Browsing by Author "Sürücüoglu, S"
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Item The reliability of tuberculin skin test in the diagnosis of latent tuberculosis infection in psoriasis patients: A case-control studySürücüoglu, S; Ermertcan, AT; Çetinarslan, T; Özkütük, NTuberculin skin test (TST), which is used in the diagnosis of latent tuberculosis infection, may cause Koebner's phenomenon and false-positive results in psoriasis patients. The purpose of this study is to compare TST with QuantiFERON-TB Gold Plus (QFT-plus) test in psoriasis patients and to determine the effects of psoriasis on TST results. Ninety-two psoriasis patients and 30 control subjects were included in the study. QFT-plus test, TST, and prick test to distinguish the increase of induration because of the skin trauma were performed on both groups. The demographics, risk factors for latent tuberculosis infection, BCG vaccination history, Koebner's history, psoriasis severity, and treatment history of the patients were recorded. The effects of these variables on test results were investigated by comparing those with control group. The criteria of National Tuberculosis Diagnosis and Treatment Guidelines were used in the evaluation of test results, and threshold value of positivity for TST was taken as 10 mm in BCG-vaccinated patients who are planned to start biological treatment. Prick test results were negative in the control group. There was no significant relation between the results of prick test and TST induration diameters in the patient group. Although TST positivity was significantly higher in patients (62%) compared with control group (33%), QFT-plus test results were not statistically different between two groups. Agreement between two tests was determined to be low in patient group with 48% (K = 0.1), and it was determined to be moderate with 77% in control group (K = 0.4). QFT-plus test was found to be negative in 46 of 57 TST-positive patients (80.7%) in patient group. It was determined in both groups that vaccination did not have any effect on test results. When threshold value was lowered to 5 mm in patient group without considering BCG reaction, the number of TST-positive patients increased from 57 to 65. Mean TST induration diameter was 10 mm and 14 mm in cases with mild and moderate to severe clinical manifestation, respectively (P = .04). However, no effect of disease period and treatment was determined on both test results. TST positivity was higher in psoriasis patients compared with control group. It was considered due to the increased reaction of the skin to mycobacterial antigens rather than the Koebner's response. Although TST results were not affected by BCG, it was concluded that a 10-mm threshold value of positivity was a suitable approach in order to reduce the number of patients receiving unnecessary preventive treatment in patients who are considered to initiate biologic agents. Furthermore, it was also concluded that QFT-plus test may be preferred in psoriasis patients since it is applied in vitro and its specificity is higher and not affected by disease severity.Item Antimicrobial Resistance Patterns of Mycobacterium abscessus Complex Clinical IsolatesSürücüoglu, S; Özkütük, N; Gazi, H; Çavusoglu, CObjective:This study aimed to identify subspecies of Mycobacterium abscessus complex (MABC) isolates from clinical samples by a molecular technique and to determine mutations responsible for macrolide and aminoglycoside resistance. We also aimed to investigate the correlation of phenotypic and molecular test results by examining the resistance to antimicrobial agents according to CLSI standard using the liquid microdilution test. Methods: 27 MABC isolates from clinical samples were examined. Molecular subspecies identification and mutations responsible for aminoglycoside (rrs mutation) and macrolide resistance (rrl mutation) were determined using the GenoType NTM-DR test. The resistance phenotypes of the strains to various antimicrobial agents were investigated by the Sensititre (TM) RAPMYCOI AST microdilution test. Results: Of the 27 isolates tested, 21 were M. abscessus subsp. abscessus, three were M. abscessus subsp. bolletii, and three were M. abscessus subsp. massiliense; rrs and rrl mutations were not observed in any strains. Except for one isolate, all M. abscessus subsp. abscessus strains showed the erm(41) T28 genotype, which indicates inducible macrolide resistance. The correlation between the GenoType NTM-DR and phenotypic susceptibility test results was 81% (k=0.5, p=0.02) for inducible macrolide resistance and 89% for acquired macrolide resistance. The most effective antimicrobial agents were amikacin, cefoxitin, imipenem, linezolid, and tigecycline. Conclusion: Although the GenoType NTM-DR test is reliable in identifying and detecting molecular macrolide and aminoglycoside resistance, there were discrepancies in the results. We recommend confirming the results with the phenotypic susceptibility method after growth on culture. Although the M. abscessus complex is