Iatrogenic botulism cases after gastric and axillary application of botulinum toxin and review of literature

INTRODUCTION

Iatrogenic botulism is a rare, serious disease that progresses with descending paralysis and develops after cosmetic or therapeutic botulinum toxin-A (BoNT-A) application.

CASE PRESENTATIONS

In this case series; six cases of iatrogenic botulism followed up in our center are presented. Four of these developed after gastric BoNT-A and two after axillary BoNT-A application.

RESULTS

The most important cause for the disease was the use of unlicensed products and high-dose toxin applications. The first symptoms were blurred vision, double vision, difficulty in swallowing, and hoarseness. Symptoms appeared within 4-10 days after the application of BoNT-A. Symptoms progressed in the course of descending paralysis in the following days with fatigue, weakness in extremities and respiratory distress. Diagnosis was based on patient history and clinical findings. The main principles of foodborne botulism therapy were applied in the treatment of iatrogenic botulism. If clinical worsening continued, regardless of the time elapsed after BoNT-A application, the use of botulinum antitoxin made a significant contribution to clinical improvement and was recommended.

CONCLUSIONS

Routine and new indications for BoNT-A usage are increasing and, as a result, cases of iatrogenic botulism will be encountered more frequently. Physicians should be alert for iatrogenic botulism in the follow-up after BoNT-A applications and in the differential diagnosis of neurological diseases that are presented with similar findings.

ANTIBIOTIC MANAGEMENT PROGRAM IN A TERTIARY INTENSIVE CARE UNIT: INVESTIGATION OF THE EFFECTS OF A CARBAPENEM-RESTRICTED PERIOD ON CLINICAL AND LABORATORY PARAMETERS AND COSTS OF INFECTIONS

OBJECTIVES

The aim of this study was to investigate the effects of the carbapenem-restricted antimicrobial stewardship program (ASP) on changes in the resistance profiles of infectious agents, the amount of antibiotics used, length of stay in the intensive care unit (ICU), mortality and costs.

MATERIALS AND METHODS

The patients hospitalized in ICU between July 1, 2020 - May 1, 2021 were included the study. The study was divided in to two different periods, carbapenem not-restricted period (CNRP) and carbapenem restricted period (CRP). During CNRP, carbapenem were used by any restriction, and in CRP, the alternative antibiotics to carbapenems were preferred during infection. The Defined Daily Dose (DDD)-100 Patient Day (PD) methodology was used to calculate the antibiotic consumption.

RESULTS

Of the 572 patients included in the study, 62.2% of the patients were male, mean age was 70.5 years. In the blood culture the most frequently gram negative agent was A.baumannii (25%). A. baumannii bloodstream infections with MDR, XDR was significantly different between the two periods (CNRP: 95.6% (22), CRP: 66.6%(8) p=0.04). A gradual decrease in the incidence density and rate of nosocomial infection was noted (p=0.06). During the study, a significant decrease in meropenem consumption was detected between the two periods (CNRP-CRP: 21.19-6.37 DDD/100 PD p=0.007). ASP provided a 8600 USD of antibiotic cost savings and a total of 14% patient cost savings (p<0.05) per patient.

CONCLUSION

We believe that combining an effective ASP with a comprehensive infection control program will mitigate the emergence of antimicrobial-resistant bacteria.

Point prevalence of antibiotic usage in major referral hospital in Turkey

INTRODUCTION

The most important and undesirable consequence of inappropriate antibiotic use is the spread of antibiotic resistance, increased adverse effects, increased mortality and healthcare costs. We aimed to assess antibiotic usage characteristics in inpatient setting in our center.

MATERIALS AND METHODS

A one-day, single center point-prevalence study was carried out on June 9th 2021, in Ankara City Hospital in Turkey. Data of antibiotic consumption, appropriateness of usage and predictors of inappropriate use in adult patients were evaluated.

