiquantitative analyses of the samples revealed that the concentrations of monomeric Hla ranged from 16 to 3200 ng/mL. This is, to our knowledge, the first study directly showing the presence of S. aureus Hla in samples of airway surface liquid in human patients.

Biofilm Formation by Pathogens Causing Ventilator-Associated Pneumonia at Intensive Care Units in a Tertiary Care Hospital: An Armor for Refuge.

Background Emerging threat of drug resistance among pathogens causing ventilator-associated pneumonia (VAP) has resulted in higher hospital costs, longer hospital stays, and increased hospital mortality. Biofilms in the endotracheal tube of ventilated patients act as protective shield from host immunity. They induce chronic and recurrent infections that defy common antibiotics. This study intended to determine the biofilm produced by pathogens causing VAP and their relation with drug resistance. Methods Bronchoalveolar lavage and deep tracheal aspirates (n = 70) were obtained from the patients mechanically ventilated for more than 48 hours in the intensive care units of Tribhuvan University Teaching Hospital, Kathmandu, and processed according to the protocol of the American Society for Microbiology (ASM). Antibiotic susceptibility testing was done following Clinical and Laboratory Standards Institute (CLSI) 2017 guidelines. Biofilm formation was determined using the microtiter plate method described by Christensen and modified by Stepanovoic et al. Results Significant microbial growth was seen in 78.6% of the total samples with 52.7% monomicrobial, 45.5% polymicrobial, and 1.8% fungal infection. Among the 71 isolates obtained, bulk was gram-negative (n = 64, 90.1%). Pseudomonas aeruginosa (31.0%) was the predominant isolate followed by Acinetobacter calcoaceticus baumannii complex (16.9%), Klebsiella pneumoniae (16.9%), Citrobacter freundii (15.5%), Staphylococcus aureus (7.0%), Escherichia coli (5.6%), Citrobacter koseri (2.8%), Enterococcus faecalis (1.4%), Burkholderia cepacia complex (1.4%), and Candida albicans (1.4%). Of the total isolates, 56.3% were biofilm producers. Multidrug-resistant (MDR) organisms, extended-spectrum β-lactamase (ESBL), and metallo-β-lactamase (MBL) producers were preeminent among the biofilm producers. The highest producer of biofilm was P. aeruginosa (19.7%). Among gram-negative biofilm producers, 42.2% were MDR, 21.9% were ESBL producers, and 7.8% were MBL producers. Conclusion Gram-negative nonfermenter bacteria account for the bulk of nosocomial pneumonia. MDR, ESBL, and MBL production was preponderant among the biofilm producers. The rampant spread of drug resistance among biofilm producers is summoning novel interventions to combat multidrug resistance.

Continuous Endotracheal Tube Cuff Pressure Control Decreases Incidence of Ventilator-Associated Pneumonia in Patients with Traumatic Brain Injury

Background Ventilator-associated pneumonia (VAP) is a common cause of morbidity and mortality in intensive care unit (ICU), and among the several preventative strategies described to reduce the incidence of VAP, the most important is the endotracheal tube cuff (ETC) pressure. The present study was conducted on 60 patients who required mechanical ventilation (MV) in the ICU with traumatic brain injury (TBI). Methods The patients were randomized into two groups of 30, in which ETC pressure was regulated using a smart cuff manager (SCM) (Group II), or manual measurement approach (MMA) (Group I). Demographic data, MV duration, length of ICU stay and mortality rates were recorded. The clinical pulmonary infection scores (CPISs), C-reactive protein (CRP) values, and the fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) values of the groups were compared at baseline, and at hours 48, 72 and 96. Results In Group I, CPIS values significantly higher than Group II in 48th, 72nd and 96th hours (p < 0.05). In Group I, PEEP values and deep tracheal aspirate (DTA) culture growth rates significantly higher than Group II in 72nd and 96th hours (p < 0.05). Conclusion The continuous maintenance of ETC pressure using SCM reduced the incidence of VAP.