resistant to many antimicrobial agents, it has shown high sensitivity to amikacin, cefoxitin, imipenem, linezolid, and tigecycline. High levels of inducible macrolide resistance in isolates indicate the importance of subtyping and sensitivity testing of iso-lates in patients where culture conversion has not been achieved.Item Significance of Fluorescent In-Situ Hybridization Method in Rapid Diagnosis of BrucellosisGazi, H; Yurtsever, SG; Sürücüoglu, S; El, S; Ertural, PObjective: Brucellosis is a zoonosis commonly seen worldwide it causes severe disease and great economic loss. Rapid and sensitive tests are increasingly required for detection of the disease since currently used conventional diagnostic methods give results late and there are some factors affecting its sensitivity. Recently, a number of diagnostic tests have been determined that use different clinical samples in order to diagnose brucellosis in a short time. However a sufficiently sensitive and specific, optimized, routinely applicable molecular method is still lacking for detection of brucellosis which is defined as a difficult infection in terms of diagnosis and treatment. Fluorescent in situ hybridization (FISH) is a novel molecular diagnostic method that can detect Brucella spp. from hemoculture tubes signaling positively by shortening identification time. In this study, we aimed to compare FISH technique with conventional culture method in diagnosis of brucellosis and to investigate its use routinely. Material and Methods: A total of 100 hemoculture samples of patients who applied with the suspicion of brucellosis were studied with FISH and culture methods concurrently, after gram staining. Standard Wright's tube agglutination (STA) test was also used for interpretation of the FISH results. Results: Of the tested samples, 43 studied with cultures, 52 with STA and 44 with FISH were found positive. The FISH detected Brucella spp. in 34 positive cultures and in 29 STA positive sample. Sensitivity, specifity, positive and negative predictive values of FISH method were found as 79.0%, 82.4%, 77.2% and 83.9% respectively when evaluated together with culture which is the gold standard method. Conclusion: FISH is a rapid and easily applicable method not requiring much equipment. However, it was concluded that it could not be used as a cost-effective diagnostic tool as it was not as sensitive enough as desired, and in case of it is used, it would be useful to confirm FISH negative samples with culture and/or serum tube agglutination test.Item Molecular Diversity of Drug Resistant Mycobacterium Tuberculosis Strains in Western TurkeySürücüoglu, S; Günal, S; Özkütük, N; Biçmen, C; Özsöz, A; Gazi, H; Durmaz, RObjective: The aim of this study was to investigate the molecular diversity and clonal relationship of drug resistant Mycobacterium tuberculosis strains isolated in Western Turkey. Materials and Methods: A total of 87 strains isolated between 2006 and 2009, eight of which were rifampicin monoresistant and 79 were multidrug resistant, were analyzed with IS6110 RFLP and spoligotyping methods. Results: The results of spoligotyping showed that 7% of the strains were orphans, and 8% were undefined for family in the SpolDB4 database. Major families of the strains were LAM (38%), T (35%), Haarlem (7%), Beijing (2%), S (2%) and U (1%) families. The clustering rate by spoligotyping was calculated as 75%. The most predominant SIT cluster was SIT41 (29%). According to the results of IS6110 RFLP, 71 different patterns of IS6110 were observed. Low copy number was found in 26% of the strains. When the results of two methods were combined, the final clustering rate was calculated as 26%. Conclusions: The genotypical distribution of drug resistant tuberculosis isolates in our region indicates genetic diversity and the clustering rate was found low in our region. However, more comprehensive and long-term molecular epidemiological studies are needed to control the drug resistant strains.Item A comparison of two different fluorochrome stains for the detection of acid-fast bacilli in sputum specimensOguz, VA; Sezak, N; Öztop, A; Yapar, N; Sürücüoglu, S; Yüce, AAim: The early diagnosis of active tuberculosis still depends on the presence of acid-fast bacilli (AFB) in stained sputum smears. In this study, our aim was to investigate the efficiency and cost-effectiveness of two different fluorochrome stains. Materials and methods: A total of 1013 sputum specimens were collected from 642 patients. Three smears and cultures were prepared from each specimen. Double-blind and prospective laboratory procedures were performed. Slides were stained with a commercial auramine/acridine orange kit (Stain 1), an in-house preparation of auramine- rhodamine/KMnO4 (Stain 2) and a Ziehl-Neelsen stain (EZN). Results: Of the 1013 specimens, 101 were culture positive. Among these, AFB was detected in 60 specimens by EZN, in 53 by Stain 1, in 81 by Stain 2. By cultures, the sensitivities and specificities of Stain 2 were 80.1% and 83.8%, respectively, and for Stain 1, 52.4% and 