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External Contamination and Decontamination Techniques

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Contamination; the transmission of dangerous substances (chemical, biological, radiological and nuclear agents) to the human body, objects and the environment. The subject of this paper is contamination with radioactive materials. Contaminating radioactive substances may be in solid, liquid, gas and aerosol form and may enter the human body in different ways (skin, eyes, lungs, digestive tract, injection route). The most common form of external contamination in the human body is through the percutaneous (skin).

External External Dose Exposure ”means the person's external irradiation without being contaminated with radiation sources. The difference in contamination of a patient exposed to radioactive irradiation is that there is no physical contact or contamination with any radioactive material and that it has no harmful effects on the environment. External contamination is mentioned in the presence of physical contact with radioactive material in the human body, articles or environment.

Sources of radioactive external contamination can be summarized as follows (1):

- Accidents in medical treatment units (radiotherapy, nuclear medicine),

- Nuclear reactors,

- Industrial radiation,

- Lost / stolen medical / industrial radioactive sources,

- Accidents during storage, transportation,

- Terrorism,

- Dirty bomb,

- Attack on nuclear facilities, sabotage,

- Nuclear weapons.

The most common radioactive contaminants are alpha and beta emitters. Gamma-ray emitters cause the whole body irradiation. Beta emitters can cause skin burns and scars. Alpha emitters cannot penetrate the epithelium.

The devices used for detecting and measuring radiation to determine contamination and the amount of exposure are:

- Geiger Mller (GM) meter: Surface contamination meter. It provides a radiation measurement of radioactive material on a surface, a device suitable for measuring open radioactive material. It is used for soil contamination measurement, body contamination screening and routine workplace screening. Different probes are used to measure different types of radiation.

- Ion chamber.

- Personal dosimeters.

- Film dosimeter.

- Pen dosimeter (analog & digital).

Decontamination; to ensure the safety of people, goods and the environment by removing or inactivating chemical, biological, radiological and nuclear agents from the human body, objects and environment.

Decontamination has two main purposes:

1. To reduce the dose to which the patient will be exposed by removing harmful substances from the skin and thus the severity of the effects of the radioactive agent,

2. Protecting healthy people (emergency response teams, health teams, etc.) by preventing secondary exposure.

Decontamination in the first few minutes after exposure is the most effective way of protecting the patient, and it should not be ignored that the later decontamination process may benefit the patient by reducing the dose the patient is exposed to and protect healthy people from secondary exposure.

The first rule of controlling radioactive contamination is to limit the spread of the material. This is usually achieved by controlling the entrances and exits to the contaminated area, the use of appropriate protective clothing, minimization of the amount of radioactive material emitted in the air, and personnel monitoring (2).

Patients contaminated with radiological material are generally considered not to pose a potential risk to health personnel. Therefore, medical or surgical treatment should never be postponed. The first thing to do is to take life-saving measures independent of contamination.

As a result of nuclear terrorist attacks, many contaminated patients are encountered. Most of them are contaminated, not injured. Decontamination is the medical management of the panic and informing the public. These people should not be allowed to apply to hospital emergency services at the same time and lock the system. A triage area should be established outside the emergency room.

Radiation Measurement in Workplace Control

After the completion of the daily work in the radiopharmacy laboratory are:

- Materials such as injector casing, lead bottle protector, forceps are measured with GM counter for contamination. No contamination; these materials are removed from the closet for reuse. If contamination occurs; the lead is left behind for half-life or cleaning and measuring is done until the end of contamination.

- Tc-99m milking bottle is taken from working area like laminar flow / fume hood and left behind lead.

- Using GM, laminar flow / fume cupboard walls and the entire area are measured.

Decontamination Steps (2,3)

The first step of decontamination; decontamination. Everyone should be decontaminated, whether injured or not, if exposure is suspected.

The first principle for effective decontamination is to perform decontamination as soon as possible. Early decontamination is very important for chemical agents, especially those in liquid form. Since the absorption amount of liquid agents changes in direct proportion with the contact time, the removal of the agent in a short time decreases the penetration and absorption and minimizes the effects.

- Firstly, after taking life-saving measures and stabilizing the patient clinically, the first thing to do is to remove the people from the contaminated area. Contamination control should be performed by radiation measurement. Special transport measures should be taken for contaminated patients and a “decontamination area” should be established. In general, outdoors, the opposite direction of the direction of the wind blow is preferred, but in cases where the amount of agent in the air increases (continuation of the attack, etc.), closed areas may also be preferred. Radiation detection (in and out) should be performed in this area.