Evaluation of the Susceptibility of Staphylococcus aureus Strains to Various Antibiotics

Objective: Staphylococcus aureus continues to be a major health problem due to widespread methicillin resistance. The aim of this study was to determine the susceptibility to various antibiotics of 100 methicillin-resistant S. aureus (MRSA) and 100 methicillin-susceptible S. aureus (MSSA) strains isolated from various clinical samples between January 2016 and November 2019. Methods: Gradient test strips were used to test the susceptibilities of isolates to vancomycin, teicoplanin, and linezolid. The susceptibilities to other antibiotics were determined by automated system and evaluated based on EUCAST recommendations. Results: Seventy five percent of MRSA strains and 66% of MSSA strains included in the study were isolated from inpatients and 40% of MRSA and 21% of MSSA strains were isolated from intensive care patients. Isolates were obtained from tissue-abscess, blood, sterile body fluid, deep tracheal aspirate and sputum, urine, and catheter tip cultures, respectively. We did not detect S. aureus resistance to vancomycin, teicoplanin and linezolid in our study. Vancomycin, teicoplanin and linezolid MIC50/MIC90 values for MSSA strains were found to be 1/1.5 µg/ml, 0.75/1.5 µg/mL, 0.75/1 µg/mL and 1.5/2 µg/mL, 1.5/2 µg/mL, 0.75/1.5 µg/mL for MRSA strains, respectively. Based on MIC90 values, linezolid was 1.3 times more effective than vancomycin and 2 times more effective than teicoplanin in MRSA strains; linezolid was 1.5 times more effective than vancomycin and teicoplanin in MSSA strains. MRSA strains showed high resistance rates to all antibiotics, except daptomycin, tigecycline, cotrimoxazole and fusidic acid. All antibiotics were found to be highly effective in MSSA strains. Conclusions: MIC values of glycopeptides in MSSA isolates were found to be close to MIC values of MRSA isolates. Regarding the MIC90 values, linezolid was found to be more effective than glycopeptides. All other antibiotics were highly effective in MSSA strains

Antibiotic Resistance in Pseudomonas aeruginosaIsolated from Hospital and Community-Acquired Infections: Current Status in Northern Cyprus

Objective: Pseudomonas aeruginosa is among the most common nosocomial opportunistic pathogens capable of acquiring multi-drug resistance. Recent data on antibiotic resistance in Northern Cyprus is limited. We aimed evaluate antibiotic susceptibility profiles of P. aeruginosa strains isolated from clinical samples and contribute to the update of antibiotic use policies in the country. Methods: Total of 504 P. aeruginosa strains sent to Microbiology Laboratory from various clinics from September 2016 to October 2019 were retrospectively analyzed. Clinical samples were cultured on %5 sheep blood agar and eosin-methylene blue agar. BD Phoenix™ 100 (Becton Dickinson Co., Sparks, Maryland, USA) automated bacterial identification system and conventional antimicrobial susceptibility testing was used. Antimicrobial susceptibility was determined in accordance with the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. The distribution of P. aeruginosa isolates according to hospital services, sample types, admission types, age group, and antibiotic resistance rates were investigated. Results: P. aeruginosa was mostly isolated from urine (37.3%), deep tracheal aspirate (17.9%) and abscess/wound material (17.9%) samples. Strains were most commonly obtained from the intensive care clinics (35.9%). Infections were observed mainly in &gt;65 age group (49.6%) and in-patients (70.8%) group. Antibiotic resistance rates were detected as 47.7% for aztreonam, 32% for cefepime, 26.3% for ceftazidime, 26.4% for imipenem, 25.6% for ciprofloxacin, 24.6% for meropenem, 19.7% for piperacillin-tazobactam, 13.5% for gentamicin, 12.2% for colistin and 5.3% for amikacin. Multi-drug resistant P. aeruginosa rate was 19.2%. When compared with 2010-2014, a substantial increase in rates of cefepime, ceftazidime, ciprofloxacin, piperacillin-tazobactam and carbapenem resistance was detected within the last three years. Conclusions: In this study, the highest resistance rates were detected against aztreonam and cefepime, and the highest susceptibility was observed for colistin and amikacin. These results may be used for empirical treatments, establishment of rational antibiotic use policies and prevention of emerging antibiotic resistance problem in Cyprus.