94.6% respectively. There is no significant difference between the costs of these methods. Conclusion: Stain 1 was easy to apply and inexpensive but the sensitivity of Stain 1 was lower than that of Stain 2. However, Stain 2 required longer preparation time, more work, and had a higher risk of exposure to carcinogens. In order to increase the sensitivity of Stain I, it is suggested that the contents of the prepared Stain 1 kit could be rearranged. In tuberculosis diagnosis, this revised kit may provide practicality in use.Item Second-line drug susceptibilities of multidirug-resistant Mycobacterium tuberculosis isolates in Aegean region - TurkeyÖzkütük, N; Sürücüoglu, S; Gazi, H; Coskun, M; Özkütük, A; Özbakkaloglu, BAim: The emergence of multidrug-resistant tuberculosis (MDR-TB) is increasing, and the standard short-course regimen used for the treatment of TB is likely to be ineffective against MDR-TB, leading to the need for second-line drugs. In such situations, drug susceptibility testing is necessary to select an appropriate treatment regimen. Unfortunately, there are few studies showing the pattern of the second-line drug resistance in Turkey. We aimed to analyze the resistance to second-line anti-tuberculosis drugs of MDR strains of Mycobacterium tuberculosis isolated from the Aegean region of Turkey. Materials and Methods: In this study, drug susceptibility testing of 40 MDR-TB strains isolated from the Aegean region of Turkey was performed using the BACTEC 460 TB radiometric system. Capreomycin, ethionamide, kanamycin, amikacin, clofazimine and ofloxacin were tested in 1.25 mu g/ml, 1.25 mu g/ml, 5.0 mu g/ml, 1.0 mu g/ml, 0.5 mu g/ml, and 2.0 mu g/ml concentrations, respectively. Results: The results showed that 37.5% of the strains were resistant to ethionamide, 25% to capreomycin, 5% to kanamycin, amikacin and ofloxacin, and 2.5% to clofazimine. One (2.5%) of the 40 MDR-TB cases was defined as extensively drug-resistant tuberculosis (XDR-TB). Conclusions: The results of the study indicate that the high rates of resistance to ethionamide and capreomycin may be a problem in the treatment of patients with MDR-TB; XDR-TB is not yet a serious problem in our region.Item Comparison of interferon-gamma whole blood assay with tuberculin skin test for the diagnosis of tuberculosis infection in tuberculosis contactsÖztürk, N; Sürücüoglu, S; Özkütük, N; Gazi, H; Akçali, S; Köroglu, G; Çiçek, CTuberculin skin test which is used for the detection of latent tuberculosis (TB), has many disadvantages such as false positivities due to cross reactions between environmental mycobacteria and BCG strain, false negativities due to immunosuppression and malpractice, and also difficulties in application and evaluation. Recently a new diagnostic test which measures the production of interferon (IFN)gamma in whole blood upon stimulation with specific ESAT-6 and CFP-10 antigens of Mycobacterium tuberculosis has been introduced. Since most of the mycobacteria other than tuberculosis and BCG strain do not contain these antigens, the detection of IFN-gamma levels indicates the specific T-cell response against M.tuberculosis. The aim of the study was to compare the tuberculin skin test and whole blood IFN-gamma assay (QuantiFERON (R)-TB Gold, Cellestis Ltd, Carnegie, Victoria, Australia) for the identification of latent TB infection in the contacts with active TB patients. The tests results were evaluated by using Kappa (K) analysis, and K coefficients of < 0.4, 0.4-0.75 and > 0.75 were accepted as poor, moderate and excellent agreements, respectively. A total of 233 subjects from three risk groups were included to the study. Group 1 included the household members (n=133) who had contact with smear positive index cases, Group 2 included the subjects from community (n=46) who had contact with smear positive index cases, and Group 3 included health care workers (n=74) who had contact with TB patients or their specimens. The positivity rates of tuberculin skin test and IFN-gamma assay in the cases were found as 37% and 42%, respectively. There were no significant differences among the three patient groups with regard to the results of the tuberculin skin test (p > 0.05). However, the positive result of the IFN-gamma assay in Group 1 was found statistically higher than the other groups (51.3%, p=0.013). A poor agreement between the two tests was detected in the results taken from 233 subjects (65.7%, K=0.28), while agreement was moderate in unvaccinated group (72.7%, K=0.44). Evaluation of agreement rates of the tests according to the risk groups yielded 64.6% (K=0.3) for Group 1, 71.7% (K=0.32) for Group 2, and 63.5% (K=0.21) for Group 3, which all coefficients showed poor agreement. Although IFN-gamma blood assay has many advantages such as objective and quantitative results, no interference with vaccination due to the use of specific antigens and being practical, the high cost and the need for well-equipped laboratory are its disadvantages. As a result it was concluded that, IFN-gamma blood assay has limited