- Once the person has been taken to a safe place, clothing and accessories (jewelry, watch, clasp, etc.) are completely removed (cut if possible) and hair and skin decontamination is performed. Multiple shower systems can be installed for the injured. The removed clothing and accessories are placed in a medical waste bag, labeled and stored.

- Even simply removing clothes or combing the hair usually reduces the amount of agent carried by the patient to a large extent, and in some cases even provides the necessary decontamination.

- Secondary exposure to the liquid or gaseous agent in the patient's clothing and hair may cause contamination of the surrounding healthy individuals. It is therefore important that persons and health personnel in close contact with the contaminated person wear protective equipment (masks, clothing, pair of gloves, etc.).

- A decontamination area should also be established for health personnel.

- A place where people can rest after decontamination should be provided.

Decontamination Methods

1. Physical removal.

2. Detoxification.

The first and most effective decontamination is the physical removal of the chemical agent. Detoxification is the second target, but not always possible.

Decontamination Materials

- Gloves,

- Bag,

- Decontamination drugs,

- Absorbent paper, paper towel,

- Shoe covers.

Radioactive Area Decontamination

- The radiation protection officer shall be informed and supervised,

- Radioactive area is determined by measuring with radiation monitor,

- Immediately absorbing paper is placed on the contamination area to prevent its spreading, its surroundings are determined and passages are prevented,

- Absorbing paper is removed, paper towel is wiped from outside to inside and re-measured,

- Dry area is wiped and dried from outside to inside with towel moistened with decontamination drugs,

- Cleaning is continued until the radioactivity of the area is less than 2-3 times the background count.

Wound Decontamination

In the event of exposure to most radioactive agents, removal of clothing from the wound provides a substantial decontamination, no other method is necessary. However, additional measures may be required. During decontamination, all bandages that are suspected of contamination are removed and the wounds are washed with isotonic solution or water. If there is bleeding after decontamination, the wound is bandaged again. During decontamination, the skin should not be rubbed; rubbing of the skin accelerates the penetration of the agent to the skin (2,3).

Personnel Decontamination

- The bottle of radioactive material breaks, spills and so on. In this case, everyone in the room proceeds to the door and calls for help,

- The radiation protection officer is informed and decontamination is carried out under his supervision,

- Everybody in the room is measured by using radiation monitor.

- Contaminated clothes are placed in plastic bags and waste is applied,

- Radiation measurement is done again, if contamination continues, showering is provided,

- Skin; Wash with mild soap and plenty of water, no hard brush or irritant soap,

- Body; areas are marked and quickly entered into the shower,

- Eye; rinse with plenty of water and saline, take precautions for irritation,

- Hair; It is cleaned with a mild detergent and care is taken to the eyes, ears and mouth area when washing.

Patient Management and Decontamination (2,3)

- Carefully take off the clothes and personal belongings of the injured, bag them, store them safely (contamination is reduced by 95%).

- Take biological samples from the injured (nasal smear) if possible.

- Treat foreign objects as if they were radioactive material until otherwise instructed.

- Decontamination priority:

a. First wounds, then solid skin.

b. Start at the most contaminated area.

- Replace the outer gloves after each injury.

- To minimize contamination, shave mustaches and beards with the aid of an electric machine.

- Cover non-contaminated wounds with waterproof material.

- Contaminated wounds:

a. Irrigate with sterile material.

b. After consultation with a specialist, remove contaminated debridements and store in a safe place.

- Avoid aggressive intervention.

- Change the cleaning agent frequently.

- Decontaminate scalp and intact skin with soap and water.

- Cover cleaned and dressed wounds with waterproof material.

- Additional measures may be taken for sweating the injured hands and feet (surgical gloves).

- Detect and measure after decontamination.

- Accumulate the medical devices used in sealed bags and special containers.

- Always use stretchers in the dirty area.

decontaminant for

An ideal decontaminant should be capable of removing or neutralizing or detoxifying all known agents from the human body, articles and environment. During decontamination, responsible personnel should wear protective clothing.

Properties of Ideal Decontaminant (4,5,6)

- Effective against chemical, biological, radiological and nuclear agents, toxic industrial substances, toxic industrial chemicals and new threats,

- Neutralizing all chemical and biological agents,

- Safe to use on skin, eyes and wounds,

- Able to clean the agent under the skin,

- Easy to apply,

- Ready to use,

- Fast action over a wide temperature range,

- No toxic product,

- Can be stored for a long time,

- Accessibility,

- Not to increase percutaneous absorption of the agent,

- No irritant,

- Hypoallergenic,

- It must be easily destroyed.

