Search

Introduction: This study was performed to investigate the value of acute phase reactants and LightCycler® SeptiFast test to differentiate bacterial and viral infections., Population and Methods: Children with fever were enrolled to this prospective study. Peripheral white blood cell (WBC), C-reactive protein (CRP) and procalcitonin (PCT) were studied from all patients on day 1, 3 and 7. Blood culture and chest X-ray were also obtained on day 1. Blood samples for LightCycler® SeptiFast test were obtained in all patients to use them if there was uncertain diagnosis between bacterial or viral infection. The patients were divided into two groups as bacterial and viral infection., Results: A total of 94 children with fever were enrolled. The mean value of fever was significantly higher in bacterial group than viral group (p <0.001). In bacterial infection group, 34 (72.3%) patients had negative blood culture. Of those, 12 (35.2%) had positive SeptiFast test. There were no positive blood culture in patients with viral infection group and all of them had negative SeptiFast test. The mean levels of CRP on the first day of admission were significantly higher in bacterial group than viral group (p <0.001). CRP and PCT levels of day 3 and 7 were significantly higher in bacterial group (p <0.001). The sensitivity and specificity levels of WBC, CRP and PCT were 63.8%, 44.7%, 74.5% and 78.7% ,68.1% and 100%, respectively., Conclusions: We found that acute phase reactants, especially PCT, and LightCycler® SeptiFast test may help to differentiate bacterial and viral infections., (Sociedad Argentina de Pediatría)

Infection is the main problem among the patients receiving cancer therapy. The mortality rate can be reduced by the appropriate treatment in the right time. Although blood culture is the gold standard for the diagnoses of sepsis, many factors influence the results of blood culture in children. For this reason, real time polymerase chain reaction (Rt-PCR) has gained importance for the diagnoses of microbiological agents as it is faster than the conventional methods. In this study, we aimed to compare the efficacy of SeptiFast (SF) test with blood culture among children with neutropenic fever. Between January 2013 and December 2014, 62 children (34 boys, 38 girls) mean age 7.56 ± 4.8 (0-18) years with cancer were included in this study during their 94 febrile attacks of neutropenia (NA). Blood samples for blood culture and Septifast test were taken before the initiation of antibiotic therapy. Blood cultures were routinely collected in aerobic and anaerobic media and incubated using the BACTEC 9120 system (Becton-Dickinson Diagnostic Systems, USA). Identification and antimicrobial susceptibility testing of the isolates were performed using the Vitek2® system (bioMérieux, France) according to the recommendations of the Clinical and Laboratory Standards Institute. The LightCycler SF test was used according to the manufacturer instructions. Of 94 attacks 34 (36.1%) were positive for blood culture and 33 (35.1%) for SF test. The positivity ratio is found as 29.7% (28/94) by blood culture when the analysis of five coagulase negative staphylococci were excluded due to contamination. Positivity was detected in 25 (26.6%) of the 94 NA both with blood culture and SF test.The difference between these two tests was statistically significant (p< 0.05). There was discordance with a rate of 28.7% between these two methods. Polymicrobial infections were detected only with SF test. The detection of fungal infection rate was higher with SF test than blood culture. When SF test was compared with blood culture the results were as follows; sensitivity 91%, specificity 98.3%, positive predictive value 97%, negative predictive value 96.7%, diagnostic performance was 96.2%, respectively. As a result, PCR based tests can be used in children with NA attacks even though blood culture is still needed to perform the antibiotic sensitivity tests. SF test seems to be a sensitive test for the early diagnosis of the pathogens and the initiation of the appropriate therapy according to the etiological agent.

The serogroup epidemiology of invasive meningococcal disease (IMD), which varies considerably by geographic region and immunization schedule, changes continuously. Meningococcal carriage data are crucial for assessing IMD epidemiology and designing f potential vaccination strategies. Meningococcal seroepidemiology in Turkey differs from that in other countries: serogroups W and B are the predominant strains for IMD during childhood, whereas no serogroup C cases were identified over the last 10 y and no adolescent peak for IMD was found. There is a lack of data on meningococcal carriage that represents the whole population. The aims of this multicenter study (12 cities in Turkey) were to evaluate the prevalence of Neisseria meningitidis carriage, the serogroup distribution and the related risk factors (educational status, living in a dormitory or student house, being a household contact with Hajj pilgrims, smoking, completion of military service, attending bars/clubs) in 1518 adolescents and young adults aged 10-24 y. The presence of N. meningitidis DNA was tested, and a serogroup analysis was performed using polymerase chain reaction. The overall meningococcal carriage rate was 6.3% (n = 96) in the study population. A serogroup distribution of the 96 N. meningitidis strains isolated from the nasopharyngeal specimens revealed serogroup A in 5 specimens (5.2%), serogroup B in 9 specimens (9.4%), serogroup W in 64 specimens (66.6%), and serogroup Y in 4 specimens (4.2%); 14 were classified as non-grouped (14.4%). No serogroup C cases were detected. The nasopharyngeal meningococcal carriage rate was 5% in the 10-14 age group, 6.4% in the 15-17 age-group, and 4.7% in the 18-20 age group; the highest carriage rate was found in the 21-24 age group (9.1%), which was significantly higher than those of the other age groups (p < 0.05). The highest carriage rate was found in 17-year-old adolescents (11%). The carriage rate was higher among the participants who had had close contact with Hajj/Umrah pilgrims (p < 0.01) or a history of upper respiratory tract infections over the past 3 months (p < 0.05). The nasopharyngeal carriage rate was 6.3% among adolescents and young adults in Turkey and was similar to the recent rates observed in the same age groups in other countries. The most prevalent serogroup was W, and no serogroup C cases were found. In conclusion, the present study found that meningococcal carriage reaches its peak level by age 17, the highest carriage rate was found in 21 - to 24 - year-olds and the majority of the carriage cases were due to serogroup W. Adolescents and young adult carriers seem to be a potential reservoir for the disease, and further immunization strategies, including adolescent immunization, may play a role in the control of IMD.