value for the detection of latent TB infection in our country, since the prevalence of TB infection and BCG vaccination rates are high in Turkey.Item Chronic subcutaneous nodules, plaques and ulcers of the handErmertcan, AT; Özkütük, N; Temiz, P; Çavusoglu, C; Sürücüoglu, SItem In vitro Activity of Rifabutin and Clofazimine to Macrolide- Resistant Mycobacterium abscessus Complex Clinical IsolatesSürücüoglu, S; Özkütük, N; Gazi, H; Çavusoglu, CMycobacterium abscessus complex (MABSC) is one of the most resistant bacteria against antimicrobial agents. The number of agents that can be used by oral route, such as macrolides, is limited in antimicro- bial therapy. In recent years, rifabutin and clofazimine have gained importance as they can be admin- istered by oral route and have shown synergistic effects with macrolides and aminoglycosides. The aim of this study was to determine the in vitro activity of rifabutin and clofazimine against clinical isolates of MABSC resistant to macrolides. A total of 48 MABSC isolates obtained from respiratory tract and other clinical samples in the Tuberculosis Laboratories of the Faculty of Medicine of Manisa Celal Bayar and Ege Universities were included in the study. Subspecies differentiation and aminoglycoside and macrolide resistance of the isolates were determined by GenoType NTM-DR test. Rifabutin and clofazimine sus- ceptibilities were determined by standard broth microdilution method. Of the MABSC isolates 42 were identified as M.abscessus subsp. abscessus, three as M.abscessus subsp. bolletii and three as M.abscessus subsp. massiliense. None of the isolates exhibited rrs and rrl mutations indicating acquired macrolide resistance and aminoglycoside resistance. However, the erm(41) T28 genotype which is associated with inducible macrolide resistance was detected in 41 (85%) of the strains. All M.abscessus subsp. massiliense isolates were found to be genotypically susceptible to macrolides. The minimum inhibitory concentration (MIC) range values for rifabutin were 0.0625 to 32 mu g/mL, while for clofazimine, the range was 0.0625 to 1 mu g/mL. Rifabutin MIC values were significantly higher (mean 5.98 mu g/mL vs 0.5 mu g/mL, p= 0.026) in the isolates with macrolide resistance. There was no correlation between macrolide resistance and clofazimine MIC values (mean 0.25 mu g/mL vs. 0.214 mu g/mL, p= 0.758). The MIC50 and MIC90 values for rifabutin were 1 and 8 mu g/mL, respectively, while for clofazimine they were 0.25 and 0.5 mu g/mL. Macrolide resistance was found to be higher in isolates with rifabutin MIC values above the MIC50 value (p= 0.045). In conclusion, the determination of higher rifabutin MIC values in isolates resistant to macrolides suggested that susceptibility testing should be performed before adding rifabutin to the treatment regimen. The low MIC values of clofazimine in all strains indicated that it may be used as a first choice in the combination therapy. However, further studies using a larger number of clinical isolates and applying genotypic and phenotypic susceptibility tests are needed to determine threshold MIC values to assist clinicians in treatment decisions.Item Prevalence and evaluation of a choromogenic medium for isolation of Escherichia coli O157 from children with acute gastroenteritisDegerli, K; Kurutepe, S; Gazi, H; Demirel, M; Gülkan, E; Sürücüoglu, SObjective: Comparative performance status of CHROMagar O157 (CHROM) sorbitol-MacConkey (SMAC) media for the detection of Escherichia coli (E. coli) O157 in stool specimens isolated from 339 children under 5 years of age who presented with acute gastroenteritis between September 2008 and September 2010 was determined. Methods: Stool specimens were inoculated onto Sorbitol-MacConkey agar (SMAC), CHROMagar O157, Selenit F, Salmonella-Shigella (SS) and MacConkey agars. All plates were incubated aerobically for 24 to 48 h at 35 degrees C. Colorless colonies on the SMAC plate and mauve colonies on the CHROM plate were selected for further identification by conventional biochemical tests as well as by semi-automated system. Colonies confirmed to be E. coli were screened for O157 antigen by Dry spot E. coli O157 latex particle agglutination test. Results: In 339 stool samples examined, Salmonella spp was isolated in 14 (4.1%), and Shigella spp. in 11 (3.2%), while Escherichia coli O157 was detected in only 1 (0.3%) sample. Suspect E. coli O157 stains grew on 8 CHROMagar (2.1%; 8/339) and 14 SMAC (14/339; 3.8%) plates. Rate of false positivity for colony picks from SMAC (n= 13; 65%) media was almost 2-fold higher than that for CHROM (n= 7; 35%). Conclusion: Routine use of chromogenic media for the investigation of E. coli O157' nin in the selected cases with bloody diarrhea is deemed appropriate.Item Risk of Travel Associated TuberculosisSürücüoglu, STuberculosis has spread by human movements throughout history. There have been reports indicating tuberculosis transmission on all travel vehicles, including aircrafts, ground vehicles and vessels until today. However, due to the