Diagnosis, treatment and prevention of infective endocarditis: Turkish consensus report-2019 [İnfektif endokarditin tanısı, tedavisi ve önlenmesi: Ulusal uzlaşı raporu-2019]

Infective endocarditis (IE) is a rare but still important as an infectious disease due to high rate of morbidity and substantial mortality. Although IE is not a notifiable disease in Turkey, and an incidence study has not been performed, the incidence may be higher than that in the developed countries due to frequent predisposing cardiac conditions and higher rates of nosocomial bacteremia, which may lead to IE in risk groups. IE generally affects the elderly in developed countries but it is frequently encountered among young individuals in Turkey. In order to reduce mortality and morbidity, it is critical to diagnose IE, to determine the causative agent, and to start treatment rapidly. Most patients cannot be diagnosed at the first visit, about half can be diagnosed after 3 months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of the identification of a causative organism is significantly lower in Turkey than that in developed countries. Some important microbiological diagnostic tests are not performed in most centers and several antimicrobials that are recommended as the first option for the treatment particularly antistaphylococcal penicillins, are unavailable in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. The diagnosis and treatment processes of IE should be standardized at every stage so that the management can be conducted in a setting in which physicians of various specialties are involved and is consistent with the current recommendations. The Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases called for the collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the context of current information and local data in Turkey. © 2020 Turkish Society of Cardiology

Hematologic Adverse Effects of Prolonged Piperacillin- Tazobactam Use in Adults

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

The Turkish Clinical Microbiology and Infectious Diseases Society (KLİMİK) Evidence-Based Guideline for the Diagnosis and Treatment of Brucellosis, 2023

Bruselloz, dünyada ve ülkemizde çok yaygın olarak görülmesine rağmen hastalığın tanı ve tedavisini yönlendirmede kullanılabilecek kanıta dayalı bir rehber bulunmamaktadır. Bu rehber, brusellozun tanı ve tedavisi ile ilgilenen farklı uzmanlık alanlarından hekimlere kanıta dayalı öneriler sunmak üzere Türk Klinik Mikrobiyoloji ve İnfeksiyon Has- talıkları Derneği tarafından hazırlanmıştır. Rehberin hazırlanmasında, ABD İnfeksiyon Hastalıkları Derneği (IDSA)’nin Klinik Uygulama Rehberi Geliştirme Kı- lavuzu önerileri esas alınmıştır. Rehberi hazırlayan grup üyeleri tarafından, bruselloz tanı ve tedavisinde önemli olduğu düşünülen 20 soru belirlenmiş ve PICO [hasta/popülasyon (P), müdahale/indikator (I), karşılaştırma/kontrol (C), sonuç (O)] formatında oluşturulan bu sorulara yanıt verebilecek yayınlar, ULAKBİM TR Dizin, PubMed ve Cochrane veritabanlarından, tarih kısıtlaması olmadan taranmıştır. Her bir PICO sorusu ve her bir ayrı sonlanım için kanıtların derecelendirilmesinde ve önerilerin gücünün belirlenmesinde “Grading of Recommendations, Assessment, Develop- ment and Evaluation (GRADE) Working Group” yöntemi kullanılmıştır. PICO sorularına yanıt oluşturabilecek şekilde karşılaştırmalı klinik araştırmaların olması halinde bunların meta-analizleri, olmaması halindeyse olgu sunumları ve olgu serilerinden elde edilen verilerle “individual participant data” (IPD) meta-analizleri yapılmıştır. Önerilerin yeni çalışmaların sonuçları doğrultusunda belli aralıklarla güncellenmesi planlanmaktadır.Although brucellosis is very common in the world and Türkiye, there are no evidence-based guidelines to guide the diagnosis and treatment of the disease. This guide has been prepared by the Turkish Society of Clinical Microbiology and Infectious Diseases to provide evidence-based recommendations to physicians from different specialties interested in the diagnosis and treatment of brucellosis. The recommendations of the Clinical Practice Guide Development Guide of the Infectious Diseases Society of Amer- ica (IDSA) were taken as the basis for preparing this guide. The guideline preparation group determined 20 questions considered to be important in the diagnosis and treatment of brucellosis, and the publications that could answer these questions prepared in PICO (Population/Patient [P], Intervention [I], Comparison [C], Outcome [O]) format, were searched in ULAKBİM Tr Dizin, PubMed, Cochrane databases without date restrictions. The Grading of Recommen- dations, Assessment, Development, and Evaluation (GRADE) Working Group method was used to rank the evidence and determine the strength of the recommendations for each PICO question and for each individual outcome. Me- ta-analyses of comparative clinical studies were performed to answer the PICO questions. Individual participant data (IPD) meta-analyses with data obtained from case reports and case series were conducted in the absence of comparative clinical studies. It is planned to update the recommendations at regular intervals in line with the results of new studies

Native and Prosthetic Valve Endocarditis Caused by Brucella spp.; Evaluation of Eight Cases

Brucellosis and its complications are still a problem in developing countries. All cases of infective endocarditis admitted to Siyami Ersek Thoracic and Cardiovascular Surgery Hospital were recorded prospectively between July 2000 and July 2004. A total of 88 cases with infective endocarditis were recorded and 8 (9%) of these patients were identified as having endocarditis caused by Brucella spp. Underlying heart diseases were prosthetic valve in five patients and native valve sequele secondary to acute reumatic fever in three. All of the patients had positive results of Wright agglutination test with titers greater than 1/1280. Brucella melitensis were isolated in blood cultures of six patients. Vegetation, abscess, corda rupture and new dehiscence of prosthetic valve have been seen either by TTE or TEE in eight, five, one and one of eight patients respectively. Although TTE were found to be normal, TEE revealed vegetation in four (three prosthetic, one native valve) of eight patients. All of the patients were treated with trimethoprim-sulfamethoxazole, rifampin and doxycycline combination for 12 months. Surgical intervention was done for seven patients within a median of 18 days (range 7-45 day), and patients were alive after 12 months follow up. Brucella spp. should be considered in patients with infective endocarditis, especially in countries where the diseas still endemic. TEE should be done in case of normal TTE findings. Early surgical intervention can reduce mortality

Pacemaker Lead Endocarditis: Report of Two Cases

Pacemaker lead endocarditis was diagnosed in two different patients. Causative microorganism was Staphylococus aureus and Staphylococcus epidermidis in the first and the second patient respectively. Patients were treated with antibiotics including cefazoline 3 x 2 g intravenous (IV) plus gentamicin 3 x 1 mg/kg IV and rifampicin 3 x 300 mg oral, for 8 weeks and with the surgical removal of lead system. Clinical aspects, treatment options and diagnostic criteria of pacemaker lead endocarditis were discussed

[A Case of Chronic Q Fever Endocarditis Mimicking Lymphoproliferative Disorders].

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 Catalca 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 beta-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/mu l, platelet count 148000/mu l, 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

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases

Objective: In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital. Methods: All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann–Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis. Results: There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (1.2 mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality. Conclusions: In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients