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Ezgi Yılmaz,1 Aysun Benli,2 Seniha Başaran,2 Serap Şimşek-Yavuz,2 Atahan Cagatay,2 Mustafa Oral Oncul,2 Halit Özsüt,2 Haluk Eraksoy2 1Infectious Diseases and Clinical Microbiology, Istanbul Medipol University, Istanbul, Turkey; 2Infectious Diseases and Clinical Microbiology, Istanbul University Istanbul Faculty of Medicine, Istanbul, TurkeyCorrespondence: Ezgi Yılmaz, Email ezgi.yilmaz@medipol.edu.trPurpose: Immunocompromised hosts are underrepresented in clinical trials. The goal of the study to search for the unmet needs in the management of CAP in immunocompromised hosts.Patients and Methods: An observational study was conducted with CAP patients documented immunocompromise or those aged over 65 who have at least one chronic visceral disease. We clinically assessed the eligible patients at the time of the presentation with a follow-up assessment on day three of admission. The data were statistically analyzed to assess the impact of variables on mortality.Results: During a 15-month study period, 140 CAP patients were observed. The overall 30-day mortality rate was 17.8%. The mortality rate was significantly higher in patients with sputum cultures positive for Pseudomonas aeruginosa, or two bacteria (p=0.049). Tachypnea was a stronger predictor of mortality. Failure to achieve a treatment response within three days of treatment identified the population with the worst outcomes. Less than half of such patients survived past one month.Conclusion: Dynamic response assessment emerged as potentially the strongest predictor of outcomes in CAP of susceptible hosts. We propose that immunocompromised CAP patients who fail to respond early to treatment face extremely high rates of mortality, identifying an unmet need.Keywords: community acquired pneumonia, CAP, initial response to treatment, immunocompromised patient, impaired immunity

Background: Cardiovascular disease (CVD) is a major cause of mortality among people living with HIV (PLWH). We aimed to assess the prevalence of diagnosed CVD and the risk of CVD among PLWH using 5 different tools., Methods: This retrospective, cross-sectional study was conducted in 20 tertiary centers in Türkiye between October 2021 and March 2022, among 1425 PLWH aged 40-75 years. About 82.7% were male, with a median age of 51. Web-based tools for each score were used for CVD risk calculations., Results: Of 1425 PLWH enrolled, 10.8% had confirmed CVD, and 1132 had their risk scores evaluated. Of those participants, 42.8% had a higher risk of CVD (10-year risk of atherosclerotic CVD risk score (ASCVD) above 7.5%), and according to the European Society of Cardiology systemic coronary risk evaluation 2 (SCORE2), 71.7% had a high- to very high-risk rate. The agreement between various CVD risk tools varied, with Framingham heart study risk score (FRS), modified FRS, data collection on adverse effects of anti-HIV drugs (DAD), and SCORE2 for high-risk countries showing overall agreement rates of 82%, 94%, 91%, and 36%, respectively, compared to ASCVD. According to the 2021 European and 2019 American Cardiology guidelines, 75.3% and 47.1% of PLWH would be eligible for lipid-lowering agents, respectively., Conclusion: The diagnosed CVD prevalence highlighted the importance of monitoring cardiovascular health and comorbidities in this population. SCORE2 identified a greater number of individuals at high/very high risk compared to other prediction tools. The implementation of CVD prevention through lipid-lowering therapy was far from desired levels in our cohort.

Background: To the best of our knowledge, this is the first study to evaluate the effectiveness of specific concentrations of antibiofilm agents, such as N-acetyl cysteine (NAC), rifampicin, and ozone, for the treatment of pan-resistant Klebsiella pneumoniae (PRKp)., Objectives: We evaluated the effectiveness of antibiofilm agents, such as NAC, rifampicin, and ozone, on biofilm formation in PRKp at 2, 6, 24, and 72 h., Design and Setting: This single-center experimental study was conducted on June 15, 2017, and July 15, 2018, at Istanbul Faculty of Medicine, Istanbul University, Turkey., Methods: Biofilm formation and the efficacy of these agents on the biofilm layer were demonstrated using colony counting and laser-screened confocal microscopy., Results: NAC at a final concentration of 2 μg/mL was administered to bacteria that formed biofilms (24 h), and no significant decrease was detected in the bacterial counts of all isolates (all P > 0.05). Rifampicin with a final concentration of 0.1 μg/mL was administered to bacteria that formed biofilm (24 h), and no significant decrease was detected in bacterial count (all P > 0.05). Notably, ozonated water of even 4.78 mg/L concentration for 72 h decreased the bacterial count by ≥ 2 log10., Conclusion: Different approaches are needed for treating PRKp isolates. We demonstrate that PRKp isolates can be successfully treated with higher concentrations of ozone.