ever increasing of air transportation and air travelling among countries with low and high tuberculosis incidence, transmission risk especially in aircrafts has become an important issue worldwide. But in many of the studies conducted in this regard, transmission of tuberculosis in aircrafts was found very low. The case of active tuberculosis has not yet been reported. This is due to the fact that in modern aircrafts, there are ventilation systems that provide hepa filtered laminar air flow and change the air 15-20 times per hour. The guidelines for the prevention of tuberculosis infection in aircrafts published by the World Health Organization Tuberculosis and Air Travel, 2008 and European Centre for Disease Prevention and Control RAGIDA-TB, 2014 confirm each other. According to these guidelines, air travelling of patients with active pulmonary tuberculosis should be prohibited until smears of two consecutive sputum samples become negative for drug susceptible cases, and cultures of two consecutive of sputum samples become negative for multidrug or extensively drug resistant cases. When it is reported that a tuberculosis patient has travelled by the aircraft, it is recommended that the exposed passengers should be investigated for tuberculosis infection if the flight duration equal to or exceeding eight hours including ground delays and the time elapsed between flight and diagnosis of the case is no longer than three months. Contact screening is only recommended for passengers sitting in the same row, two rows ahead and two rows behind the index case. Tuberculin skin test or interferon gamma release assay can be used for investigation. It is very difficult to determine the risk of tuberculosis transmission in ground vehicles like buses, subways and trains. The reason is that it is often not possible to access the information of the passengers travelling in these vehicles. Because the ventilation systems in ground vehicles are not as reliable as in aircrafts and the crowded environment in the ground vehicles, the risk of tuberculosis transmission is theoretically higher. In modelling studies, the transmission risk in the buses was found to be higher than the trains. In the case of regular travelling with an index case such as school bus riders, the risk increases significantly. The increased human population travelling all over the world nowadays has also raised concerns about travel-related tuberculosis risk. However, because of the limited evidence, it may be more efficient to spend time and resources for the other actions in order to prevent tuberculosis. In this review article, the transmission risk of tuberculosis in vehicles has been discussed.Item Evaluation of the Xpert MTB/RIF Assay for the Diagnosis of Pulmonary and Extrapulmonary Tuberculosis in an Intermediate-Prevalence SettingÖzkütük, N; Sürücüoglu, SEarly and accurate detection of tuberculosis (TB) is a global priority for TB control. In order to obtain results in a short period of time, nucleic acid amplification tests are increasingly used worldwide for the rapid diagnosis of tuberculosis. The Xpert MTB/RIF (R) (Cepheid, USA) is a commercially available, real-time PCR-based assay, which can detect both TB and resistance to rifampicin directly in clinical samples. The aim of this study was to evaluate the performance of Xpert MTB/RIF assay for M.tuberculosis detection in pulmonary and extrapulmonary clinical samples in routine laboratory practice in Turkey, an intermediate-prevalence setting. A total of 2639 clinical specimens, 1611 of which were pulmonary and 1028 were extrapulmonary, were included in the study. The results of Xpert MTB/RIF assay were evaluated by comparing the results with those obtained by culture [BACTEC MGIT 960 (Becton Dickinson, USA) and Lowenstein Jensen medium]. Overall sensitivity, specificity, positive and negative predictive values of Xpert MTB/RIF assay were determined as 73.9%, 98.6%, 79.6% and 98.1%, respectively. These values were calculated as 80.8%, 98.8%, 84.9% and 98.4% for pulmonary specimens, and 58.2%, 98.4%, 66.7% and 97.7% for extrapulmonary specimens. The sensitivity and specificity were 100% and 58.1%, respectively, for acid-fast bacilli (AFB) smear-positive specimens, 39.7% and 99.1%, respectively for smear-negative specimens. The sensitivity and specificity were 100% and 76.2% for smear-positive pulmonary specimens; 100% and 20% for smear-positive extrapulmonary specimens; 47.8% and 99.1% for smear-negative pulmonary specimens; and 28.2% and 99.2% for smear-negative extrapulmonary specimens, respectively. The sensitivity and specificity of microscopic examination were found to be 56.7% and 98.7% for all specimens; 63.2% and 98.6% for pulmonary specimens; and 41.8% and 99% for extrapulmonary specimens, respectively. Rifampicin resistance was detected by Xpert MTB/RIF assay in only two specimens, however, rifampicin resistance was failed to be detected by BACTEC MGIT 960 TB method in one of these samples. Xpert MTB/RIF assay appeared to be a reliable method for the diagnosis of TB