Epidemiology of carbapenem-resistant Enterobacteriaceae in a Tertiary Care Center in the Kingdom of Bahrain.

PURPOSE:The purpose of the study is to estimate the rate of infection with carbapenem-resistant Enterobacteriaceae (CRE) in the main governmental tertiary care hospital in Bahrain.MATERIALS AND METHODS:All clinical samples with positive growth of CRE over 6-year period (January 2012–December 2017) were collected from the microbiology laboratory data.RESULTS:The CRE incidence was high in the first half of study period (2012–2014) and then decreased between 2015 and 2017, after implementation of intensified CRE control measure bundle. About 49.4% of CRE-positive samples were isolated from the elderly age group (above 65 years old), most of them were admitted in the intensive care unit (ICU). The most common isolated organisms were Klebsiella pneumoniae (87.0%), followed by Escherichia coli (7.9%). Isolates from deep tracheal aspirate and midstream urine specimens were the most common source of CRE isolates (27.3%) and (26.3%), respectively. Bacteremia was documented in 21.2% of cases. CRE isolates in the study showed high rates of resistance to aminoglycosides (72.2% resistant to amikacin and 67.3% to gentamicin). Alternatively, most isolates retained their susceptibility to colistin and tigecycline with sensitivity of 83.9% and 85.7%, respectively. Combined resistance to both colistin and tigecycline was observed in 0.06% of total isolates.CONCLUSION:Elderly population and ICU admission were important risk factors for CRE acquisition. Most of CRE isolates were sensitive to both colistin and tigecycline, which make them the best combination for empiric frontline therapy for suspected serious CRE infection in our facility. Implementing CRE-bundled infection control measures significantly reduced the incidence of CRE infection in our hospital.

Influenza A(H1N1)pdm09 epidemiology in the Eastern Province of Saudi Arabia.

ObjectivesThe influenza A(H1N1)pdm09 virus caused a worldwide pandemic in 2009–2010 and has since remained in seasonal circulation. This study was conducted to determine any variations in the influenza A(H1N1)pdm09 status according to sex, age group, sample type, or location within the Eastern Province of the Kingdom of Saudi Arabia.MethodsSamples from 749 patients with suspected Middle East respiratory coronavirus who presented to Johns Hopkins Aramco Healthcare facilities in the Eastern Province of Saudi Arabia were tested reflexively for influenza A/H1N1 2009 by the Ministry of Health using the RealTime ready Influenza A/H1N1 Detection Set for real-time PCR. The sample types included nasopharyngeal swabs (n = 677), expectorated deep cough sputum (n = 32), induced sputum (n = 17), and tracheal aspirates (n = 23).ResultsThe incidence of influenza A(H1N1)pdm09 was higher among younger patients; 27.94% of patients in the 0–19-year age group tested positive compared to only 3.51% of patients in the ≥80-year age group. The incidence of influenza A(H1N1)pdm09 was higher in Ras Tanura city compared to other locations in the Eastern Province.ConclusionsYounger individuals in the Eastern Province of the Kingdom of Saudi Arabia had a relatively higher risk of influenza A(H1N1)pdm09 infection. Additionally, an outbreak of influenza A(H1N1)pdm09 may have occurred in Ras Tanura city between April 2015 and February 2016.

Various antibiotic combinations against carbapenem resistant Acinetobacter baumannii infections and in vitro synergy test results (2002-2016)

