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Candida spp. has been the leading microorganism isolated from the urine specimens of patients hospitalized at the Anesthesiology and Reanimation intensive care unit (ICU) of Dokuz Eylul University Hospital, Izmir, since 1998. This study was undertaken to investigate the clonal relationship ofCandidaurine isolates in order to find the mode of spread among the patients. Epidemiological surveillance of 38Candida albicans, 15Candida tropicalisand 12Candida glabratarecovered from the urine specimens of patients who were hospitalized in the ICU between June 11, 2000 and October 15, 2001 was carried out by antifungal susceptibility testing and randomly amplified polymorphic DNA (RAPD) analysis. Two short primers [Cnd3 (5′-CCAGATGCAC-3′) and Cnd4 (5′-ACGGTACACT-3′)] were used for RAPD. None of the isolates had high minimal inhibitory concentration (MIC) values (>1 μg ml−1) against amphotericin B with MIC50values of 0.5 μg ml−1, 0.5 μg ml−1 and 0.125 μg ml−1 forC. albicans, C. tropicalisandC. glabrataisolates, respectively. However, threeC. glabrataisolates were resistant and oneC. albicansand fiveC. glabrataisolates were dose-dependent susceptible (D-DS) to fluconazole. AmongC. albicansisolates 19 and 20 patterns were detected with primers Cnd3 and Cnd4, respectively. When primers Cnd3 and Cnd4 were evaluated together, three and four genotypes were identified forC. tropicalisandC. glabrataisolates, respectively. Our results suggest that the source ofC. albicansisolates was mostly endogenous. It is difficult to interpret the mode of spread ofC. tropicalisandC. glabrataurine isolates as we obtained insufficient banding patterns for these species. [ABSTRACT FROM AUTHOR]

Aminoglycosides (AGs) are actively used in combination therapies against carbapenem resistant gram negative species in recent years. Spread of 16S rRNA methylases which can cause high-level resistance to AG antibiotics, limits this treatment choice. Although there are some studies showing that errors in determining AG susceptibility in automated systems may be related to the armA gene, one of the 16S rRNA methylase genes, the exact reason for these errors is not yet known. In our study, we aimed to investigate the relevance of 16S rRNA methylases to the discrepancies between VITEK 2.0 and disc diffusion test results for amikacin (AK) and gentamicin (GEN) susceptibility of Acinetobacter baumannii and Klebsiella pneumoniae isolates. All K.pneumoniae and A.baumannii isolates from 1st January-10th February 2018 were collected prospectively and included in the study. Additionally, two initial isolates from July 2017 (one K.pneumoniae and one A.baumannii isolate) for which first discrepant susceptibility results were determined, were also included. Amikacin and gentamicin susceptibility results of 37 isolates [A. baumannii (n= 20) and K.pneumoniae (n= 17)] were evaluated together with VITEK 2.0 system, disc diffusion and gold standard broth microdilution methods and minor error (mE), major error (ME) and very major error (VME) rates were calculated. The rmtB, rmtC and armA genes in isolates were investigated by polymerase chain reaction (PCR) and the relationship between the presence of 16S rRNA methylases and false susceptibility results were examined. In addition, disc diffusion test results were evaluated at the end of four, six, eight hours and one night incubation periods to examine the effect of the double zone phenotype observed in 13 of the study isolates on rapid susceptibility tests. All disc diffusion test results were found to be compatible with broth microdilution test results. When the VITEK 2.0 system and the broth microdilution test were compared, 10.3% and 12.1% VME and 8.1% and 5.4% mE were detected for AK and GEN susceptibility results, respectively. While rmtB and rmtC genes were not detected in the study isolates, armA gene was positive in eight (47.1%) of 17 K.pneumoniae isolates and in 15 (75%) of 20 A.baumannii isolates. All three VMEs in A.baumannii isolates were detected in AK susceptibility results. Two of those were armA gene positive and one was armA gene negative isolates. All four VMEs in K. pneumoniae isolates were detected in GEN susceptibility results only, and all of these isolates were armA gene positive. No direct correlation was found between the errors detected in the VITEK 2.0 system susceptibility results and the double zone phenotype. When the isolates were evaluated in the 4-16 hours incubation time interval, it was observed that resistant colonies could be detected after a minimum of six hours of incubation period in the inhibition zone surrounding the aminoglycoside discs. To the best of our knowledge this is the first report of armA producing A.baumannii from Turkey. The high rate of armA gene positivity detected in our isolates suggested that the prevalence of armA gene increased in our country or at least in our region, in recent years. In the AG susceptibility results of the VITEK 2.0 system, the rate of VME above the acceptance criterion has shown that the errors occurred were not directly related to armA gene positivity or double zone phenotype. Finally, our study results indicated that AG susceptibility results should be evaluated minimum six hours later of incubation while implementing rapid susceptibility tests.