Pulmonary Langerhans cell histiocytosis (PLCH) is a well known entity in adults but is exceedingly rare in children. It is better described in adults than in children. Smoking is a major etiological factor in adulthood. We report a case of a previously healthy 16-year-old male with a history of cigarette smoking, who presented with cough with sputum, breathlessness, easy fatigability and loss of appetite for two weeks. He was first diagnosed with bronchiectasis according to the cystic pulmonary changes demonstrated by computed tomography. After appropriate treatment, there was no sign of clinical improvement. A lung biopsy confirmed Langerhans cell histiocytosis (LCH). The definitive diagnosis was isolated pulmonary LCH. PLCH should be considered in the etiology of cystic lung diseases. Isolated pulmonary LCH is rare so such cases are needed to be reported and followed-up to understand the treatment response and course of this illness.

Mimaroğlu E, Çıtak EÇ, Kuyucu N, Eskendari G. The diagnostic and prognostic value of angiopoietins compared with C-reactive protein and procalcitonin in children with febrile neutropenia. Turk J Pediatr 2017; 59: 418-425. In this study, we aimed to determine serum angiopoetin (Ang) levels and compare them with levels of C-reactive protein (CRP) and procalcitonin (PCT). Cancer patients (aged 0-18 years) who experienced febrile neutropenia attacks were included in the study. Ang-1, Ang-2, CRP, and PCT were analyzed at admission and 2nd day. Ninety-four episodes of febrile neutropenia that developed in 62 patients were analyzed in this study. The mean age of the patients was 7.56 ± 4.8 (0.5-17) years. The patients had lymphoma (33.9%), solid tumors (48.4%), and other cancer (17.7%). The percentages of the patients with fever of unknown origin (FUO), clinically documented infection (CDI), and microbiologically documented infection (MDI) categories were 45.7%, 22.3%, and 31.9%, respectively. During the study period 11 patients were lost to follow-up. The levels of CRP, PCT and Ang-2 were significantly higher; and that of Ang-1 was significantly lower, compared to the controls. The differentiation cannot be made between the groups by CRP and PCT levels. The level of Ang-1 was the lowest in MDI group; the level of Ang-2 and the ratio of Ang-2/Ang-1 were high in each group. Ang-1, Ang-2 and the ratio of Ang-2/Ang-1 were significantly associated with mortality. Angs correlated with the severity of infection.

This is an observational epidemiological study to describe causes of bacterial meningitis among persons between 1 month and 18 y of age who are hospitalized with suspected bacterial meningitis in 7 Turkish regions. covering 32% of the entire population of Turkey. We present here the results from 2013 and 2014. A clinical case with meningitis was defined according to followings: any sign of meningitis including fever, vomiting, headache, and meningeal irritation in children above one year of age and fever without any documented source, impaired consciousness, prostration and seizures in those < 1 y of age. Single tube multiplex PCR assay was performed for the simultaneous identification of bacterial agents. The specific gene targets were ctrA, bex, and ply for N. meningitidis, Hib, and S. pneumoniae, respectively. PCR positive samples were recorded as laboratory-confirmed acute bacterial meningitis. A total of 665 children were hospitalized for suspected acute meningitis. The annual incidences of acute laboratory-confirmed bacterial meningitis were 0.3 cases / 100,000 population in 2013 and 0.9 cases/100,000 in 2014. Of the 94 diagnosed cases of bacterial meningitis by PCR, 85 (90.4%) were meningococcal and 9 (9.6%) were pneumococcal. Hib was not detected in any of the patients. Among meningococcal meningitis, cases of serogroup Y, A, B and W-135 were 2.4% (n = 2), 3.5% (n = 3), 32.9% (n = 28), and 42.4% (n = 36). No serogroup C was detected among meningococcal cases. Successful vaccination policies for protection from bacterial meningitis are dependent on accurate determination of the etiology of bacterial meningitis. Additionally, the epidemiology of meningococcal disease is dynamic and close monitoring of serogroup distribution is comprehensively needed to assess the benefit of adding meningococcal vaccines to the routine immunization program.