Human pegivirus (HPgV) is transmitted through sexual or parenteral exposure and is common among patients receiving blood products. HPgV is associated with lower levels of human immunodeficiency virus (HIV) RNA and better survival among HIV-infected patients. This study aimed to investigate the prevalence of HPgV and determine its subtypes in HIV-infected individuals living in Istanbul, which has the highest rate of HIV infection in Türkiye. Total RNA extraction from plasma, cDNA synthesis, and nested PCR were performed for HPgV on plasma samples taken from 351 HIV-1-infected patients. The HPgV viral load was quantified on HPgV-positive samples. HPgV genotyping was performed by sequencing the corresponding amplicons. In the present study, the overall prevalence of HPgV RNA in HIV-infected patients was 27.3%. HPgV subtypes 1, 2a, and 2b were found, with subtype 2a being the most frequent (91.6%). Statistical analysis of HIV-1 viral load on HPgV viral load showed an opposing correlation between HIV-1 and HPgV loads. In conclusion, these data show that HPgV infection is common among HIV-positive individuals in Istanbul, Türkiye. Further comprehensive studies are needed to clarify both the cellular and molecular pathways of these two infections and to provide more information on the effect of HPgV on the course of the disease in HIV-infected individuals., Competing Interests: The authors declare no conflicts of interest.

Background: The authors aimed to determine the efficacy of frequently used antibiotics, alone or in combination, against biofilms of ventilator-associated pneumonia isolates. Materials & methods: The authors determined the MICs, minimum biofilm inhibitory concentrations and minimum biofilm eradication concentrations of meropenem, ciprofloxacin and colistin as well as their combinations against planktonic forms and biofilms of Pseudomonas aeruginosa , Klebsiella pneumoniae and Acinetobacter baumannii clinical isolates. Results: Generally, the minimum biofilm inhibitory concentrations and minimum biofilm eradication concentrations of the antibiotics were 1000-fold higher than their MICs, and synergy was provided by different concentrations of meropenem-colistin and meropenem-ciprofloxacin combinations with checkerboard and time-kill curve methods. Conclusion: The combination of meropenem and ciprofloxacin seems to be a good candidate for the treatment of biofilm-associated infections; none of the concentrations obtained as a result of the synergy test were clinically significant.

Introduction: The authors aimed to investigate the biofilm-forming features of panresistant Klebsiella pneumoniae (PRKp). Material & methods: The biofilm formations were shown under light microscope and laser scanning confocal microscopy. The optical densities of the wells were measured and classified according to biofilm-forming capacities. Results: The ratio of biofilm-forming K. pneumoniae was established to be 100%. All isolates were found to form high-level biofilms in classification compared with positive and negative controls. No significant difference was detected in the biofilm-forming capacities of K. pneumoniae strains isolated from different sample types. Conclusion: No previous study associated with PRKp isolates was identified in the literature search. There is a need for different approaches characterizing the biofilm-forming features of PRKp.

COVID-19 vaccines are highly protective against severe disease; however, vaccine breakthrough infections resulting in hospitalization may still occur in a small percentage of vaccinated individuals. We investigated whether the clinical and microbiological features and outcomes were different between hospitalized COVID-19 patients who were either fully vaccinated with Coronovac or not. All hospitalized COVID-19 patients who had at least one dose of Coronavac were included in the study. The oldest unvaccinated patients with comorbidities, who were hospitalized during the same period, were chosen as controls. All epidemiologic, clinical and laboratory data of the patients were recorded and compared between the fully vaccinated and unvaccinated individuals. There were 69 and 217 patients who had been either fully vaccinated with Coronavac or not, respectively. All breakthrough infections occurred in the first 3 months of vaccination. Fully vaccinated patients were older and had more comorbidities than unvaccinated patients. There were minor differences between the groups in symptoms, physical and laboratory findings, anti-spike IgG positivity rate and level, the severity of COVID-19, complications, and clinical improvement rate. The mortality rate of fully vaccinated patients was higher than the mortality rate in unvaccinated patients in univariate analysis, which was attributed to the fact that vaccinated patients were older and had more comorbidities. The severity and clinical outcomes of hospitalized patients with breakthrough COVID-19 after Coronavac vaccination were similar to those of unvaccinated patients. Our findings suggest that the immune response elicited by Coronovac could be insufficient to prevent COVID-19-related severe disease and death within 3 months of vaccination among elderly people with comorbidities.