Objectives : To determine the serotype distribution of pneumococcus causing invasive pneumococcal disease (meningitidis, bacteremia and empyema) in children in Turkey, and to observe potential changes in this distribution in time to guide effective vaccine strategies. Methods : We surveyed S. pneumoniae with conventional bacteriological techniques and with real-time polymerase chain reaction (RT-PCR) in samples of cerebrospinal fluid (CSF), blood and pleural fluid. S. pneumoniae strains were isolated from 33 different hospitals in Turkey, which are giving health services to approximately 60% of the Turkish population. Results : A total of 167 cases were diagnosed with invasive pneumococcal disease between 2015 and 2018. We diagnosed 52 (31.1%) patients with meningitis, 104 (62.2%) patients with bacteremia, and 11 (6.6%) patients with empyema. Thirty-three percent of them were less than 2 years old and 56% less than 5 years old. Overall PCV13 serotypes accounted for 56.2% (94/167). The most common serotypes were 19 F (11.9%), 1 (10.7%) and 3 (10.1%). Conclusions : Besides the increasing frequency of non-vaccine serotypes, vaccine serotypes continue to be a problem for Turkey despite routine and high-rate vaccination with PCV13 and significant reduction reported for the incidence of IPD in young children. Since new candidate pneumococcal conjugate vaccines with more serotype antigens are being developed, continuing IPD surveillance is a significant source of information for decision-making processes on pneumococcal vaccination.

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

Establishment of sustainable and evidence-based surveillance systems are recommended for prevention of microbial resistance by the World Health Organization (WHO). As a necessity of these surveillance systems, participants are recommended to implement an external quality assessment (EQA) program. In this scope, National Antimicrobial Resistance Surveillance System (NARSS) has been established within the Public Health Institute of Turkey (PHIT) in our country since 2011. In the scope of this surveillance, NARSS EQA program has been implemented in a cycle per year and four isolates were sent to participants per cycle every year since 2011. In this study, it was aimed to evaluate the six years results of the EQA programs being implemented on NARSS participants between 2011 and 2016. The surveillance system consisted of 118 laboratories. Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecium/faecalis and Acinetobacter baumannii bacteria included in scope of the surveillance were sent to participants. Identification of bacteria to the species level, verification of the antibiotic susceptibility test results and existence of specified resistance of the isolates performed with valid test methods required from the participants. Identified isolates were cultured with routine microbiological methods and sent to participants in ambient temperature in triple carrying pouches inside suitable carrying media via PTT Cargo. The results were entered by means of passwords prepared by PHIT and sent to the web based system. The analysis of results were made with SPSS program. A total of twenty-three isolates were sent to participants between 2011 and 2016. It was determined that participants commonly preferred automated systems for bacterial identification and antibiotic sensitivity test results. The use of MALDI TOF MS system was determined to be raised up to 15.65% in 2016. It has been determined that usually little mistakes were done in bacterial identification but the error rate was high especially in antimicrobial susceptibility test results with close clinical threshold values. Although not required for antibiotic susceptibility test results, it was determined that phenotypic tests have been used more widely in determining the specific resistance mechanisms that are important for epidemiological data. It was determined that 80% of participants have used EUCAST standards in 2016. As a result of this research, we have observed that EQA studies of NARSS EQA are a good performance tool for sustainable and evidence based surveillance studies, that the national antimicrobial resistance data quality is sufficiently good and that the data can be shared on international platforms. In addition, the regular maintenance of national surveillance studies shown that laboratories have positive reflections on self improvement in achieving up to date and accurate results.