RESULTS

Out of 2640 adult patients, 893 (33.8%) were receiving at least one antibiotic. A total of 1212 antibiotic prescriptions with an average of 1.44±0.64 were found. Antibiotics were most commonly used for therapeutic purpose (84.7%), followed by surgical prophylaxis (11.6%). Majority of therapeutically used antibiotics were empirical (67.9%). Infectious diseases consultation was present in 68.3% with a compliance rate of 95.7%. Rate of inappropriate use was 20%. The most frequent cause of inappropriateness was unnecessary use (52.5%). Most commonly and most inappropriately used antibiotics were carbapenems (17.5%) and first generation cephalosporins (38.7%), respectively. Most of the inappropriateness observed in first-generation cephalosporins was due to inappropriate longer surgical prophylaxis. While age is an independent risk factor for inappropriate antibiotic use (p = 0.042), COVID-19 unit admission, use for therapeutic purpose and infectious diseases consultation were protective factors (p<0.001, p<0.001, p<0.001).

CONCLUSION

Rate of inappropriate use was low, but inappropriate surgical prophylaxis remains an important problem in surgical units. There is a considerable need to implement an antimicrobial stewardship program that focuses on surgical prophylaxis practices.

Impact of Inflammation-Related Genes on COVID-19: Prospective Study at Turkish Cohort

The pandemic coronavirus disease 2019 (COVID-19) has caused a high mortality rate and poses a significant threat to the population. The disease may progress with mild symptoms or may cause the need for intensive care, depending on many factors. In this study, it was aimed to determine if there is a tendency due to genetic factors in COVID-19 patients. Ninety-four of 188 patients with mild clinical and 94 with severe clinical symptoms were included in the study. The targeted panel including coagulopathy (F2, F5), viral invasion (ACE2), and inflammation (CXCL8, IFNAR2, IFNL4, IL10, IL2, IL6, IRF7, TLR3, TLR7, TNF) related genes was performed sequenced by the next generation sequencing (NGS). The variants found were classified and univariate analyses were performed to select candidate variables for logistic model. Risk factors and variants were compared. It was revealed that the presence of 2 or more risk factors caused the disease to progress severely (p < 0.001). Heterozygous IRF7:c.1357-23dup variant had a 2.5 times higher risk for mild disease compared to severe disease. Other variants were found to be more significant in mild disease. Since polymorphic variants were not evaluated in the literature, the findings of our study could not be compared with the literature. However, as variants that may be effective in the severity of infections may differ according to ethnicity. This study has the feature of being a guide for subsequent studies to be carried out especially in Turkish population. Clinical course of the COVID-19 is likely to depend on a variety of risk factors, including age, sex, clinical status, immunology and genetic factors.

BNT162b2 or CoronaVac as the Third Dose against Omicron: Neutralizing Antibody Responses among Transplant Recipients Who Had Received Two Doses of CoronaVac

We evaluated neutralizing antibodies against the Omicron variant and Anti-Spike IgG response in solid organ (SOT) or hematopoietic stem cell (HSTC) recipients after a third dose of BNT162b2 (BNT) or CoronaVac (CV) following two doses of CV. In total, 95 participants underwent SOT (n = 62; 44 liver, 18 kidney) or HSCT (n = 27; 5 allogeneic, 22 autologous) were included from five centers in Turkey. The median time between third doses and serum sampling was 154 days (range between 15 to 381). The vaccine-induced antibody responses of both neutralizing antibodies and Anti-Spike IgGs were assessed by plaque neutralizing assay and immunoassay, respectively. Neutralizing antibody and Anti-Spike IgG levels were significantly higher in transplant patients receiving BNT compared to those receiving CV (Geometric mean (GMT):26.76 vs. 10.89; p = 0.03 and 2116 Au/mL vs. 172.1 Au/mL; p < 0.001). Solid organ transplantation recipients, particularly liver transplant recipients, showed lower antibody levels than HSCT recipients. Thus, among HSCT recipients, the GMT after BNT was 91.29 and it was 15.81 in the SOT group (p < 0.001). In SOT, antibody levels after BNT in kidney transplantation recipients were significantly higher than those in liver transplantation recipients (GMT: 48.32 vs. 11.72) (p < 0.001). Moreover, the neutralizing antibody levels after CV were very low (GMT: 10.81) in kidney transplantation recipients and below the detection limit (<10) in liver transplant recipients. This study highlights the superiority of BNT responses against Omicron as a third dose among transplant recipients after two doses of CV. The lack of neutralizing antibodies against Omicron after CV in liver transplant recipients should be taken into consideration, particularly in countries where inactivated vaccines are available in addition to mRNA vaccines.