Objective: Severe acute respiratory syndrome (SARS) coronavirus 2 (SaRS-Cov-2) associated respiratory disease (COVID-19), announced as a pandemic, is a multisystem syndrome. SARS-CoV-2 directly infects and damages vascular endothelial cells, which leads to microvascular dysfunction and promotes a procoagulant state. Dipyridamole (DP) acts as a reversible phosphodiesterase inhibitor and is used mainly as an antiplatelet agent. It is hypothetised that it has possible activities in COVID-19., Design and Methodology: We report our retrospective, real-world results of DP added to low-molecular weight heparin (LMWH) in the treatment of 462 clinically diagnosed and hospitalized COVID-19 patients. We compared anticoagulation with and without DP addition with no administration of anticoagulation in the same time frame. The primary outcome was proven or highly suspected coagulopathy within 30 days of hospitalization., Results: Definitive coagulopathy has been diagnosed in 3 (3.5%) of 85 LMWH administered patients and 7 (2.13%) of 328 DP + LMWH received patients (P=0.456). Five cases with definitive coagulopathy were not initiated any anticoagulation at the time of the event. The multivariate analysis showed that DP addition to the anticoagulant approach did not have any impact on the risk of demonstrated coagulopathy and highly-suspected coagulopathy., Conclusion: We think that our clinical experience is valuable in showing the real-life results of DP + LMWH treatment in COVID-19. This approach did not affect the coagulopathy rate. Our data did also not document an additive effect of DP in the COVID-19 outcome. Prospective controlled trials would give more convincing results regarding the role of DP in COVID-19 endothelial dysfunction and clinical outcome., Competing Interests: None., (AJBR Copyright © 2022.)

Q fever is a zoonosis caused by Coxiella burnetii. In this report, a case of chronic Q fever endocarditis with pancytopenia and hypergammaglobulinemia mimicking a lymphoproliferative disease was presented. A 39-years-old male living in Çatalca and whose family is engaged in animal husbandry admitted with the complaints of weakness and fatigue. The patient had aortic valve replacement 29 years ago and had aortic valve re-replacement, and ascending aorta grafting because of endocarditis three years ago. It was revealed that the second operation of the patient was due to possible infective endocarditis, but no definitive agent could be identified. He was evaluated for massive hepatosplenomegaly, pancytopenia, hypergammaglobulinemia, presence of M-spike and elevated β-2 microglobulin levels and was referred to our hematology clinic with a preliminary diagnosis of lymphoproliferative disease. Lymphoplasmacytic lymphoma was excluded with the result of bone marrow biopsy and he was referred to our clinic for the investigation of possible infectious etiologies. We detected hepatosplenomegaly and finger clubbing. His blood analyses were normal except for the following: leukocyte count 3800/μl, platelet count 148000/μl, gamma globulin 5.9 gr/dl, rheumatoid factor (RF) and antinuclear antibody (ANA) positivity. Chronic Q fever endocarditis was suspected and C.burnetii Phase I IgG test was found positive in 1/132071 titers. Although transesophageal echocardiography showed no lesion of endocarditis, positron emission tomography/computed tomography revealed increased fluorodeoxyglucose uptake around the prosthetic heart valve and graft. The patient was diagnosed as having Q fever endocarditis and graft infection. He refused hospitalization and was started on hydroxychloroquine and doxycycline treatment. The patient stopped taking these antibiotics by himself seven days after the diagnosis. He was admitted with a headache to another hospital and operated for an intracranial hemorrhage and died shortly after. Apart from unfamiliarity, wide range of clinical presentations of disease could also lead to delayed diagnosis. Among patients with chronic Q fever, continuous bacteremia and antigenic stimulus causes inflammatory syndrome with hepatosplenomegaly, hypergammaglobulinemia and, presence of autoantibodies which leads to misdiagnoses of rheumatologic, autoimmune or hematologic diseases Chronic Q fever should be investigated in patients with known valvulopathy and chronic hepatomegaly or splenomegaly, pancytopenia, hypergammaglobulinemia, and unexplained autoantibody positivity.