for AFB smear-positive samples, but less sensitive for smear-negative samples, particularly for extrapulmonary samples which include low numbers of bacilli. However, we concluded that the MTB/RIF is a useful assay for rapid diagnosis of tuberculosis, considering that the results can be given in the same day of sample collection and the assay is superior in sensitivity than microscopic examination.Item Antimicrobial susceptibility of bacterial pathogens in the oropharynx of healthy school children in TurkeyGazi, H; Kurutepe, S; Sürücüoglu, S; Teker, A; Özbakkaloglu, BBackground & objectives: Information on oropharyngeal carriage rates of Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus Pyogenes and Moraxella catarrhalis and their resistance pattern in healthy school children in Turkey is lacking. The present study was undertaken to determine the carriage rates and antimicrobial resistance of these bacterial pathogens in such children aged 6-14 yr in Manisa, Turkey. Methods: A total of 1022 children were included from nine schools selected randomly from 32 schools. Throat swabs were cultured for bacteria which were identified using standard microbiological methods. Antimicrobial susceptibility was determined as per National Committee for Clinical Laboratory Standards guidelines. Results: Of the 1022 children 240 (23.4%) harboured S. pneumoniae, , 162 (15.8%) H. influenzae. 30 (2.9%) S. pyogenes and 82 (8%) M.. catarrhalis in their oropharynx. For S. peumoniae overall 17.9 per cent of the isolates were intermediately and 7 per cent were resistant to penicillin and resistance to erythromycin trimethoprim-sulphamethoxasole (TMP/SMX), and chloramphenicol was 13.7, 9.1 and 1.6 per cent, respectively. Ampicillin resistance observed in 20.9 per cent of H. influenzae isolates was associated with the presence of D-lactamase. except two isolates interpreted as -lactamase-negative ampicillin resistant strains. Resistance of H. influenzae to TMP/SMX, chloramphenicol, azithromycin, cefaclor and amoxicillin/clavulanic acid was 14.2. 2.4, 1.8, 1.2 and 1.2 per cent, respectively. M. catarrhalis isolates produced beta-lactamase in 80.5 per cent of the cases and all were susceptible to macrolides and clavulanic acid/amoxicillin combination; the highest rate of resistance of 17 per cent was for TMP/SMX. One (3.3%) isolate of S. pyogenes was resistant to macrolides tested. Interpretation & conclusion: Our data shows that upper respiratory tract of about 50 per cent children was colonized with respiratory pathogens. There is a need for surveillance of nasopharyngeal carriage of resistant strains in healthy school children.Item Levels of Cytokines Indicative of T Cell Response in Bronchoalveolar Lavage of Tuberculin Skin TestPositive ChildrenYuksel, H; Yilmaz, O; Onur, E; Sürücüoglu, S; Erdin, S; Kirmaz, COBJECTIVES: The aim of the study was to evaluate the levels of interleukin (IL)-4, IL-10, transforming growth factor-beta (TGF-beta), IL-17, and IL-23 cytokines, which reflect different T lymphocyte responses, in bronchoalveolar lavage (BAL) samples of tuberculin skin test (TST)-positive children. MATERIAL AND METHODS: Twelve children with TST positivity, who underwent flexible videobronchoscopy (FB) to evaluate airway involvement and to obtain BAL to improve diagnostic yield, and 11 control children with negative TST, who underwent FB for other reasons, were enrolled in this case-control study. BAL samples were obtained from all children during the FB procedure. Levels of IL-4, interferon gamma (IFN-gamma), IL-10, TGF-beta, IL-17, and IL-23 were measured by the ELISA method. RESULTS: Mean age of the children enrolled in the TST-positive and -negative groups were 8.6 (4.3) vs. 6.8 (4.5), respectively (p=0.35). There was a trend of higher TGF-beta levels in TST-positive children compared with TST-negative children [557.9 (515.3) vs. 386.3 (208.1), respectively, p=0.07]. Mean levels of IL-23 were 39.2 (29.5) in TST-positive children vs. 46.2 (72.3) in TST-negative children (p=0.49). IFN-gamma, IL-4, IL-10, and IL-17 levels were not significantly different among the groups (p> 0.05 for all). CONCLUSION: Results of this study suggest that TGF-beta in BAL fluid of children with TST positivity tends to be higher than that in TSTnegative children, which indicates an increased activity of regulatory T lymphocytes that may decrease the Th1 immune response. TGF-beta might be studied in future research for its potential as a diagnostic modality and immunomodulatory treatment target.Item Antimicrobial Resistance of Gram-Negative Bacteria Isolated from Lower Respiratory Tract Specimens of Hospitalized PatientsGazi, H; Ecemis, T; Kurutepe, S; Gürsev, N; Sürücüoglu, SObjective: In this study, we aimed to determine the distribution of the genera of Gram-negative bacteria isolated from lower respiratory tracts of patients treated as in-patients and to calculate the antibiotic resistance rates to guide empirical antibiotic therapy. Methods: Samples taken from the lower respiratory tract and sent to the Bacteriology Laboratory