Effect of 2 Different High-Dose Methylprednisolone Treatments on Clinical Outcomes in Severe COVID-19 Patients

OBJECTIVE

The present study aimed to evaluate and compare the use of 2 different high-dose methylprednisolone posology in treating severe coronavirus disease 2019 pneumonia regarding mortality and recovery time between themselves and against steroidal/ non-steroidal treatment.

MATERIAL AND METHODS

Severe coronavirus disease 2019 patients followed up between March 2020 and January 2021 were included. The steroid-free treatment protocol was applied before August 2020 (non-pulse group) and a treatment algorithm containing normal and high doses of methylprednisolone was applied after August 2020 (pulse group). Patients with clinical deterioration under the normal dose of methylprednisolone were administered 250 mg or 1000 mg of methylprednisolone for 3 days. We compared the pulse and non-pulse groups, in addition to pulse subgroups with each other, for clinical outcomes.

RESULTS

A total of 138 patients were included, including 36 patients in the non-pulse group and 102 in the pulse group. In the pulse group, 70 patients received 1000 mg/day and 32 received 250 mg/day of high-dose methylprednisolone therapy. In the comparison of pulse and non-pulse patient groups, mortality rate was lower in the pulse group (P < .001), and the time to discharge without oxygen support was shorter. Although the patients in the 250 mg subgroup were older, there was no difference between the 250 mg and 1000 mg subgroups in terms of end of oxygen requirement, discharge with oxygen support, and mortality. In addition, the required time to reach the oxygen-free period in patients discharged without oxygen support was similar in the 2 subgroups, and the majority of patients in both subgroups reached the oxygen-free period on the 20th day after initiating methylprednisolone.

CONCLUSION

Since there was no difference in clinical improvement between the use of 250 mg or 1000 mg methylprednisolone in patients with severe coronavirus disease 2019 infection, 1000 mg methylprednisolone was not required.

Acute severe hepatitis outbreak in children: A perfect storm. What do we know, and what questions remain?

During the first half of 2022, the World Health Organization reported an outbreak of acute severe hepatitis of unknown aetiology (AS-Hep-UA) in children, following initial alerts from the United Kingdom (UK) where a cluster of cases was first observed in previously well children aged <6 years. Sporadic cases were then reported across Europe and worldwide, although in most countries incidence did not increase above the expected baseline. There were no consistent epidemiological links between cases, and microbiological investigations ruled out known infectious causes of hepatitis. In this review, we explore the evidence for the role of viral infection, superimposed on a specific host genetic background, as a trigger for liver pathology. This hypothesis is based on a high prevalence of Human Adenovirus (HAdV) 41F in affected children, together with metagenomic evidence of adeno-associated virus (Adeno-associated viruses)-2, which is a putative trigger for an immune-mediated liver injury. Roles for superantigen-mediated pathology have also been explored, with a focus on the potential contribution of SARS-CoV-2 infection. Affected children also had a high frequency of the MHC allele HLA-DRB1*04:01, supporting an immunological predisposition, and may have been vulnerable to viral coinfections due to disruption in normal patterns of exposure and immunity as a result of population lockdowns during the COVID-19 pandemic. We discuss areas of ongoing uncertainty, and highlight the need for ongoing scrutiny to inform clinical and public health interventions for this outbreak and for others that may evolve in future.

Prognostic utility of pulmonary artery and ascending aorta diameters derived from computed tomography in COVID-19 patients

Aim

Chest computed tomography (CT) imaging plays a diagnostic and prognostic role in Coronavirus disease 2019 (COVID‐19) patients. This study aimed to investigate and compare predictive capacity of main pulmonary artery diameter (MPA), ascending aorta diameter (AAo), and MPA‐to‐AAo ratio to determine in‐hospital mortality in COVID‐19 patients.