Introduction: Co-receptors involved in cell entry of the human immunodeficiency virus (HIV) and mutations in genes encoding their ligands may play a role in the susceptibility to infection and resistance to the progression of the infection. The best studied mutations that can exist in these genes are the CCR5-Δ32, CCR2-64I and SDF1-3'A mutations. The frequency of these mutations vary from continent to continent and even from region to region. However, there is limited information on their distribution throughout the Turkish population. Istanbul is the city with the highest number of documented HIV-infected patients in Turkey, which can be attributed to the population size. The aim of this study was to determine the distribution of three AIDS-related gene variants among HIV-infected and uninfected population in Istanbul, Turkey and to estimate the contribution of these variants to susceptibility or resistance to HIV., Methodology: A total of 242 healthy individuals and 200 HIV-positive patients were included in the study. CCR5 polymorphisms were genotyped by polymerase chain reaction. CCR2 and SDF1 polymorphisms were genotyped using PCR restriction fragment length polymorphism (PCR-RFLP)., Results: The allelic frequencies for CCR5-Δ32, CCR2-64I and SDF1-3'A were 4.07%, 19.8% and 28.7%, respectively. No individual was found to carry the homozygous CCR5-Δ32 mutation in either cohort. No polymorphism was found to be significantly elevated in the HIV-infected cohort compared to the healthy group., Conclusions: The distribution of CCR5-Δ32, CCR2-64I, and SDF1-3'A variants does not differ between HIV-infected and uninfected patients. CCR2-64I and SDF1-3'A frequencies are relatively high where as the frequency of CCR5-Δ32 is low., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2021 Muammer Osman Koksal, Baki Akgul, Hayati Beka, Sevgi Ciftci, Fahriye Keskin, Haluk Eraksoy, Ali Agacfidan.)

Gastrointestinal (GI) tuberculosis (TB) remains a significant problem worldwide, and may involve the luminal GI tract from oral cavity to perianal area in addition to associated viscera and peritoneum. Although GI TB more commonly affects immunocompromised hosts, it can also occur in immunocompetent people. Diagnosis is difficult because it usually mimics a malignancy or inflammatory bowel disease. A high index of clinical suspicion and appropriate use of combined investigative methods help in early diagnosis, and reduce morbidity and mortality. Anti-TB therapy is the same as for pulmonary disease, and invasive and specialized interventions are reserved for selected complications., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Disease severity, previous medications and immunosuppressive agents could affect the antibody response against SARS-CoV-2. This study aimed to analyze variables affecting the humoral response to SARS-CoV-2., Methods: This prospective cohort study included adult patients who recovered from COVID-19 and were admitted to a COVID-19 follow-up unit. Eight patient groups were defined in accordance with the results of thoracic computed tomography (CT), SARS-CoV-2 PCR test, and tocilizumab or anakinra use during active disease. Anti-S IgG antibodies were determined by ELISA in serum samples. Anti-S positive and negative cases were compared., Results: A total of 518 patients were included in the study. SARS-CoV-2 IgG antibodies were positive in 82.8% of patients. SARS-CoV-2 PCR positivity, extent of lung involvement on CT, and time to antibody testing were independently associated with antibody positivity. Tocilizumab, anakinra or prednisolone use was not a factor affecting the antibody response. The rate of antibody response and sample/CO values among antibody-positive patients showed a linear relationship with the extent of lung involvement on CT., Conclusions: The use of tocilizumab, anakinra and prednisolone for COVID-19 did not affect the antibody response against SARS-CoV-2. The main driver of antibody response among patients with COVID-19 was the extent of pulmonary involvement on CT., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: There is limited evidence on the modification or stopping of antiretroviral therapy (ART) regimens, including novel antiretroviral drugs. The aim of this study was to evaluate the discontinuation of first ART before and after the availability of better tolerated and less complex regimens by comparing the frequency, reasons and associations with patient characteristics., Methods: A total of 3019 ART-naive patients registered in the HIV-TR cohort who started ART between Jan 2011 and Feb 2017 were studied. Only the first modification within the first year of treatment for each patient was included in the analyses. Reasons were classified as listed in the coded form in the web-based database. Cumulative incidences were analysed using competing risk function and factors associated with discontinuation of the ART regimen were examined using Cox proportional hazards models and Fine-Gray competing risk regression models., Results: The initial ART regimen was discontinued in 351 out of 3019 eligible patients (11.6%) within the first year. The main reason for discontinuation was intolerance/toxicity (45.0%), followed by treatment simplification (9.7%), patient willingness (7.4%), poor compliance (7.1%), prevention of future toxicities (6.0%), virologic failure (5.4%), and provider preference (5.4%). Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based (aHR = 4.4, [95% CI 3.0-6.4]; p < 0.0001) or protease inhibitor (PI)-based regimens (aHR = 4.3, [95% CI 3.1-6.0]; p < 0.0001) relative to integrase strand transfer inhibitor (InSTI)-based regimens were significantly associated with ART discontinuation. ART initiated at a later period (2015-Feb 2017) (aHR = 0.6, [95% CI 0.4-0.9]; p < 0.0001) was less likely to be discontinued. A lower rate of treatment discontinuation for intolerance/toxicity was observed with InSTI-based regimens (2.0%) than with NNRTI- (6.6%) and PI-based regimens (7.5%) (p < 0.001). The percentage of patients who achieved HIV RNA < 200 copies/mL within 12 months of ART initiation was 91% in the ART discontinued group vs. 94% in the continued group (p > 0.05)., Conclusion: ART discontinuation due to intolerance/toxicity and virologic failure decreased over time. InSTI-based regimens were less likely to be discontinued than PI- and NNRTI-based ART.