Carbapenems are the choice of treatment in infections caused by multidrug resistant Enterobacteriaceae. In recent years carbapenem-resistant Enterobacteriaceae isolates due to carbapenemases have been increasingly reported worldwide. Multicenter studies on carbapenemases are scarce in Turkey. The aim of this study was to determine the distribution of carbapenemases from different parts of Turkey as a part of the European Survey of Carbapenemase Producing Enterobacteriaceae (EuSCAPE) project. Beginning in November 2013, carbapenem-resistant isolates resistant to at least one of the agents, namely imipenem, meropenem, and ertapenem were sent to the coordinating center. Minimum inhibitory concentrations for these carbapenems were determined by microdilution tests following EUCAST guidelines. Production of carbapenemase was confirmed by combination disk synergy tests. Types of carbapenemases were investigated using specific primers for VIM, IMP; NDM, KPC and OXA-48 genes by multiplex polymerase chain reaction. In a six month period, 155 suspected carbapenemase-positive isolates were sent to the coordinating center of which 21 (13.5%) were E.coli and 134 (86.5%) were K.pneumoniae. Nineteen (90.5%) strains among E.coli and 124 (92.5%) strains among K.pneumoniae were shown to harbour at least one carbapenemase gene by molecular tests, with a total of 92.3% (143/155). Carbapenemases were determined as a single enzyme in 136 strains (OXA-48: 84.6%; NDM: 6.3%; VIM: 2.8%; IMP: 1.4%) and as a combination in seven isolates (OXA-48 + NDM: 2.1%; OXA-48 + VIM: 2.1%; VIM + NDM: 0.7%). KPC was not detected in any of the isolates. According to the microdilution test results, resistance to imipenem, meropenem and ertapenem in OXA-48 isolates were 59.5%, 52.9% and 100%, respectively. The combination disk synergy test was 100% compatible with the molecular test results. As most of the OXA-48 producing isolates were susceptible to meropenem but all were resistant to ertapenem, ertapenem seems to be the most sensitive agent in screening carbapenemases in areas where OXA-48 is prevalent and phenotypic combination tests can be useful in centers where molecular tests are not available.

Objective: Fecal calprotectin is used as a good indicator of intestinal mucosal inflammation. The aim of this study is to evaluate the diagnostic value of fecal calprotectin (f-CP) for the etiology of acute gastroenteritis in children., Materials and Methods: All patients presenting with acute diarrhea (<18 years) who had 3 or more soft or watery stools per day were enrolled in this study. Stool microscopic examination and cultures for bacteria and parasites were performed. Polymerase chain reaction test was also applied to stool samples for viruses (Rotavirus, Adenovirus, Norwalk, and Astrovirus). The level of f-CP was carried out by using enzyme-linked immunosorbent assay test., Results: Eighty-four patients with diarrhea were enrolled. The f-CP level was higher in patients with microscopic examination positive (n=17) (median with interquartile range, 1610.0 [908.8-2100] mg/L) than in patients with microscopic examination negative (n=67) (123.8 [25.0-406.3] mg/L) (P<.001). Concentrations of f-CP in patients with stool culture positive (1870.0 [822.5-2100] mg/L) were significantly elevated compared with the concentrations of the patient with virus detected in stool (95.0 [21.3-240.9] mg/L) (P<.001). In the diagnosis for bacterial acute gastroenteritis, the area under the receiver operating characteristic curve for f-CP was 0.867 (95% confidence interval, 0.763-0.971), sensitivity was 88.9%, and specificity was 76.0% if the threshold was taken as 710 mg/L., Conclusion: We conclude that f-CP, which is useful, valuable, noninvasive, easily and rapidly measured laboratory test along with simple microscopic examination of stool, can be used as an indicator of intestinal inflammation and to distinguish the bacterial gastroenteritis from the viral gastroenteritis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to determine the distribution of vancomycin and daptomycin MICs among methicillin-resistant Staphylococcus aureus (MRSA) blood isolates, the prevalence of heterogeneous vancomycin-intermediate S. aureus (hVISA) and the relationship between hVISA and vancomycin MIC values., Methods: A total of 175 MRSA blood isolates were collected from seven university hospitals in Turkey. All isolates were tested for susceptibility to vancomycin and daptomycin by reference broth microdilution (BMD) and by standard Etest method. BMD test was performed according to CLSI guidelines and Etest was performed according to the instructions of the manufacturer. All isolates were screened for the presence of the hVISA by using macro Etest (MET) and population analysis profile-area under the curve (PAP-AUC) methods., Results: The vancomycin MIC50, MIC90 and MIC ranges were 1, 2, and 0.5-2 μg/ml, respectively, by both of BMD and Etest. The daptomycin MIC50, MIC90 and MIC ranges were 0.5, 1 and 0.125 -1 μg/ml by BMD and 0.25, 0.5 and 0.06-1 μg/ml by Etest, respectively. The vancomycin MIC for 40.6% (71/175) of the MRSA isolates tested was >1 μg/ml by BMD. No vancomycin and daptomycin resistance was found among MRSA isolates. Percent agreement of Etest MICs with BMD MICs within ±1 doubling dilution was 100% and 73.1% for vancomycin and daptomycin, respectively. The prevalence of hVISA among MRSA blood isolates was 13.7% (24/175) by PAP-AUC method. MET identified only 14 of the hVISA strains (sensitivity, 58.3%), and there were 12 strains identified as hVISA that were not subsequently confirmed by PAP-AUC (specificity, 92.1%)., Conclusions: Agreement between BMD and Etest MICs is high both for vancomycin and daptomycin. Daptomycin was found to be highly active against MRSA isolates including hVISA. A considerable number of isolates are determined as hVISA among blood isolates. As it is impractical to use the reference method (PAP-AUC) for large numbers of isolates, laboratory methods for rapid and accurate identification of hVISA need to be developed.