Background: The aim of this study was to evaluate the diagnostic value of red blood cell distribution width (RDW) in children with acute appendicitis., Methods: In this retrospective study, a total of 344 children aged ≤18 years with clinically suspected acute appendicitis who underwent appendectomy between January 2007 and January 2014 were reviewed, and 200 healthy controls of the same age group were included. Based on histopathology, the patients were classified as having normal appendix, simple or perforated appendicitis, and preoperative white blood cell count (WBC), C-reactive protein (CRP) and RDW were compared., Results: Compared with the controls, mean WBC, CRP and RDW were significantly higher in the appendectomy group (P <0.001). The children with simple or perforated appendicitis had significantly higher WBC, CRP and RDW than did those with normal appendix (P <0.001). Mean WBC and CRP were significantly higher in the children with perforated appendicitis (P <0.001), but no statistically significant difference was found in RDW between the simple and perforated appendicitis groups (P = 0.081)., Conclusions: Children with histologically proven acute appendicitis have higher RDW than children without appendicitis, but the diagnostic value of RDW was not superior to WBC or CRP in children with acute appendicitis. Although higher RDW may be valuable for aiding the diagnosis of acute appendicitis in children, it is not a useful marker for predicting perforated appendicitis., (© 2015 Japan Pediatric Society.)

Glucose-6-phosphatase catalytic subunit 3 (G6PC3) deficiency is a newly described syndrome characterized by severe congenital neutropenia associated with multiple organ abnormalities including cardiac and urogenital malformations. The underlying pathophysiology of increased apoptosis of myeloid cells and of neutrophil dysfunction in G6PC3 deficiency involves disturbed glucose metabolism, increased endoplasmic reticulum stress and deficient protein folding. Here, we report a new case of G6PC3 deficiency caused by a novel homozygous G6PC3 gene mutation p.Trp59Arg. The patient showed pancytopenia and a variable bone marrow phenotype with maturation arrest and vacuolization in myeloid lineage cells and a normocellular marrow, respectively. She also showed persistent lymphopenia with low CD4 T- and CD19 B-cell counts. Lymphopenia and even pancytopenia as well as a variable bone marrow phenotype can be part of this syndrome. These clinical findings in a patient with chronic neutropenia should alert the clinician to consider a diagnosis of G6PC3 deficiency., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Acute bronchiolitis, mostly seen in infants and younger children, is a lower respiratory tract infection frequently caused by viral agents. We aimed to determine the frequency of a broad panel of respiratory viruses including human bocavirus (HBoV) and to assess the clinical characteristics of acute bronchiolitis in a group of children under 24 months of age. A total of 62 children (45 male, 17 female; age range: 0-2 years) with the initial diagnosis of acute bronchiolitis and 33 healthy children (21 male, 12 female; age range: 0-2 years) as control group who were admitted to the Pediatrics Department of Mersin University Hospital, southern Turkey, from January to July 2010 were included in the study. Nasopharyngeal aspirates were collected from the study groups and the detection of respiratory viruses [respiratory syncytial virus (RSV) A & B; rhinovirus (RV); human metapneumovirus (hMPV) A & B; influenza virus type A [H1N1, H3N2, H1N1v], B & C; parainfluenza virus (PIV) type 1, 2, 3 & 4A/B; adenovirus (AdV); HBoV; coronavirus (CoV 229E); enterovirus (EV)], were performed by using a commercial system namely CLART®Pneumovir (Clinical Array Technology, Genomica, Spain) based on the principle of multiplex polymerase chain reaction (M-PCR) and DNA microarray. Demographic features, clinical and laboratory findings of the patients, treatment protocols and the relationship between the length of hospitalization and the viral agents determined were also evaluated. Of the 62 samples collected from bronchiolitis cases, at least one virus was detected in 52 (83.9%) and viral co-infections were detected in 31 (50%) of them. Including the co-infections, RSV was the most commonly identified virus (n= 21; 33.9%), followed by influenza A [H1N1] (n= 18; 29%), RV (n= 18; 29%), hMPV (n= 13; 21%), PIV (n= 10; 16.1%), AdV (n= 5; 8%), HBoV (n= 3; 4.8%) and EV (n= 1; 1.6%). Of the 33 samples from healthy children, at least one virus was detected in 21 (63.6%) and viral co-infections were detected in seven (21.2%) samples. Including the co-infections, the most commonly detected virus was RV (n= 10; 30.3%), followed by influenza A [H1N1] (n= 6; 18.1%), AdV (n= 6; 18.1%), RSV (n= 4; 12.1%) and PIV (n= 3; 9%), however HBoV and hMPV were not detected in the control group. The differences of demographic features (age, gender, history of atopy, exposure of smoking, length of breast-feeding, presence of school-age sibling) and frequency of virus detection (83.9% and 63.6%, respectively) between the patient and control groups were not statistically significant (p> 0.05). The most common complaints of patients on admission were cough (100%), runny nose (82.3%) and respiratory difficulty (71%), whereas fever was present in 21 (33.9%) patients. The most common findings on physical examination were prolonged expirium (98.4%), rhonchi (98.4%), rales (80.6%), tachypnea (71%) and tachycardia (67.7%). Pulmonary graphies revealed that diffuse air trappings were more common in virus-associated bronchiolitis (36/52; 69.2%) cases, on the other hand infiltrations were more common (6/10; 60%) in patients who were virus-negative (p< 0.05). The demographic features, clinical and laboratory findings, clinical severity scores, hospitalization rates and duration of hospitalizations in bronchiolitis cases did not show statistically significant differences between the viral agents (p> 0.05 for each parameter). However the rates of antibiotic and steroid use in hospitalized patients (24/34 and 5/34, respectively) were significantly higher than those of outpatients (7/28 and 0/28, respectively) (p= 0.001 and p= 0.03). Our data indicated a high rate (~84%) of respiratory viruses in children with bronchiolitis in the Mersin province and the detection of hMPV (21%) and HBoV (4.8%) only in the patient group encouraged their roles in the etiology of acute brochiolitis. It was concluded that viral etiology should be investigated in selected cases to prevent unnecessary antibiotic treatment and to initiate appropriate antiviral therapy when necessary.