Syphilis has become a serious issue for human immunodeficiency virus (HIV)-infected patients worldwide in recent years; however, the studies related to HIV coinfection and syphilis reinfections in Istanbul, Turkey, are limited. Our objective was to determine the seroprevalence of syphilis among HIV-infected men in the city which has one of the highest HIV prevalence rates in Turkey. Two hundred and forty four (244) HIV-positive men were evaluated at Istanbul Medical Faculty, Department of Medical Microbiology from March to June 2018. Serum samples were screened for the presence of antibodies against Treponema pallidum using the chemiluminescent microparticle immunoassay (CMIA). Samples found to be positive were investigated with the rapid plasma reagin (RPR) test and the T. pallidum hemagglutination assay (TPHA). The patients completed a questionnaire for sociodemographic data. The mean age was found to be 41.8 years; 35.6% were men who have sex with men (MSM). The overall seroprevalence of syphilis among the patients was 19.3%. MSM had a significantly higher seroprevalence than heterosexual patients (28.7%). In Turkey, there is a high seroprevalence of syphilis in HIV-infected patients, MSM being the most affected group. Therefore, HIV-infected patients should be screened for syphilis at least annually and should be informed about sexually transmitted diseases (STDs)., (Copyright © 2020 Asociación Argentina de Microbiología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Encephalitis is an inflammatory process involving the brain parenchyma associated with neurologic dysfunction. The main causes of infectious encephalitis are viruses, including Herpes simplex virus type 1 (HSV-1). As the mortality rate of HSV-1 encephalitis could be reduced with early acyclovir treatment, it is imperative to distinguish HSV-1 encephalitis from other type of viral encephalitis as early as possible. However, sophisticated methods for definitive diagnosis of HSV-1 encephalitis are not readily available. We aimed to explore distinctive clinical and laboratory features of HSV-1 encephalitis. All of the adult patients with viral encephalitis hospitalized between 2011-2017 were enrolled, including 16 patients with HSV-1 encephalitis and 51 patients non-HSV-1 viral encephalitis. Determination of viruses in cerebrospinal fluid was performed by PCR tests. Female sex, hyponatremia, and abnormalities in MRI were independently associated with HSV-1 encephalitis (p < 0.05 for each). In particular, hyponatremia (< 135 mEq/L) was found in nine patients with HSV-1 encephalitis (56.3%) and 10 patients with non-HSV-1 viral encephalitis (19.6%) (p = 0.005). As serum sodium is determined easily and quickly in clinical practice, the presence of hyponatremia among patients with viral encephalitis could be helpful for the early diagnosis of HSV-1 encephalitis before cerebrospinal fluid PCR results were available. Moreover, the presence of positive finding in MRI could further support the diagnosis. This is the first study that compared the serum sodium levels among patients between HSV-1 and non-HSV-1 viral encephalitis. We thus propose the diagnostic value of hyponatremia for HSV-1 encephalitis.