Carbapenem resistant Acinetobacter baumannii is a bacterium that causes various hospital acquired infections, primarily ventilator-associated pneumonia and bloodstream infections. The multidrug resistance problem of the bacteria all over the world, is also a problem in our center. As the treatment options are decreasing combination therapies become a current issue. It is believed that in vitro synergy tests may guide to the selection of antibiotic combinations. The aim of this study was to present the antibiotic combinations used in the treatment of carbapenem resistant A.baumannii infections and the synergy test results of these combinations. A total of 71 carbapenem-resistant A.baumannii isolates from various clinical samples of patients in Hacettepe University Adult and Oncology Hospitals was included in the study. All isolates were from nosocomial infections that were being requested for synergy testing by the consulting physicians in the Department of Infectious Diseases and Clinical Microbiology between January 2002 and December 2016. Only one isolate from one patient was included in the analysis. The synergy test for these isolates was performed by E-test method. Of the total, 41 (58%) isolates were from various clinical samples of patients in intensive care units and 30 (42%) were from patients in different wards. Twenty-three of the isolates were obtained from bronchoalveolar lavage (BAL) fluid, 18 from pus, 14 from deep tracheal aspirate, 6 from central venous catheter, 5 from blood and 5 from other various samples. The fractional inhibition concentration (FIC) index for each combination was calculated and the results were interpreted as synergistic, additive, indifferent and antagonist. A total of 38 different combinations of antibiotics were tested. According to the frequency of synergistic activity, the combinations were; meropenem-colistin (11/12), meropenem-amikacin (7/9), meropenem-tobramycin (9/13), rifampicin-colistin (7/11), cefaperazone-sulbactam-tobramycin (8/16) and sefaperazon-sulbactam-amikacin (5/10). The most common antagonistic combinations were tigecyclin-colistin (2/6), meropenem-tobramycin (3/13), cefepim-tobramycin (4/19), rifampicin-colistin (2/11) combinations. In our center, different combinations of antibiotics are being used for the treatment of carbapenem-resistant A.baumannii due to the changing and increasing antibiotic resistance of the bacteria over the years. Sensitivity tests as well as synergy tests are used when selecting different combinations of antibiotics. However generalizability of the synergistic effect of combinations is limited. It is important to repeat these studies at regular intervals. In addition there is also a need for further studies to evaluate the correlation between in vitro laboratory results and in vivo clinical compliance.

Clinical Characteristics of Acinetobacter baumannii Infection in Solid-Organ Transplant Recipients.

Acinetobacter baumannii, depending on the immune status of the host, may result in one of the most serious hospital infections. Infections involving A. baumannii infection have been recently rising. However, little is known about the clinical features of A. baumannii infection in solid-organ transplant recipients. We aimed to share our clinical experiences with A. baumannii infection in our transplant recipients. Between 2011 and 2017, 41 solid-organ transplant patients developed A. baumannii infection at Baskent University Hospital. Medical records were reviewed, and patient demographics, microbiology results, and overall outcome data were noted. Of 41 solid-organ transplant patients with A. baumannii infection, 29 were male and 12 were female patients with mean age of 47.15 ± 13.24 years. Our infection rate with A. baumannii infection was 6.1%. The most common sites of infection were deep tracheal aspirate (48.8%)and bloodstream (36.6%). Onset of infection 1 year posttransplant was identified in 58.5% of recipients. Risk factors included presence of invasive procedures (56.1%) and administration of high-dose corticosteroids for rejection 1 year before infection (68.3%). Thirty-day mortality rate was 41.5% (17/41 patients) and was not associated with the infection site, microbiological cure, clinical cure, and drug resistance in our study group. Acinetobacter baumannii is an important cause of hospital-acquired infection and mortality worldwide. A major problem with A. baumannii infection is delayed initiation of appropriate antibiotic treatment and the rising numbers of extensively drug-resistant organisms. Predicting the potential risk factors, especially in the already at-risk solid-organ transplant population, has an important role in patient outcomes.