Substances recommended for skin decontamination:

- Water and soap,

- Dry decontaminants,

- Liquid decontaminants,

- Chemical decontaminants.

Water and soap: Liquid decontaminants are best suited for decontamination of large or uneven surfaces. The most suitable decontaminant for decontamination of health centers and equipment is soapy water. Washing using high amounts of soapy water removes the agent by hydrolysis and is also an extremely inexpensive method. It is also a convenient and practical method for emergency decontamination.

One liter of water, five milliliters of soap by putting; For decontamination suitable liquid is prepared (Approximately 1 bucket of water 3 spray). Depending on the amount of water used for decontamination, it is collected in tanks, neutralized or directly supplied to the sewer.

Dry decontaminants: All substances capable of absorbing and drying liquid agents and then removing them by means of wiping or brushing without damaging the skin can be used for decontamination of liquid agents. Clean sand, clay, baking soda, Fuller soil, dry or wet wipes are applied to the liquid agent, after absorbing the agent, it is removed from the skin. Maximum effectiveness is achieved if the absorbent is applied within the first 4 minutes after exposure. However, dry decontaminants are not suitable for wound decontamination.

Liquid decontaminants: Liquid decontaminants are available to rapidly decontaminate radioactive contamination. It can be applied directly to leather, clothing, all surfaces, plastic and glass materials, laboratory equipment. It removes radioactive particles, the resulting composition is non-toxic and is removed from the contaminated area by washing with water. It is not used for wound and eye decontamination. After application to the contaminated area, it is dried with dry and clean paper towels.

Chemical decontaminants: 0.5% sodium or calcium hypochlorite solution is used for skin decontamination and 5% for equipment decontamination. The solution should be prepared before use, should not be prepared and kept in advance. The pH of the solution should be at alkaline pH (pH 10-11). Hypochlorite solutions (bleach) are not suitable for eye and wound decontamination and may cause corneal damage and adhesions.

Post-decontamination procedures

- Record in record format,

- Investigation of the causes of contamination,

- Take necessary measures to prevent it from recurring.

Result

It is essential that health personnel first protect themselves. Protective clothing is a must. Decontamination is not a simple process. It requires a high number of staff, materials and effort. Effective decontamination has two basic principles: the shortest time and the most appropriate method. If an attack is suspected, everyone is considered contaminated and decontaminated, whether injured or not, until proven otherwise. During skin decontamination, the skin should not be rubbed, it accelerates the penetration of the rubbing agent into the skin.


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Endotracheal Aspirate Culture Used to Diagnose Ventilator-Related Pneumonia Comparison of Mini-BAL Culture

SUMMARY

The aim of this study was to compare the culture results of endotracheal aspirate (ETA) and mini-bronchoalveolar lavage (BAL) methods, which are used to quickly and accurately identify the possible cause of ventilator-associated pneumonia (VAP), especially in intensive care units. Thirty (32.2%) patients who developed VAP from 92 patients who were followed up on mechanical ventilator between June 2010 and June 2011 in our intensive care unit were included in the study. The diagnosis of VAP was made clinically and radiologically; The patients were evaluated with clinical pulmonary infection score (CPIS) scoring system and CPIS value> 6 was considered in the diagnosis. ETA and mini-BAL samples were collected before VAP patients; In addition, two blood cultures and urine cultures were obtained from the patients. Microbiological evaluation and identification were performed using conventional methods and the Phoenix 100 automated system (BD Diagnostic Systems, USA). Bacterial growth of> 10,000 cfu / ml for BAL and> 100,000 cfu / ml for ETA was considered significant in the evaluation of quantitative cultures. The mean age of patients who developed VAP (n = 30; 18 males) and non-developed (n = 62; 39 males) during mechanical ventilation; 68.23 ± 16.19 and 52.16 ± 10.41 years; the duration of mechanical ventilation was as follows; 29.57 ± 15.78 and 12.11 ± 6.01 days. When examined by multivariate logistic regression analysis; advanced age (p <0.001) and duration of mechanical ventilation (p <0.001) were independent risk factors for VAP development. There was a statistically significant difference between CPIS values ​​of patients with and without VAP (6.8 ± 1.15 and 2.71 ± 1.06 points, respectively; p <0.001). Accordingly, the use of a CPIS score was considered useful in the diagnosis of VAP in patients with mechanical ventilators. In our study, 16 strains (six Acinetobacter baumannii , three Pseudomonas aeruginosa , one Klebsiella pneumoniae , six Staphylococcus aureus ) and 30 strains (16 A.baumannii , six P.aeruginosa , four Klebsiella ) from ETA cultures of 30 patients with VAP pneumoniae , two, Escherichia coli , six S.aureus ). Contamination rate was 27% (8/30) in ETA cultures, while no contamination was observed in mini-BAL cultures. There was no growth in 20% (6/30) of ETA cultures and 7% (2/30) of mini-BAL cultures. Pathogenic bacterial growth (six A.baumannii , one K.pneumoniae ) was detected in 7 (87.5%) of the mini-BAL cultures from eight patients with ETA contamination. Similarly, pathogenic bacteria (two E.coli , two K.pneumoniae , one P.aeruginosa ) were isolated from mini-BAL cultures of 5 (83%) of six patients who had no growth in ETA culture. No statistical correlation was found between the culture results of the samples taken by ETA and mini-BAL methods (p = 0.464). The agreement between the culture results of the samples taken by ETA and mini-BAL methods was found to be 50%. In conclusion, due to the increased risk of contamination in ETA culture methods and higher isolation rate from mini-BAL samples, it was concluded that mini-BAL sampling would be more suitable for EAP instead of ETA microorganisms.