Acinetobacter spp. are opportunistic bacterial pathogens primarily associated with hospital-acquired infections and the spread of multidrug resistant Acinetobacter strains is a growing problem in terms of infection control. The aim of this study was to determine the clonal relationship between strains of nosocomial Acinetobacter baumannii by using rep-PCR method. A total of 75 Acinetobacter strains isolated from various clinical samples of the hospitalized patients between October 2011-May 2012 were included in the study. Antibiotic susceptibilities of Acinetobacter isolates were investigated by Kirby-Bauer disk diffusion method according to CLSI guidelines. According to disk diffusion test, the resistance rates for piperacillin, piperacillin-tazobactam, cefepime, ceftazidime, imipenem, meropenem, gentamicin, amikacin, tetracycline, levofloxacin, ciprofloxacin and trimetoprim-sulfamethoxazole were 96%, 96%, 97.3%, 89.3%, 96%, 94.6%, 66.7%, 85.3%, 68%, 82.7%, 97.3% and 89.3% respectively. In this study, 73 (97%) strains were found resistant to three or more than three antibiotics (multidrug resistant). Rep-PCR analysis have shown the presence of eight clones, including two major clones [A (7subtypes), B (3 subtypes)] and six unique clones (C-H). Clone A was found to be the dominant type. Fifty-four (72%) of the 75 Acinetobacter strains belonged to clone A, 13 (17.3%) to clone B, two strains to clone C, D, and one of each to the other clones (E, F, G, H). Clone A was isolated from 71% (20/28), 70% (7/10) and 100% (6/6) of the samples sent from reanimation intensive care unit, surgery ward and internal diseases intensive care units, respectively. The time interval between the first and last strain was eight months. The results of this study indicated an increase in the resistance rates of Acinetobacter strains in our hospital and this increase was attributed to the clonal dissemination of the strains. Strains of the clone A were found to be dominant at the intensive care and other clinics of our hospital. It is contemplated that Acinetobacter strains were scattered as a result of cross transmission and patient transfer among clinics. The rep-PCR method which was used in this study was evaluated as a rapid, easily applicable and successful procedure for epidemiological studies. Clonal distribution of resistant strains in the hospital environment emphasizes the significance of infection control measures.

Background: We evaluate the effectiveness of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infections (CAUTIs) in 13 intensive care units (ICUs) in 10 hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of Turkey., Methods: A before-after prospective active surveillance study was used to determine rates of CAUTI. The study was divided into baseline (phase 1) and intervention (phase 2). In phase 1, surveillance was performed applying the definitions of the Centers for Disease Control and Prevention/National Healthcare Safety Network. In phase 2, we implemented a multidimensional approach that included bundle of infection control interventions, education, surveillance and feedback on CAUTI rates, process surveillance, and performance feedback. We used random effects Poisson regression to account for clustering of CAUTI rates across time periods., Results: The study included 4,231 patients, hospitalized in 13 ICUs, in 10 hospitals, in 10 cities, during 49,644 patient-days. We recorded a total of 41,871 urinary catheter (UC)-days: 5,080 in phase 1 and 36,791 in phase 2. During phase 1, the rate of CAUTI was 10.63 per 1,000 UC-days and was significantly decreased by 47% in phase 2 to 5.65 per 1,000 UC-days (relative risk, 0.53; 95% confidence interval: 0.4-0.7; P value = .0001)., Conclusion: Our multidimensional approach was associated with a significant reduction in the rates of CAUTI in Turkey., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Central line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey., Methods: We conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention., Results: During baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 - 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB., Conclusions: The implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Background: Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections in pediatric intensive care units (PICUs). Practice bundles have been shown to reduce VAP rates in PICUs in developed countries; however, the impact of a multidimensional approach, including a bundle, has not been analyzed in PICUs from developing countries., Methods: This was a before-after study to determine rates of VAP during a period of active surveillance without the implementation of the multidimensional infection control program (phase 1) to be compared with rates of VAP after implementing such a program, which included the following: bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on VAP rates, and performance feedback on infection control practices (phase 2). This study was conducted by infection control professionals applying the National Health Safety Network's definitions of health care-associated infections and the International Nosocomial Infection Control Consortium's surveillance methodology., Results: During the baseline period, we recorded a total of 5,212 mechanical ventilator (MV)-days, and during implementation of the intervention bundle, we recorded 9,894 MV-days. The VAP rate was 11.7 per 1,000 MV-days during the baseline period and 8.1 per 1,000 MV-days during the intervention period (relative risk, 0.69; 95% confidence interval, 0.5-0.96; P = .02), demonstrating a 31% reduction in VAP rate., Conclusions: Our results show that implementation of the International Nosocomial Infection Control Consortium's multidimensional program was associated with a significant reduction in VAP rate in PICUs of developing countries., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Design: A before-after prospective surveillance study to assess the impact of a multidimensional infection control approach for the reduction of catheter-associated urinary tract infection (CAUTI) rates., Setting: Pediatric intensive care units (PICUs) of hospital members of the International Nosocomial Infection Control Consortium (INICC) from 10 cities of the following 6 developing countries: Colombia, El Salvador, India, Mexico, Philippines, and Turkey., Patients: PICU inpatients., Methods: We performed a prospective active surveillance to determine rates of CAUTI among 3,877 patients hospitalized in 10 PICUs for a total of 27,345 bed-days. The study was divided into a baseline period (phase 1) and an intervention period (phase 2). In phase 1, surveillance was performed without the implementation of the multidimensional approach. In phase 2, we implemented a multidimensional infection control approach that included outcome surveillance, process surveillance, feedback on CAUTI rates, feedback on performance, education, and a bundle of preventive measures. The rates of CAUTI obtained in phase 1 were compared with the rates obtained in phase 2, after interventions were implemented., Results: During the study period, we recorded 8,513 urinary catheter (UC) days, including 1,513 UC-days in phase 1 and 7,000 UC-days in phase 2. In phase 1, the CAUTI rate was 5.9 cases per 1,000 UC-days, and in phase 2, after implementing the multidimensional infection control approach for CAUTI prevention, the rate of CAUTI decreased to 2.6 cases per 1,000 UC-days (relative risk, 0.43 [95% confidence interval, 0.21-1.0]), indicating a rate reduction of 57%., Conclusions: Our findings demonstrated that implementing a multidimensional infection control approach is associated with a significant reduction in the CAUTI rate of PICUs in developing countries.