Objective: We aimed to find the incidence and risk factors of hematologic adverse effects of piperacillin-tazobactam (TZP)., Materials and Methods: Adult patients who used TZP for more than 10 days were included in the study., Results: The incidence of leukopenia, neutropenia, and eosinophilia in 110 TZP therapy episodes was found to be 16.3%, 10%, and 10%, respectively. Lower Charlson Comorbidity Index score, lower initial leukocyte count, combination of TZP with another antibiotic, and total duration of TZP therapy were found to be independent risk factors for leukopenia, while initial higher eosinophil count (IHEC) and usage of TZP for >20 days were independent risk factors for neutropenia and IHEC and total duration of TZP therapy were independent risk factors for eosinophilia., Conclusion: Longer duration of therapy, combination with other antibiotics, younger age with fewer comorbidities, and IHEC could result in hematologic adverse effects in patients treated with TZP. Patients with IHEC may be more prone to allergic reactions, so immunological mechanisms may facilitate the development of hematological adverse effects of TZP.

Objectives: We described the clinical outcomes of the diabetic patients who had foot infections with multidrug resistant organisms., Methods: We included the patients with diabetic foot infections (DFI) from 19 centers, between May 2011 and December 2015. Infection was defined according to IDSA DFI guidelines. Patients with severe infection, complicated moderate infection were hospitalized. The patients were followed-up for 6 months after discharge., Results: In total, 791 patients with DFI were included, 531(67%) were male, median age was 62 (19-90). Severe infection was diagnosed in 85 (11%) patients. Osteomyelitis was diagnosed in 291(36.8%) patients. 536 microorganisms were isolated, the most common microorganisms were S. aureus (20%), P. aeruginosa (19%) and E. coli (12%). Methicillin resistance (MR) rate among Staphylococcus aureus isolates was 31%. Multidrug resistant bacteria were detected in 21% of P. aeruginosa isolates. ESBL (+) Gram negative bacteria (GNB) was detected in 38% of E. coli and Klebsiella isolates. Sixty three patients (8%) were re-hospitalized. Of the 791 patiens, 127 (16%) had major amputation, and 24 (3%) patients died. In multivariate analysis, significant predictors for fatality were; dialysis (OR: 8.3, CI: 1.82-38.15, p=0.006), isolation of Klebsiella spp. (OR:7.7, CI: 1.24-47.96, p=0.028), and chronic heart failure (OR: 3, CI: 1.01-9.04, p=0.05). MR Staphylococcus was detected in 21% of the rehospitalized patients, as the most common microorganism (p<0.001)., Conclusion: Among rehospitalized patients, methicillin resistant Staphylococcus infections was detected as the most common agent, and Klebsiella spp. infections were found to be significantly associated with fatality., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Coccidioidomycosis caused by Coccidioides immitis or Coccidioides posadasii is a rare infectious disease except in endemic regions. In this report the third documented imported case of coccidioidomycosis in Turkey was presented. A thirty-year-old male patient was admitted to our hospital with fever and purulent drainage from his chest tube. He had worked in Arizona, USA, until 4 months before this presentation. While in Arizona, he experienced cough and hemoptysis and was diagnosed as pulmonary coccidioidomycosis. He was treated with itraconazole for two months and he had no symptoms for 3 years. He then returned to Turkey and 2 months after his return to Turkey, he was admitted to another hospital in Istanbul with dyspnea and diagnosed as hydro-pneumothorax, and pleural fluid obtained from the inserted chest tube was found to be purulent. One gram of BID amoxicillin-clavulanate was given. Physical examination on admission revealed a purulent drainage on the right side chest tube, a temperature of 38.5°C and decreased breath sounds on the right lung. Piperacillin-tazobactam 3 x 4.5 g intravenous and fluconazole 400 mg intravenous once daily were started. Human immunodeficiency virus test was negative. Gram-negative diplococci and rods, gram-positive cocci and septate hyphae were seen in the Gram stain of his pleural fluid. Pleural fluid culture revealed Moraxella catarrhalis after 24 hours incubation and a mold after 72 hours of incubation. Anti-coccidioidal antibodies were found positive in a titer of 1/2. Hydro-pneumothorax, atelectasis and a 3 mm nodules in the right lung were seen in his thorax CT. The patient's pleural fluid and the culture plates were sent to the Public Health Institute of Turkey, Mycology Reference Laboratory (PHIT-MRL), with a clinical suspicion of coccidioidomycosis. The specimen and plates were submitted to the PHIT-MRL Bio Safety Level-3 laboratory for mycological evaluation. The microscopic examination of 15% KOH preparations of pleural fluid specimens revealed septate hyphae which appear to be in the early stages of forming arthroconidia. The pleural fluid culture grew buff-white coloured colonies with aerial hyphae, which were suspected of being a Coccidioides spp. The strain was identified as C.immitis/posadasii by direct microscopy and culture, and subsequently confirmed by the FDA-approved DNA probe. DNA sequence analysis of the ITS and D1/D2 rDNA regions confirmed the isolate to be C.posadasii species [ITS 100% match to GenBank Accession No. AB232901 (630/630 base pair match), and D1/D2 100% match to GenBank Accession No. AB232884 (617/617 base pair match)]. ITS1 and ITS2 barcode analysis also confirmed the species to be C.posadasii, which is the species endemic in Arizona. Susceptibility testing was performed according to Clinical and Laboratory Standards Institute M38-A2 guidelines in the Fungus Testing Laboratory of the University of Texas Health Science Center at San Antonio and minimal inhibitory concentration values were; 0.125 µg/ml for amphotericin B, posaconazole and voriconazole, 0.5 µg/ml for itraconazole and 8 µg/ml for fluconazole. He had decortication of the pleura and was discharged from hospital after six weeks treatment with intravenous fluconazole which was continued orally for one year. Anti-coccidioidal antibodies were negative after two months of treatment. The patient is currently asymptomatic. The presented case is the third case reported from Turkey and provides additional contribution to the existing literature with regard to the appearance of arthroconidium, which is the unusual hyphal form, instead of the expected spherules in the infected tissue.

Turkey is seeing a steady rise in rates of HIV infection in the country. The number of individuals with HIV/AIDS was greater than 7000 in 2014 according to data released by the Ministry of Health, and heterosexual contacts were reported to be the main transmission routes. Istanbul has the highest number of reported cases of HIV infection. The aim of the study was to determine the prevalence of HIV-1 drug resistance in 50 heterosexual patients from Istanbul. The most prevalent subtype was found to be subtype B (56.2 %). Resistance-associated mutations were found in 14 patients with 6/14 patients being therapy-experienced and 8/14 therapy naive at the time point of analysis. With increasing number of patients who require treatment and the rapid up-scaling of the antiretroviral therapy in Turkey, HIV-1 drug resistance testing is recommended before starting treatment in order to achieve better clinical outcomes.

Nosocomial infections caused by multidrug-resistant (MDR) microorganisms are a major problem in intensive care units (ICUs) with high mortality and morbidity rates and the prior colonization is an important risk factor for these infections. The aim of this study was to investigate the prevalence of rectal colonization of MDR microorganisms and the association between the microorganisms that caused colonization and infection in the patients with nosocomial infections in ICUs. Rectal swabs were obtained on the day of 0, 3, 7, 14, 21 and weekly thereafter from 80 patients over 18 years of age hospitalized in ICU for more than 48 hours, and cultured for vancomycin-resistant enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase (ESBL)- producing gram-negative bacilli (GNB) and carbapenem-resistant enteric and nonenteric bacilli. Patients whose rectal swabs were not obtained on admission (on the day of 0), were excluded even they were hospitalized more than 48 hours. Bile esculin agar containing 64 μg/mL ceftazidime and 6 μg/mL vancomycin, chromogenic MRSA agar and blood agar media, MacConkey agar containing 1 mg/L ceftazidime and ceftriaxone, and 5 mL tryptic soy broth media containing 10 µg imipenem and meropenem discs were used for identification. Identification of GNB was determined by conventional methods and ESBL production was determined by double-disc synergy test. Patients have been followed up for nosocomial infections. Bacterial identification and antibiotic susceptibility tests were performed with standard microbiological methods. In 37 (46%) of the 80 patients, at least one MDR microorganism was isolated in rectal swab cultures on the day of 0. The most common microorganisms were ESBL-positive E.coli (19%), followed by ESBL-positive K.pneumoniae (13%), carbapenem-resistant P.aeruginosa (10%), ESBL-positive K.oxytoca (3%), MRSA (1%), VRE (1%), carbapenem-resistant Acinetobacter sp. (1%) and carbapenem-resistant K.pneumoniae (1%), respectively. The number of microorganisms isolated from rectal swab cultures on the following days have increased, and on the 7th day, the rate of the patients with rectal colonization ascended to 72%. Out of 80 patients, 52 (65%) had nosocomial infections in the follow-up and the mean duration of infection development was 11.8±9.9 days in these patients. Patients with and without rectal colonization were compared in terms of subsequent nosocomial infection rates. While no statistically significant difference has been detected between two groups on the day of 0, patients with rectal colonization detected on the day of 3 and 7, had a significantly higher incidence of nosocomial infections (p=0.02, p=0.01). Among the patients with ESBL-positive GNB, carbapenem-resistant K.pneumoniae, carbapenem-resistant P.aeruginosa and VRE infections, the same microorganisms have been isolated in the rectal swab cultures taken before the development of infection. This result was statistically significant for each of these microorganisms (p=0.00-0.03). However, such a correlation was not observed for Acinetobacter infections. Since MRSA infections developed in only two patients, no istatistical analysis has been done for this microorganism. In conclusion, our data suggest that MDR microorganisms that cause nosocomial infections, initially colonize the gastrointestinal tract, and early detection of colonized patients in ICUs may help an effective infection control by preventing the spread of these resistant microorganisms.