Epidemiological and Clinical Characteristics of Streptococcus pneumoniae Infections in a Tertiary Care Center in Bahrain (2010-2014)

Objective: &#x0D; To describe the epidemiology of invasive and non-invasive pneumococcal disease during a 5-year period in a major hospital in Bahrain.&#x0D; &#x0D; Design and Setting: &#x0D; Retrospective study of cases of pneumococcal diseases among patient ≥ 14 years old during a five-year period (2010-2014), who attended Salmaniya Medical Complex, Bahrain.&#x0D; &#x0D; Patients and Methods:&#x0D; Laboratory data was obtained on Streptococcus pneumoniae isolates. Patients ≥14 years old of age, both inpatient and outpatient with cultures positive for Streptococcus pneumoniae were included. Only samples from blood, cerebrospinal fluid (CSF), pleural fluid, sputum, deep tracheal aspirate (DTA), bronchial wash, eye discharge and middle ear fluid were included. Demographics and clinical records from medical files were then reviewed.&#x0D; &#x0D; Results:&#x0D; A total of 130 culture samples met the inclusion criteria and were analyzed. One-hundred twenty-six patients with pneumococcal disease were identified; with 65% being non-invasive and 35% being invasive pneumococcal disease. Overall, non-bacteremic Pneumonia was the most frequent manifestation, followed by bacteremia. Pneumococcal disease was more common among male patients (62.7%). Mean age was 57.67 (15-95 years). The most common comorbidities were hypertension, Diabetes Mellitus followed by cardiovascular disease. Twenty-seven patients received mechanical ventilation during their admission, 13 patients were admitted to the intensive care unit, and 6 patients developed para-pneumonic effusion as a complication. In-hospital Mortality rate was 13.5%. &#x0D; &#x0D; Conclusion: &#x0D; This study supports the current literature where pneumococcal infection is more prevalent in elderly and those with comorbidities. Mortality was related to age, certain chronic medical illness, admission to intensive care unit and need for mechanical ventilation.

Culture-Positive Pulmonary Aspergillosis Infection: Clinical and Laboratory Features of Solid-Organ Transplant Recipients.

Aspergillosis is a common fungal infection among solid-organ transplant recipients. Even after awareness of this infection occurs, there are still gaps in nonculture diagnostic tests, which can delay treatment initiation. Here, we aimed to define the common traits of pulmonary aspergillosis infection among solid-organ transplant recipients, thus shedding light on prevention and early diagnosis. We conducted a database search of patients at Baskent University who had a positive aspergillosis culture between January 2010 and March 2016. Among 20 patients identified, 15 (mean age of 50.93 ± 11.17 y, 2 female and 13 male patients) with solid-organ transplant were included in the study. Of the 15 study patients, 7 were heart transplant, 6 were kidney transplant, and 2 were liver transplant recipients. Three patients had positive aspergillosis cultures from extrapulmonary specimens (1 brain biopsy and 2 wound swap cultures). Other patients with positive cultures were from bronchoalveolar lavage (6 patients), sputum (4 patients), both bronchoalveolar lavage and sputum (1 patient), and deep tracheal aspiration specimen (1 patient). Aspergillus fumigatus was the most common species. Mean hospitalization duration was 31.53 days (range, 2-135 d). Although all patients had positive culture results, 7 patients (46.7%) had negative galactomannan test results at the time of culture specimen collection. Positive galactomannan test results were statistically higher in 6 heart transplant patients (P = .045). All patients had fever at presentation, and 13 patients had been referred to the pulmonary disease department before positive culture results were obtained. Risk factors for pulmonary aspergillosis and its clinical presentation in solid-organ transplant recipients are still unclear. Although the expected time for aspergillosis infection in solid-organ transplant recipients is 6 months after transplant, clinicians must remember the nonspecific presentation of infections in these patients and be aware of the reliability of diagnostic tools.

A rare aspect of Crohn's disease: Pulmonary involvement in a child.