Penicillin-binding proteins (PBPs) are the natural targets of beta-lactam antibiotics and mutations in pbp1a, pbp2b, and pbp2x genes, which encode PBPs, are responsible for resistance to beta-lactams in Streptococcus pneumoniae. In the present study, we intended to determine how often the common mutation patterns occurred within the pbp1a, pbp2b, and pbp2x PBP gene regions and evaluate the PBP genotype mutations which were associated with penicillin resistance in several penicillin-susceptible and - resistant S.pneumoniae isolates in Mersin, Turkey. A total of 62 S.pneumoniae strains isolated from different clinical specimens (32 nasopharyngeal swab, 16 sputum, 3 blood, 3 wound, 2 cerebrospinal fluids and one of each urine, abscess, bronchoalveolar lavage, conjunctival swab, tracheal aspirate, middle ear effusion) were included in the study. Penicillin susceptibilities of the isolates were searched by disc diffusion and E-test methods, and 23 of them were identified as susceptible, 31 were intermediate susceptible, and eight were resistant to penicillin. A rapid DNA extraction procedure was performed for the isolation of nucleic acids from the strains. Distribution of PBP gene mutations in pbp1a, pbp2b, and pbp2x gene regions related to penicillin resistance was determined by using a wild-type specific polymerase chain reaction (PCR) based technique. PBP gene alterations of those isolates were also evaluated in relation to penicillin susceptibility and resistance patterns. Twenty two (95.7%) of 23 penicillin-susceptible S.pneumoniae isolates exhibited no mutation in the three PBP genes (pbp1a, pbp2x, and pbp 2b), while 1 (4.3%) of these harbored mutations in all of the three PBP genes. The penicillin-intermediate susceptible S.pneumoniae isolates exhibited various combinations of mutations. One (3.2%) of 31 penicillin-intermediate susceptible isolates exhibited no mutation in the three PBP genes, while 22 (71%) of them yielded mutations in all of the three PBP genes. The remaining 8 (25.8%) isolates harbored mutations for dual PBP genes (in five strains pbp1a and pbp2b; in two strains pbp2x and pbp2b; in one strain pbp1a and pbp2x). Seven (87.5%) out of eight penicillin-resistant S.pneumoniae isolates (MIC ≥ 2 µg/ml) revealed mutations in all of the three PBP genes and the other penicillin-resistant isolates exhibited no mutation in the PBP genes. The present study supplied important data on the frequency of different patterns of mutations occurring at various regions of PBP genes related to penicillin resistance in S.pneumoniae isolates in our restricted region. The results supported the notion that penicillin resistance in S.pneumoniae was mainly attributed to alterations in pbp1a, pbp2x, and pbp2b gene regions and wild-type sequence specific PCR could be applied to characterize genotypic background of penicillin resistance in S.pneumoniae strains.

This study aimed at evaluating the value of C-reactive protein (CRP) and procalcitonin (PCT) levels in the differential diagnosis of fever in patients with sickle cell disease (SCD). The study included 86 children with SCD (group 1) and 49 controls (group 2). During the study, the patients had 114 acute episodes or routine visits to the units. They were classified as having vasoocclusive crisis with fever (group 1A), vasoocclusive crisis without fever (group 1B), and no crisis or fever (steady state, group 1C). Only patients with crises were admitted to the hospital. Patients admitted to the hospital with various clinical signs and symptoms each and every time were included in groups 1A, 1B, and 1C. Thus, a total of 114 clinical episodes were analyzed. The mean CRP levels in the 3 patient groups were significantly higher than that in the group 2, and among the patient groups, the mean CRP was significantly higher in group 1A than the other groups. The mean CRP level in group 1A and group 1B was significantly higher than that in group 1C. There were no significant differences among the 3 SCD groups in terms of the median serum PCT level; however, the median PCT level in group 1A, group 1B, and group 1C patients was significantly higher than that in group 2 patients. These data indicate that vasoocclusive disease with or without fever apparently does not significantly increase PCT levels in relation to the baseline status of children with SCD, which in turn are clearly more elevated than PCT levels of control children.