Introduction: HIV-TR is a recently established (2012) multicentre cohort in Turkey. The aim of this study is to analyze epidemiological, immunologic and virologic data of recently diagnosed HIV patients., Materials and Methods: Epidemiologic, clinical and laboratory data of all patients diagnosed in 2011 and 2012 were recorded by a web-based data collection system, retrospectively., Results: A total of 693 patients (561 male, 132 female) at 24 sites were enrolled. The median age at first presentation for HIV care was 36. The proportion of patients presenting with advanced HIV disease (CD4 count<200/mm(3) or presenting with an AIDS-defining event) was 30.6%; and 52.4% of patients were late presenters (CD4 count<350/mm(3) or presenting with an AIDS-defining event). Median CD4 counts at presentation and before treatment were 344 (IQR: 175-540) and 295 (IQR: 150-430), respectively. Pretreatment CD4 count was >500 copies/mL in 18.5% of patients. Of 531 patients receiving ART, initial combinations consist of tenofovir/emtricitabine (TDF/FTC) plus efavirenz (EFV) in 48.2% and TDF/FTC plus lopinavir/ritonavir (LPV/r) in 37.5% and other combinations in 14.3% of the patients. Pre-treatment HIV-RNA was over 100.000 copies/mL in 52.3% of patients. At Weeks 24 and 48, HIV-RNA were<50 copies/mL in 63,4% of 385 patients and 82% of 311 patients reported to be still on ART and had a viral load measurement, respectively. Median pretreatment CD4 count was lower for TDF/FTC+LPV/r recipients than TDF/FTC+EFV recipients (250 vs 316) (p<0.05). The median increase from baseline CD4 cell count was 230 in TDF/FTC+LPV/r group, 193 in TDF/FTC+EFV group and 216 among all treated patients. Of 531 patients receiving ART, 11 had died and 19 were lost to follow-up., Conclusion: Despite 52.4% of recently diagnosed patients were late presenters; a high rate of virologic suppression was achieved in HIV-TR Cohort. A national HIV testing strategy targeting subpopulations with higher risk is urgently needed.

Introduction: Routes of transmission and reasons for HIV testing are important epidemiologic data to analyze the epidemic and to tailor the response to AIDS. The aim of this study was to analyze reasons for testing and transmission ways of HIV among recently diagnosed HIV patients registered in the multicenter HIV-TR cohort in Turkey., Methods: Transmission ways and reasons for testing of all patients diagnosed in 2011 and 2012 were recorded on a web-based data collection system and were analyzed retrospectively., Results: The study included 693 patients (561 male, 132 female) from 24 sites. Reason for HIV testing was available in 640 patients (92%). The most common reason for HIV testing was diagnostic workout for other conditions or illness followed by patient-initiated testing. The reasons for testing were listed in Table 1. The most common routes of HIV transmission were heterosexual intercourse (62.7%) and sex among men who have sex with men (MSM) (22.6%). At the time of HIV diagnosis, the mean CD4 lymphocyte cell count was 355/mm(3) (3-1433/mm(3)). Primary HIV infection was determined in 42/693 (6%) patients and 9/693 (% 1, 2) cases were considered "probable primary HIV infection." The majority of the cases presented to a clinic for follow-up right after the diagnosis. On the other hand 32/616 (5.2%) patients delayed their presentation for more than 3 months. The longest delay was 11 months., Conclusions: The results of the database suggest that targeted testing is lacking in the country. The shift toward homosexual transmission during the last 2 years emphasizes the need for targeted interventions. Patients present relatively late and HIV infection could only be diagnosed when immunosuppression related findings appeared. Patient-initiated testing,an indicator of awareness, was very low suggesting a need to scale-up awareness raising interventions.