Key words: Ventilator-associated pneumonia; bronchoalveolar lavage; mini-BAL, endotracheal aspirate; culture.

ABSTRACT

The objective of this study was to compare the results of cultures obtained by mini-bronchoalveolar lavage (BAL) and endotracheal aspiration (ETA) techniques, used for rapid and accurate determination of pathogens causing ventilator-associated pneumonia (VAP) in intensive care units. Of the 92 patients on mechanical ventilation followed by the emergency care unit of our hospital between June 2010 and June 2011, 30 (32.2%) patients were diagnosed as VAP and they were included in this study. VAP diagnosis was based on clinical and radiological findings. Clinical pulmonary infection score (CPIS) of> 6 was accepted as the clinical criteria of VAP. Initially ETA samples were collected from the patients followed by mini-BAL sampling 15 minutes later, together with urine and two blood cultures. Microbiological evaluation and identification were performed by conventional methods and Phoenix 100 (BD Diagnostic Systems, USA) automated system. In quantitative culture analysis,> 10,000 cfu / ml for BAL and> 100,000 cfu / ml for ETA were accepted as positive results. The mean ages of VAP-developed (n = 30; 18 were male) and nondeveloped (n = 62; 39 were male) patients were 68.23 ± 16.19 and 52.16 ± 10.41 years, respectively, and the mean durations of mechanical ventilation were 29.57 ± 15.78 and 12.11 ± 6.01 days, respectively. Multivariate logistic regression analysis showed that older age (p <0.001) and duration of mechanical ventilation (p <0.001) were independent risk factors for VAP development. VAP and not (6.8 ± 1.15 and 2.71 ± 1.06, respectively; p <0.001). The use of CPIS for VAP diagnosis has been found to be useful in patients on mechanical ventilation. In our study, a total of 16 strains (six A.baumannii , three P.aeruginosa , one K. pneumoniae , six S.aureus ) were isolated from ETA cultures, while 34 strains (16 A.baumannii , six P.aeruginosa , four K. pneumoniae , two E. coli , six S. aureus ) were isolated from mini-BAL cultures of 30 VAP patients. The contamination rate for ETA cultures was found as 27% (8/30), however there was no contamination in mini-BAL samples. The rates of negative cultures for ETA and mini-BAL were 20% (6/30) and 7% (2/30), respectively. Seven (87.5%) of the eight contaminated ETA samples, yielded pathogenic bacterial growth (six A.baumannii , one K. pneumoniae ) in mini-BAL samples. Similarly, of the six negative ETA samples, 5 (83%) yielded bacterial growth (two E. coli , two K. pneumoniae , one P. aeruginosa ) in mini-BAL samples. Statistical analysis with Spearman test indicated no positive correlation between the results of mini-BAL and ETA (p = 0.464), and the concordance between the results of these methods was found as 50%. It was used in the study of mini-BAL instead of ETA samples for the isolation of causative microorganisms of VAP.

Key words: Ventilator-associated pneumonia; bronchoalveolar lavage; mini-BAL; endotracheal aspirate; cultura.

Received Date: 14.11.2011 • Accepted Date: 13.03.2012

LOGIN

Ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours after intubation in a patient without invasive mechanical ventilation and without pneumonia during intubation 1 , 2 . Tracheal intubation and mechanical ventilation increase the incidence of pneumonia 7 to 21 times 3 .