Background: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey., Methods: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals., Results: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis., Conclusions: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.

Invasive fungal infections (IFIs) are important causes of morbidity and mortality in immunocompromised children. The increased incidence and high mortality rates associated with IFIs has led to development of novel antifungal agents to expand the breadth and effectiveness of treatment options available to clinicians. Since its initial approval in 1958, conventional amphotericin B deoxycholate had been considered the standard in treatment for IFIs. However, because of the dose-limiting toxicity of conventional amphotericin B deoxycholate, lipid formulations of amphotericin have been developed to potentially improve outcomes and mitigate the adverse effects associated with antifungal therapy. While less frequently employed today as prophylaxis (given the expanded availability of safer alternatives), amphotericin B is still considered a treatment option in select cases of severe or life-threatening IFIs. This article reviews the clinical use of amphotericin B for the prevention and treatment of IFIs.

The vaccine strain Mycobacterium bovis BCG may lead to disseminated infection in patients with immune deficiency. In this report a patient who developed fatal disseminated tuberculosis caused by M. bovis BCG strain was presented. One year old male patient with the previous history of recurrent lower respiratory tract infection, was admitted to the hospital with the complaints of fever, cough and diarrhea continuing for 20 days. There was no family history of tuberculosis or history of contact with a tuberculosis case. Physical examination of the case revealed growth retardation and reticular and reticulonodular infiltration was detected in his chest X-ray. The results of sweat test, cystic fibrosis gene mutation analysis and metabolic screening tests were normal. Since fever continued and infiltrations persisted in the chest X-ray despite antibiotic therapy, PPD test was applied and acid-fast bacilli (AFB) were investigated in his gastric aspirate and stool samples for three consecutive days. PPD test was negative and no AFB were detected in the microscopic examination of the clinical samples. However, growth in Lowenstein-Jensen medium was detected in the stool sample on the 38th day of incubation. The antimycobacterial susceptibility testing performed at BACTEC MGIT (Mycobacterial Growth Indicator Tube) 960 system (Becton-Dickinson, USA) revealed that the isolate was susceptible to rifampin, isoniazid, streptomicin and ethambutol. Since the isolates did not grow at PNB (para-nitro benzoic acid) medium and niacin and nitrate activities were negative, spoligotyping (spacer oligonucleotide typing) was performed and DR loci characteristic for M. bovis BCG strain were detected. However, the patient died 2 weeks before the culture results were obtained. The effective use of mycobacteriology laboratories and cooperation between laboratory and clinics provide advantages in the early diagnosis and treatment of tuberculosis cases, decreasing the morbidity and the mortality.

Nasopharyngeal carriage of Streptococcus pneumoniae plays an important role for the development of invasive disease and the spread of resistant strains within the community. The aims of this study were to determine the carriage rate of nasopharyngeal S. pneumoniae at healthy school children, to search the susceptibility of the strains to various antibiotics and to evaluate the risk factors for nasopharyngeal carriage of penicillin-resistant pneumococci. A total of 1440 healthy children (age range: 6-13 years old) attending to three primary schools which were chosen randomly in Mersin province (Mediterranean region of Turkey) were included to the study between April 2003 to March 2004. The isolation and identification of S. pneumoniae strains from nasopharyngeal samples were performed by conventional culture methods. Antibiotic sensitivity tests were done according to the Clinical Laboratory Standards Institute directions by disk diffusion method, and penisilin MIC values were detected by E-test (AB Biodisk, Solna, Sweden). S.pneumoniae were isolated from 201 (13.9) of the children. The susceptibility rate of the isolates to penicilin was found as 87.1% (n:175), while 12% (n:24) of the strains yielded intermediate and 1% (n:2) yielded high resistance against penicilin. Overall percentages of resistance to trimethoprim-sulfamethoxazole (TMP-SMX) and macrolides were 30% and 4%, respectively. Two out of eight erythromycin (E) resistant strains showed inducible MLS(B) (macrolide, lincosamide and streptogramin B) type while six showed M (due to active efflux system) type of resistance. Resistance to meropenem, vancomycin, ceftriaxone and ciprofloxacin were not detected. Of S. pneumoniae isolates, 20% were found resistant to only one antibiotic (two strains to penicilin; 39 strains to TMP-SMX), 8.9% to two antibiotics (16 strains to penicillin+TMP-SMX; two strains to penicillin+E) and 2.9% to three or more antibiotics (five strains to penicillin+E+TMP-SMX; one strain to TMP-SMX+E+chlaritromycin). Living in a crowded family (p = 0.009) and use of antibiotics in the last two months (p = 0001) were considered as the risk factors for nasopharyngeal carriage of penicillin-resistant pneumococci. When comparing our data with the results of the other studies reported in Turkey, the nasopharyngeal carriage rate was moderate between healthy children in Mersin, nevertheless the rate of high level penicillin-resistant S. pneumoniae strains was quite low. As a result, improving the living conditions and restriction of antibiotic use could minimize the nasopharyngeal carriage and penicillin-resistant pneumococci.