The aim of this study was to investigate the prevalence and types of plasmid-mediated AmpC (pAmpC) beta-lactamase enzymes in Escherichia coli and Klebsiella pneumoniae strains isolated from blood cultures of hospitalized patients in Dokuz Eylul University Hospital between 2007 and 2012. A total of 261 isolates which consisted of 184 E.coli (70.5%) and 77 K.pneumoniae (29.5%) were included in the study. All isolates were resistant to cefotaxime and/or ceftazidime but susceptible to imipenem. Cefoxitin resistance was investigated as an indicator of AmpC type enzymes. A total of 57 (21.8%) isolates which were cefoxitin-resistant (32 E.coli, 25 K.pneumoniae), were screened for pampC genes by a multiplex polymerase chain reaction (PCR) assay. Additionally, 10 of each cefoxitin susceptible isolates per year were chosen randomly and screened by the same PCR assay to detect the presence of ACC enzymes, which can not hydrolyze cefoxitin. Positive PCR results were confirmed by sequence analysis. Plasmid analysis and macrorestriction analysis were performed for pampC-positive isolates. The presence of pAmpC enzymes has been shown in 9.4% (3/32) of cefoxitin-resistant E.coli, and 8% (2/25) of cefoxitin-resistant K.pneumoniae strains. It was noted that there were no strains producing this enzyme isolated in 2007 and 2008, however the prevalence of pAmpC was detected as 1.6% in 2009 (one ACT-1 producing K.pneumoniae), increasing to 4.8% in 2011 (one ACT-1 producing K.pneumoniae) and 6.4% in 2012 (three CMY-2 producing E.coli). These enzymes were found to be carried on 81 kb size plasmids in K.pneumoniae isolates and on a 9 kb size plasmid in E.coli isolates. Macrorestriction analysis indicated that two of the three CMY-2 producing E.coli had the same PFGE (Pulsed-field gel electrophoresis) pattern. If these two strains are considered as identical, it can be concluded that the prevalence of pAmpC was low in the strains isolated between 2007-2012 (4/261; 1.5%) in our institution. On the other hand, the increasing prevalence of pAmpC in 2011 and 2012 should be considered as a warning for the implementation of infection control measures and monitorization of the prevalence in order to prevent the dissemination of pAmpC. As far as the current literature is concerned, this is the first study that demonstrated the presence of the ACT-1 enzyme in K.pneumoniae isolates in Turkey.

Carbapenem resistance due to OXA-type carbapenemases seriously limits therapeutic options in nosocomial infections caused by Acinetobacter baumannii. Previous studies have shown the presence of OXA-51, OXA-58, and OXA-23 carbapenemases but not OXA-24/40 in A. baumannii in Turkey. In this study, we investigated carbapenem-hydrolyzing class D β-lactamases (CHDLs) in A. baumannii and the molecular epidemiology of CHDL producers at the Dokuz Eylul Hospital, Izmir Turkey, and detected blaOXA-24/40 in a clinical isolate from a patient in the medical intensive care unit (ICU). The specific enzyme type was OXA-72. Additional studies revealed 22 more isolates from 20 patients and that the OXA-72-producing strain caused an outbreak in the medical ICU from September 2012 to March 2013, which still continues. To our knowledge, this is the first report of OXA-24/40 carbapenemases in A. baumannii in Turkey. Emergency infection control should be implemented following the arrival of a new OXA at a hospital where A. baumannii is highly endemic.