at the Celal Bayar University Faculty of Medicine from January 2008 to December 2010 were retrospectively analyzed. Results: A total of 853 Gram-negative bacteria were isolated from specimens of in-patients. The rates of carbapenem (85%) and multidrug resistance (47%) among A. baumannii were higher than those observed for P. aeruginosa (30% and 19.2%). Carbapenem resistance was not found among the bacteria of the family Enterobacteriaceae, while the highest rates of resistance were detected for ciprofloxacin and trimethoprim-sulfamethoxazole. Conclusions: Implementation of effective treatment protocols based on sensitivity test results can be useful in preventing nosocomial lower respiratory infections caused by resistant Gram-negative bacteria.Item A case of mycetoma successfully treated with itraconazole and co-trimoxazoleGündüz, K; Örgüç, S; Demireli, P; Inanir, I; Sürücüoglu, S; Ovali, GYA 29-year-old woman with swelling, multiple nodules and discharging sinuses of her right foot is presented. A single nodule on the sole was excised 15 years ago and since then she has had recurrent attacks of swelling and discharging sinuses that improved partially with antibiotics. Magnetic resonance images (MRI) revealed an ill-defined mass predominantly with low signal intensity on T2W images. Within the granulomata, multiple unenhancing foci, with low T1W and T2W signal most likely representing the fungal balls or grains were detected. Histopathological examination revealed large clusters of microorganisms resembling fungal hyphae and bacteria, which were surrounded by mixed inflammatory infiltrate cells and stained positively by PAS and Gomori's methenamine silver stain. As minimal regression was seen on MRI with 4 months' itraconazole (200 mg day(-1)) treatment, co-trimoxazole (160 TMP/800 SMX b.i.d.) was added to treatment. Complete remission was established by MRI examination after 10 months with this combination therapy.Item PYRAZINAMIDE MONORESISTANT MYCOBACTERIUM TUBERCULOSIS IN MANISA REGION, TURKEYÖzkütük, N; Ecemis, T; Sürücüoglu, SPyrazinamide (PZA) is a primary antituberculous drug. BACTEC 460TB is the recommended reference method for the detection of PZA resistance in Mycobacterium tuberculosis. This method is more expensive than the conventional susceptibility methods and therefore, it is recommended that each laboratory should establish their own protocol for the inclusion of PZA in the panel of primary drugs tested. One of the most important factors that help this decision is the prevalence of PZA resistance, particularly PZA monoresistance in the related community. The aim of the present study was to determine the extent of PZA monoresistance in M.tuberculosis complex (MTBC) isolates in our region. In this study, PZA susceptibility testing of 109 MTBC strains (susceptible to isoniazid, rifampicin, ethambutol and streptomycin) isolated from Manisa province in the Aegean region of Turkey was performed by using the BACTEC 460TB radiometric system (Becton Dickinson, MD). Two (1.8%) of the 109 isolates which were susceptible to all primary drugs revealed monoresistance against PZA. One of the PZA-monoresistant isolates has been identified as M.bovis and the other as M.tuberculosis by molecular method (Genotype MTBC, Hain Lifescience, Germany). The results of our study indicated that since the rate of PZA monoresistance was low, susceptibility testing of a panel of primary drugs without PZA may be an economical alternative in our region.Item Comparison of Lowenstein Jensen Medium and Bactec 460TB Culture System for Diagnosis of TuberculosisBaskesen, T; Sürücüoglu, S; Özkütük, N; Ecemis, TObjective: In this study, it was intestigated that whether the use of Lowenstein Jensen (LJ) medium with BACTEC460 TB liquid culture system contributed to bacteria isolation rates for diagnosis of tuberculosis. Material and Methods: A total of 4237 specimens were evaluated in the study for the results of microscopic examination and culture. Of 4237 specimens, 2719 were obtained from respiratory tract and remaining 1518 were obtained out of the respiratory tract. Results: According to the results of culture. Mycobacterium tuberculosis complex were isolated in 271 (6.4%) specimens on BACTEC 460TB system and in 238 (5.6%) specimens on Lowenstein Jensen medium. Contamination rates at BACTEC 460TB system and Lowenstein Jensen medium were 3.6% and 10.2%, respectively. The mean times of recovery were determined as 9.6 days for BACTEC system and 21 days for Lowenstein Jensen medium. When contaminated specimens were excluded, Mycobacterium tuberculosis was grown on at least one culture technique in 258 out of 3718 (6.9%) specimens. Sensitivity of BACTEC 460 TB culture system was found as 96%, while sensitivity of Lowenstein Jensen medium was found as 92%. The correlation between two culture techniques was found as 99%. Contribution of BACTEC 460 TB system and LJ medium alone to culture positivity were found as 8.3% and 3.9% respectively. No statistically significant difference was found when microscopic