Background & Objective: There is scanty information available on the pharyngeal carriage of Streptococcus pneumoniae and serotype distribution in healthy Turkish children. We therefore undertook this study to determine the serotype prevalence of pharyngeal S. pneumoniae isolates of healthy school children in Turkey., Methods: Pharyngeal swabs were collected from 1440 healthy children (Ages 6-13) between April 2003 and March 2004. S. pneumoniae was identified by standard microbiological culture methods. The serotyping was performed and penicillin minimal inhibitory concentration was detected by the E test., Results: S. pneumoniae carrier rate was 13.9 per cent (n=201) and penicillin resistance 12.9 per cent (n=26). Twenty four of 201 (11.9%) isolates were found intermediately resistant and 2 of 201 (1%) highly resistant by E test. A total of 169 of 201 (84%) pneumococcal isolates were typable with the available antisera. The six most frequent serotypes were 6, 19, 1, 23, 20 and 17. The majority of penicillin-resistant isolates were serotypes 20, 23, 14, 6 and 19., Interpretation & Conclusion: The serotype distribution of the isolates showed diversity and that some common circulating serotypes are invasive. A majority of invasive serotypes are covered by pneumococcal conjugate vaccine formulations in at risk groups of children suggesting that vaccine use could reduce the incidence of invasive pneumococcal disease.

We describe a 13-year-old systemic lupus erythematous (SLE) patient who presented with severe headache. The diagnosis of pseudotumor cerebri (PTC) was confirmed by an increased intracranial pressure and normal neuroimaging studies of the brain, including magnetic resonance (MR) venography. She later developed a Coombs positive anemia, lymphopenia, positive tests for antinuclear antibody (ANA) and anti-dsDNA and a migratory polyarthritis confirming the diagnosis of SLE. IgM type anticardiolipin antibodies were positive in low titer. Since she did not have a demonstrable thromboembolic phenomenon in neuroimaging studies, a diagnosis of antiphospholipid antibody syndrome could not be made and anticoagulant treatment was not given. Treatment with pulse i.v. methylprednisolone followed by oral treatment along with azathioprine produced a rapid and dramatic resolution of the clinical symptoms. PTC may also be a neurological manifestation of childhood SLE and should be considered in the differential diagnosis. We suggest that pulse steroids and azathioprine is an effective treatment for this feature.

Aim: To evaluate the efficacy of two regimens of combined interferon-alpha2a (IFN-alpha2a) and lamivudine (3TC) therapy in childhood chronic hepatitis B., Methods: A total of 177 patients received IFN-alpha2a, 9 million units (MU)/m2 for 6 months. In group I (112 patients, 8.7 +/- 3.5 years), 3TC (4 mg/kg/day, max 100 mg) was started simultaneously with IFN-alpha2a, in group II (65 patients, 9.6 +/- 3.8 years) 3TC was started 2 months prior to IFN-alpha2a. 3TC was continued for 6 months after antiHBe seroconversion or stopped at 24 months in nonresponders., Results: Baseline alanine aminotransferase (ALT) was 134.2 +/- 34.1 and 147.0 +/- 45.3; histological activity index (HAI) was 7.4 +/- 2.7 and 7.1 +/- 2.3; and HBV DNA levels were above 2,000 pg/ml in 76% and 66% of patients in groups I and II, respectively (P > 0.005). Complete response was 55.3% and 27.6% in groups I and II, respectively (P < 0.01). AntiHBe seroconversion was higher and earlier, and HBV DNA clearance was earlier in group I (P < 0.05). HBsAg clearance was 12.5% and 4.6% and antiHBs seroconversion was 9.8% and 6.2% in groups I and II, respectively (P > 0.05). Breakthrough occurred in 17.9% and 24.6%; breakthrough times were 15.9 +/- 4.6 and 14.1 +/- 5.1 months; and relapse rates were 6.8% and none in groups I and II, respectively (P > 0.05, P > 0.05, P > 0.05). Responders had higher HAI (HAI > 6) and higher pre-treatment ALT than non-responders., Conclusion: Simultaneous 3TC+IFN-alpha2a yields a higher response and earlier antiHBe seroconversion and viral clearance than consecutive combined therapy. Relapse rate is low. Predictors of response are high basal ALT and high HAI scores. 3TC can be administered for 24 months without any side effect and breakthrough rate is comparable with previous studies.

Since the first report in 1998, 10 cases of Pichia ohmeri infection have been reported in the literature. Here we present two new cases of P. ohmeri infection in the paediatric age group. The first case was an 8-month-old male infant, who was admitted with fever, convulsions and altered consciousness. Conservative therapy was started with a presumptive diagnosis of encephalitis. The patient failed to respond to the given treatments and died on the 21st day of hospitalisation. The second case was a 10-year-old male with B-cell acute lymphoblastic leukaemia. He was hospitalised with neutropenic fever. He was discharged after 3 weeks of therapy. In both cases P. ohmeri was identified in blood samples. Growing evidence indicates that P. ohmeri should be added to the lengthening list of opportunistic fungal pathogens that can cause infection in all ages, including infants, and particularly in those who are immunocompromised.