Materials and methods

This retrospective study included 255 hospitalized severe or critical COVID‐19 patients. MPA was measured at the level of pulmonary artery bifurcation perpendicular to the direction of the vessel through transverse axial images and AAo was measured by using the same CT slice at its maximal diameter. MPA‐to‐AAo ratio was calculated by division of MPA to AAo.

Results

Multivariate logistic regression model yielded MPA ≥29.15 mm (OR: 4.95, 95% CI: 2.01–12.2, p = 0.001), MPA (OR: 1.28, 95% CI: 1.13–1.46, p < 0.001), AAo (OR: .90, 95% CI: .81–.99, p = 0.040), and MPA‐to‐AAo ratio ≥.82 (OR: 4.67, 95% CI: 1.86–11.7, p = 0.001) as independent predictors of in‐hospital mortality. Time‐dependent multivariate Cox‐proportion regression model demonstrated MPA ≥29.15 mm (HR: 1.96, 95% CI: 1.03–3.90, p = 0.047) and MPA (HR: 1.08, 95% CI: 1.01–1.17, p = 0.048) as independent predictors of in‐hospital mortality, whereas AAo and MPA‐to‐AAo ratio did not reach statistical significance.

Conclusion

Pulmonary artery enlargement strongly predicts in‐hospital mortality in hospitalized COVID‐19 patients. MPA, which can be calculated easily from chest CT imaging, can be beneficial in the prognostication of these patients.

Adherence to Nucleoside/Nucleotide Analogue Treatment in Patients with Chronic Hepatitis B

BACKGROUND

Adherence to medication is an important aspect of preventing drug resistance and treatment failure in patients receiving nucleos(t)ide analogues for chronic hepatitis B.

AIMS

To assess adherence to nucleoside/nucleotide analogues in chronic hepatitis B treatment and to determine factors associated with non-adherence.

STUDY DESIGN

Cross-sectional study.

METHODS

The study enrolled 85 chronic hepatitis B patients who had been receiving nucleoside/nucleotide analogues for ≥3 months. A questionnaire was completed by patients themselves, and adherence was evaluated based on patients' self-reporting. The use of at least 95% of the drugs in the previous month was considered as adequate adherence.

RESULTS

Adherence was adequate in 82.4% of patients. Female gender (p=0.003), unemployment (p=0.041) and lower monthly family income (p=0.001) were related to lower adherence. Better adherence was significantly linked to adequate basic knowledge regarding chronic hepatitis B (p=0.049), longer treatment duration than 12 months (p<0.001), previous use of other medications for chronic hepatitis B (p=0.014) and regular follow-up by the same physician (p<0.001).

CONCLUSION

Counselling patients about their disease state and the consequences of non-adherence is an important intervention for enhancing adherence. Naïve patients should be followed up more frequently to reinforce adherence.

Unique Case of Pseudomembranous Aspergillus Tracheobronchitis: Tracheal Perforation and Horner's Syndrome

Pseudomembranous aspergillus tracheobronchitis is an uncommon form of invasive pulmonary aspergillosis, and it is generally seen in immunocompromised patients. We report about a mildly immunocompromised case with pseudomembranous aspergillus tracheobronchitis, which caused tracheal perforation, and Horner's syndrome. A 44-year-old female with uncontrolled diabetes mellitus, complaining of fever and dyspnea, was admitted to the hospital. She was hospitalized with community-acquired pneumonia and diabetic ketoacidosis. Insulin infusion and empirical antibiotics were firstly commenced. Bronchoscopy showed left vocal cord paralysis with extensive whitish exudative membranes covering the trachea and the main bronchi. Liposomal amphotericin B was added due to the probability of fungal etiology. Mucosal biopsy revealed aspergillus species. Second bronchoscopic examination demonstrated a large perforation in the tracheobronchial system. Despite all treatments, respiratory failure developed on the 25th day and the patient died within 2 days. Pseudomembranous aspergillus tracheobronchitis is fatal in about 78 % of all cases despite appropriate therapy. Early diagnosis and efficient antifungal therapy may improve the prognosis.