evaluation and culture systems were compared. Conclusion: It was concluded that the liquid culture systems are needed for rapid detection of tuberculosis, however liquid and solid culture systems should be used together in order to reach maximum isolation rates.Item Assessment of performance of amplified Mycobacterium tuberculosis direct test in pulmonary and extrapulmonary specimensSürücüoglu, S; Özkütük, N; Gazi, H; Çelik, PSince rapid diagnosis is critical in control of tuberculosis, nucleic acid amplification techniques have been widely used. The purpose of the present study was to assess the performance of Amplified Mycobacterium tuberculosis Direct Test (Amplified MTD Test, Gen-Probe) for the diagnosis of pulmonary and extrapulmonary tuberculosis in our laboratory. A total of 267 specimens (170 pulmonary and 97 extrapulmonary) were tested in the Clinical Mycobacteriology Laboratory of Manisa (a province located in Aegean part of Turkey) University Hospital from September 2001 to March 2005. When Amplified MTD (AMTD) test results were compared to the culture results taken as the gold standard, the sensitivity, specificity, positive and negative predictive values (PPV, NPV) for pulmonary specimens were found to be 84%, 96%, 73%, and 98%, respectively. When AMTD test positive, culture negative discrepant results were evaluated against the clinical history of the patients, these rates were detected as; 88%, 100%, 100%, and 98%, respectively. For 97 extrapulmonary specimens, sensitivity, specificity, PPV and NPV of AMTD test were 60%, 100%, 100%, and 98%, respectively. In conclusion, the results of the AMTD assay were reliable for the rapid diagnosis of pulmonary tuberculosis; if the results were evaluated together with the clinical status of patients, the performance of the test would be increased. However, even though the culture positive extrapulmonary specimens were sparse in our study (5%), the sensitivity of the AMTD test in extrapulmonary specimens was found less than that in pulmonary specimens. Therefore it is thought that AMTD test results should be evaluated carefully for the diagnosis of extrapulmonary tuberculosis.Item Investigation of Bacterial Etiology with Conventional and Multiplex PCR Methods in Adult Patients with Community-Acquired PneumoniaKurutepe, S; Ecemis, T; Özgen, A; Biçmen, C; Çelik, P; Özkan, SA; Sürücüoglu, SCommunity-acquired pneumonia (CAP) is still a serious life-threatening disease, in which the etiologic agent cannot be identified in more than 50% of patients despite advanced diagnostic methods. The most commonly used methods in the determination of CAP etiology are culture and serological tests. Since early and accurate therapy reduces the mortality in CAP cases, rapid and reliable diagnostic methods are needed. The aim of this study was to determine the bacterial etiology in adult patients with CAP by implementing multiplex polymerase chain reaction/reverse line blot hybridization (M-PCR/RLBH) assay combined with conventional methods. A total of 128 cases (94 were male; age range: 19-81 years, mean age: 58) who were admitted to our hospital and clinically diagnosed as CAP between November 2008 - November 2010, were included in the study. Respiratory samples (sputum and/or bronchoalveolar lavage) obtained from patients were searched by M-PCR/RLBH method (Gen ID (R) Autoimmun Diagnostika GmbH, Germany) in terms of the presence of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila nucleic acids. The samples were simultaneously inoculated onto 5% sheep blood agar, chocolate agar, haemophilus isolation agar, buffered charcoal yeast extract-selective agar and EMB agar media for cultivation. Serum samples obtained from the cases were tested for IgM and IgG antibodies against C.pneumoniae by microimmunofluorescence (Focus Diagnostic, USA) and against L.pneumophila and M.pneumoniae by indirect immunofluorescence (Euroimmun, Germany) methods. The bacterial etiology was identified in 59 (46.1%) of 128 patients with CAP and a total of 73 pathogens were detected. The leading organism was S.pneumoniae (n= 32, 25%), followed by H.influenzae and M.pneumoniae (n= 9, 7%), gram-negative bacilli (n= 10, 7.8%), M.catarrhalis (n= 6, 4.7%), C.pneumoniae (n= 4, 3.2%), L.pneumophila (n= 2, 1.6%) and Staphylococcus aureus (n= 1, 1.4%). Infection with atypical pathogens were detected in 15 (11.7%), and mixed infections in 14 (10.9%) patients. The detection rate of microorganisms (S.pneumoniae, H.influenzae, M.catarrhalis, C.pneumoniae, L.pneumophilia, M.pneumoniae) searched by M-PCR/RLBH method was 41.4% (53/128), while those microorganisms were detected in 23.4% (30/128) of the patients by conventional methods, representing a significant difference (p< 0.05). It was concluded that M-PCR/RLBH method supplemented the determination of bacterial etiology in CAP cases by increasing the rate of detection from 23.4% to 41.4%. The results indicated that empirical treatment of CAP should primarily include antibiotics against S.pneumoniae, M.pneumoniae and H.influenzae in our region.