The aim of this study was to determine whether vancomycin resistant Staphylococcus aureus (VRSA) and vancomycin intermediate susceptible S.aureus (VISA) strains were present among methicillin-resistant S.aureus (MRSA) strains isolated from patients hospitalised at intensive care units (ICU) of hospitals located at different regions of Turkey and to determine the minimum inhibitory concentration (MIC) values of teicoplanin, linezolid, tigecycline, quinupristin-dalfopristin and daptomycin, which are alternative drugs for the treatment of MRSA infections. A total of 260 MRSA clinical strains (isolated from 113 lower respiratory tract, 90 blood, 24 wound, 17 catheter, 13 nasal swabs, two urine and one CSF sample) were collected from nine health-care centers in eight provinces [Ankara (n= 52), Konya (n= 49), Antalya (n= 40), Istanbul (n= 7), Izmir (37), Diyarbakir (n= 15), Van (n= 12), Trabzon (n= 48)] selected as representatives of the seven different geographical regions of Turkey. Methicillin resistance was determined by cefoxitin disk diffusion in the hospitals where the strains were isolated and confirmed by oxacillin salt agar screening at the Refik Saydam National Public Health Agency. Screening for VISA and VRSA was conducted using the agar screening test and E-test. Susceptibility of the MRSA strains to other antibiotics was also determined by E-test method. None of the 260 MRSA strains were determined to be VRSA or VISA. All were susceptible to teicoplanin and linezolid, and susceptibility rates to daptomycin, tigecycline and quinupristin-dalfopristin were 99.6%, 96.9%, and 95%, respectively. Absence of VISA and VRSA among the MRSA strains surveyed currently seemed hopeful, however, continuous surveillance is necessary. In order to prevent the development of VISA and VRSA strains the use of linezolid, tigecycline, quinupristin-dalfopristin and daptomycin should be encouraged as alternative agents of treatment of MRSA infections.

Quinolones are widely used antimicrobial agents, particularly for the treatment of infections caused by gram-negative bacilli such as E.coli. As a consequence, quinolone resistance has been increasing among this species in recent years. Bacterial resistance to quinolones usually results from mutations in the chromosomal genes which encode topoisomerases and also the expression of efflux pumps and loss of porines contributed to development of quinolone resistance. However, recent studies have shown that the spread and increase of quinolone resistance may be due to the transfer of plasmid-mediated genes. To date, three groups of plasmid-mediated quinolone resistance genes, namely qnr, aac(6')-Ib-cr, and qepA, have been described. The aim of this study was to investigate the presence of plasmid-mediated quinolone resistance genes in E.coli clinical isolates. A total of 112 quinolone-resistant E.coli strains isolated from different clinical specimens (84 urine, 16 blood, 10 wound, 2 bronchoalveolar lavage) of which 78 (69.6%) were extended-spectrum beta-lactamase (ESBL) positive, in Afyon Kocatepe University Hospital, Microbiology Laboratory were included in the study. In the isolates, qnrA, qnrB, qnrS, qnrC, qepA, and aac(6')-1b-cr plasmid genes were analysed by polymerase chain reaction (PCR). After aac(6')- 1b determinant was amplified by PCR, all aac(6')-1b positive amplicons were analyzed by digestion with BseGI restriction enzyme to identify aac(6')-1b-cr variant. It was found that, none of the strains horboured qnrA, qnrB, qnrS, qnrC and qepA genes, however, plasmid-mediated quinolone resistance gene aac(6')-1b-cr was found positive in 59.8% (67/112) of the strains. It was notable that 86.6% (58/67) of those isolates were ESBL producers. The rates of quinolone resistance among E.coli isolates infections were high in our region and an increasing trend has been observed in recent years. Our data indicated that the presence of plasmid- mediated resistance genes such as aac(6')-1b-cr, might have contributed to the high quinolone resistance rates. In conclusion, not only qnr genes but all other plasmid-mediated quinolone resistance genes, should be tested for the detection of plasmid-mediated quinolone resistance and this fact should be taken into consideration when the reservoirs are being searched for.

Seven clusters of hospital infection due to Salmonella enterica serovar typhimurium were documented in the neonatology clinic of a children's hospital between April 2002 and March 2004. Eighty-one neonates were infected. Three cases were asymptomatic, 73 cases had gastroenteritis as the only clinical condition, and 5 cases had bacteremia associated with gastroenteritis. All isolates from stool and blood samples (n=86) were identified as Salmonella enterica serovar typhimurium. Extended-spectrum beta-lactamase (ESBL) production was determined by clavulanate disk potentiation assay in all isolates. Enterobacterial Repetitive Intergenic Consensus polymerase chain reaction (ERIC-PCR) was performed in 26 selected isolates, which were chosen as being representative of different clusters, to determine the clonal relationship. PCR, isoelectric focusing and sequence analysis revealed the production of CTX-M-3, TEM-1 and SHV-12 by these isolates in 23%, 76.9% and 100%, respectively. None of the isolates had PER beta-lactamase production. Standard infection control measures such as handwashing and disinfection procedures were implemented in initial clusters. During the two-year period, the infection control policy of the hospital was improved with appropriate actions such as assignment of an infection control nurse and increasing the number of staff of the clinic, and finally, with the establishment of an active surveillance program, the clusters were stopped.