Aim: To determine the possible routes of intrafamilial transmission pattern in pediatric cases of chronic hepatitis B virus (HBV) infection., Methods: In this descriptive retrospective study, 302 children with chronic HBV infection from 251 families and their parents attending the Social Security Children's Hospital and Doctor Sami Ulus Children's Hopsital in Ankara between December 1998 and May 2000, were enrolled in. Screenings and diagnosis of chronic HBV infections were established according to the Consensus 2000., Results: In the studied 302 children with chronic HBV infection, mothers of 38% and fathers of 23% were HBsAg positive. The HBsAg positivity in at least two siblings of the same family was 61% when both parents were HBsAg positive., Conclusion: It is well known that horizontal transmission is quite common in countries where Hepatitis B Virus is moderately endemic. To our best knowledge, this is the largest series observed regarding the horizontal transmission in pediatric chronic HBV infection in Turkey. It is necessary to expand the preventive programs to target not only the newborn period but also all stages of childhood.

Background: Although it is the most common lower respiratory infection of infancy, the optimal treatment for acute bronchiolitis is still controversial. The aim of this study was to compare the early and late effects of nebulized L-epinephrine (EPI) and intramuscular dexamethasone (DEX) combination therapy with nebulized salbutamol (SAL) and dexamethasone combination and bronchodilators alone in outpatients with acute bronchiolitis., Methods: A total of 69 infants aged 2-21 months who were admitted to the Pediatrics Department of the Faculty of Medicine, Mersin University, with acute bronchiolitis were included in a randomized, placebo-controlled, prospective trial study. Patients were assigned to receive either nebulized L-epinephrine (3 mg) or salbutamol (0.15 mg/kg) and 15 min later, either dexamethasone 0.6 mg/kg or placebo (PLA), intramuscularly, in a double-blind randomized fashion. The study groups were: epinephrine + dexamethasone group (group 1, n=23), salbutamol + dexamethasone group (group 2, n=23), epinephrine + placebo group (group 3, n=11), and salbutamol + placebo group (group 4, n=12). The outcome measures were heart rate, respiratory rate and Respiratory Distress Assessment Instrument (RDAI) score determined at 30, 60, 90 and 120 min, 24 h, and 5 days after the first therapy. Patients were then followed-up during the subsequent 2 months for the prevalance of respiratory complaints regarding bronchial hyperreactivity., Results: There were no significant differences between the outcome variables of the four groups within the first 120 min and at 24 hours, or between the rates of requirement of a second dose of the same bronchodilator. However, fifth day RDAI score values of both DEX groups were significantly lower than that of SAL + PLA group (P=0.000 and P=0.01, respectively). The fifth day score value of group 1 was also significantly better than that value of EPI + PLA group but not different from group 2., Conclusions: A single dose of intramuscular dexamethasone added to nebulized L-epinephrine, or salbutamol therapies resulted in better outcome measures than bronchodilators alone in the late phase (fifth day) of mild to moderate degree bronchiolitis attack. However, effects of EPI + DEX combination was not different from SAL + DEX combination.

We compared patients with subacute sclerosing panencephalitis who received treatment according to our protocol for at least 6 months (19 patients) with the patients who could not receive any treatment (13 patients). The treatment protocol consisted of oral isoprinosine (100 mg/kg/day), subcutaneous interferon alpha-2a (10 mU/m2/three times a week), and oral lamivudine (10 mg/kg/day). There were no statistical differences between the two groups according to Neurological Deficit Index, clinical stage, and average age on admission and also on the final evaluation after treatment. The mortality rates of both groups were similar: 3 (15.7%) for the treatment group and 6 (46%) for controls. The remission rates for the treatment and control groups were 7 of 19 (36.8%) and 0 of 13 (0%), respectively, and the difference was statistically significant (P = .036). The mean survival period of the treatment group was significantly longer than that of the control group (P = .01). In conclusion, this combination treatment protocol resulted in higher remission rates and longer survival periods when compared with controls, as well as a remission rate that was better than the spontaneous remission rate of 5%. For this reason, and as well as because interferon-alpha therapy has an easier route of application and a higher family compliance, we have considered this an alternative protocol for patients with subacute sclerosing panencephalitis.

Pentavalent antimony is still the drug of choice in the treatment of visceral leishmaniasis. Pantavalent antimony can cause a wide range of adverse effects, the most serious of which are cardiotoxicity and hepatotoxicity. Acute pancreatitis is a rarely reported adverse effect. An infant who developed pancreatitis during meglumine antimoniate treatment for visceral leishmaniasis and who was successfully treated with a combination of allopurinol and ketoconazole is reported.

Congenital malaria is an uncommon disease even in endemic areas. A 19-day-old female infant with congenital malaria is presented. The mother of the patient was diagnosed to have malaria at the seventh month of gestation and was treated with chloroquine orally for three days. No malarial prophylaxis was given. The infant developed fever, hyperbilirubinemia, anemia and hepatosplenomegaly postnatally. Thin blood smears revealed many Plasmodium vivax parasites. She was treated with oral chloroquine for three days. We emphasize the importance of adequate antenatal medical therapy and prophylaxis during pregnancy.