Sir, I read with interest the case report by Ongun et al. on the pulmonary involvement in a Turkish child with Crohn's disease (CD).[1] The authors mentioned that “the patient's history of bronchiolitis episodes in the past suspecting of a subclinical pulmonary involvement, the aggravation of respiratory symptoms after colonic surgery which is accepted as a triggering factor, a sudden decline in C-reactive protein, and dramatic clinical improvement after the initiation of prednisolone appointed us the higher possibility of CD-related pulmonary involvement.”[1] The authors did well in studying deep tracheal aspirates that were evaluated for Mycobacterium tuberculosis species and viral respiratory organisms to rule out infliximab-related infections (all were negative).[1] However, they could not differentiate the cause of the inflammatory pulmonary disease by histopathological examination due to the parental disapproval for bronchoscopy.[1] Importantly, the authors did not consider another granulomatous pulmonary lesion in pediatric population that has received ample attention worldwide. I presume that pulmonary sarcoidosis ought to be scrutinized in the case in question by the suitable diagnostic workup. My assumption is based on the following four points. First, it is obvious that sarcoidosis, a chronic multisystem inflammatory granulomatous disorder of unknown origin, is a rare disease in children and pulmonary involvement is even much rare. Due to the nonspecific clinical features and the lack of a specific test, recognizing sarcoidosis can be difficult in the pediatric population.[2] Despite that, pediatric pulmonary sarcoidosis is increasingly reported in the literature.[3] In Turkey, the available data pointed out that children with sarcoidosis were noticed to have more frequent pulmonary parenchymal involvement than in adults.[4] Second, sarcoidosis and concomitant gastrointestinal CD have been reported in patients, as well as the coexistence of CD and sarcoidosis in siblings. Common susceptibility loci have been identified in CD and sarcoidosis.[5] Third, the studied patient's clinical condition and pulmonary functions improved dramatically after initiation of steroid therapy. This further supports the need to consider concomitant sarcoidosis as steroid represents the main-stay in the treatment of CD and sarcoidosis. Fourth, due to the lack of a specific test to precisely diagnose sarcoidosis, a biopsy specimen remains the gold standard with typical epithelioid gigantocellular granuloma without caseating necrosis granuloma, after other disorders known to cause granulomatous disease have been reasonably excluded, particularly tuberculosis.[2] In sarcoidosis patients, the angiotensin-converting enzyme (ACE) level in body fluids will become elevated.[2,5] Measuring ACE in bronchoalveolar lavage fluid can better sign the activity of the pulmonary sarcoidosis than in serum. I presume that the parental decline to do bronchoscopy in the case in question should lead the authors to consider measuring ACE level in deep tracheal aspirates as a last resort to exclude sarcoidosis. If that was achieved and it was proved to be a case of sarcoidosis, the case in question would be considered a novel case report of concomitant pediatric CD and sarcoidosis-associated pulmonary involvement as such association has never been described in the pediatric literature so far. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest

Terapötik hipotermi uygulamasının enfeksiyöz komplikasyonlar üzerindeki etkisinin retrospektif değerlendirilmesi

Objective: Our study aims at determining infection frequency in patients receiving or not receiving therapeutic hypothermia (TH) after cardiopulmonary resuscitation (CPR), detecting the microorganisms most frequently isolated, and measuring the effect of TH on mortality and morbidity. Material and Method: We examined retrospectively the files of 44 patients receiving successful CPR. Patients were separated into two groups: the ones receiving (n=20) and not receiving (n=24) TH. Their leucocyte numbers and C- reactive protein (CRP) values were recorded in the 1st, 3rd, 5th, 7th and 9th day. Their demographic data, hospitalization period in intensive care unit (ICU), the first day that culture positivity occurred, in which culture(s) reproduction occured, which microorganisms reproduced in these cultures, and discharge state of the patients from ICU were recorded. Results: No significant difference was found in patients’ demographic data, and Glasgow coma score (GCS) averages. Culture positivity observed in the first 10 days after intensive care follow-ups, blood, deep tracheal aspiration (DTA), urine culture growth rate, and leukocyte numbers were not significantly different between the groups. Although there was no significant difference between the mortality rates of the groups, hospitalization time in the ICU was significantly lower in the group receiving TH. No significant difference was observed between the groups in terms of leucocyte numbers in the 1st, 3rd, 5th, 7th and 9th day. The CRP value in the 1st day in the group receiving TH was significantly lower than those not receiving TH. There was no significant difference between the CRP values in other days. Conclusion: Although mortality rates are not significantly affected, hospitalization period in ICU was found to be shorter in the group receiving TH. For this reason, we think that TH which was proved to have favorable neurologic advances, should be applied to post CPR patients in ICU practice.