The diagnosis of VAP is very difficult. Studies have shown that 50% of patients diagnosed with VAP clinically do not have VAP, whereas approximately 1/3 of patients with VAP cannot be diagnosed 4 . Diagnosis alone is not sufficient clinical evaluation, radiological methods, microscopic and microbiological examination of respiratory secretions are needed. The clinical pulmonary infection score (CPIS) may also contribute to the diagnosis of patients with VAP. In this scoring, the presence of CPIS> 6 increases the probability of pneumonia. One of the important criteria for the diagnosis of VAP is the diagnostic criteria of "Centers for Disease Control and Prevention (CDC)". In addition to all these diagnostic criteria, the diagnosis of patients with clinical suspicion of VAP should be supported by microbiological cultures. Respiratory tract samples are obtained by bronchoscopic and nonbronchoscopic methods. Today, nonbronchoscopic methods are preferred more because of its ease of use and less cost.

Microbiological examination of endotracheal aspirate (ETA) sample is the most commonly used method in the diagnosis 1 . Another method used for diagnosis is the examination of mini-bronchoalveolar lavage (BAL) sample. The most important advantage of this method is to minimize contamination with possible upper respiratory tract flora. The aim of this study was to compare the results of ETA and mini-BAL culture used to quickly and accurately identify the possible cause of VAP, especially in intensive care units.

Materials and Methods

Selection of Cases and Data Collection

Thirty patients (32.6%) diagnosed as VAP were included in this study from 92 patients who were followed up in mechanical ventilator between June 2010 and June 2011 in the internal medicine intensive care unit of our hospital. All patients who were seropositive to human immunodeficiency virus (HIV), who received immunosuppressive therapy, and who had radiotherapy and / or chemotherapy oncology, and who had mechanical ventilation for more than 48 hours were included in the study. The patients underwent a physical examination every day; Daily fever follow-up, daily leukocyte count and chest x-ray every three days. The amount and character of tracheobronchial secretion were also noted at the same time; mechanical ventilation times were recorded. Clinically diagnosed patients with VAP were evaluated with CPIS scoring system and CPIS was considered to be over 6. Antibiotic use of the patients was monitored before culture. ETA, mini-BAL, two blood cultures and urine cultures were obtained.

Clinically, VAP was defined by adding at least two of the following criteria to the newly detected infiltration or increase in existing infiltrative involvement on chest X-ray: (1) Fever (> 38.5 ° C) or hypothermia (<36 ° C), (2) Purulent tracheobronchial (3) leukocytosis (12,000 / µL) or leukopenia (4000 / µL). Pneumonia developed in the first four days in patients who underwent mechanical ventilation was defined as early-onset VAP and pneumonia developed in the fifth and subsequent days were defined as late-onset VAP.

Taking Samples

Collection of the ETA sample: Fourteen F sterile aspiration catheters ( Figure 1A ) were advanced through the endotracheal tube and further distal 2 cm. The tip of the aspiration probe was connected to the aspiration device. 5-10 ml of ETA was obtained in the aspirate tube 6 .

Picture 1

Mini-BAL removal: 10-15 minutes after ETA removal , a mini-BAL catheter (Combicath ® ) ( Figure 1B ) was advanced blindly through the endotracheal tube. When catheter progression stopped, the outer catheter was withdrawn and the inner catheter was advanced 2-3 cm further. 20 ml of saline was administered through the internal catheter. A sterile syringe was aspirated to obtain 1-3 ml of bronchoalveolar fluid.

Microbiological Methods

After the sample was vortexed for 1 minute, sheep blood agar (CCA), chocolate agar and EMB agar were added with 0.001 loop. CCA and chocolate agar were incubated for 48 hours in a CO 2 oven and EMB in an aerobic environment for 48 hours. Plates were checked after 24 hours and no growth was expected at the end of 48 hours. Gram staining was performed from the colonies. Bacteria were identified as gram-negative or gram-positive as a result of gram staining and evaluation of growth in culture plates. Species identification and antibiogram tests of the bacteria were performed using the Phoenix 100 automated system (BD Diagnostic Systems, USA). The colonies of single fallen bacteria on the blood agar were removed with sterile swabs and the McFarland was adjusted to turbidity of 0.5-0.6. Bacterial suspension prepared from gram-negative bacteria was placed into the device via the Phoenix NMIC / ID panel and gram-positive bacteria were placed into the device via the Phoenix PMIC / ID panel. Reading and evaluation procedures were performed automatically by the device.

The quantitative evaluation was performed as follows: The total number of colonies was multiplied by 1000 and the result was the number of bacteria per ml. If this number was over 10,000 for BAL and over 100,000 for ETA, the result was considered positive. The values ​​below were evaluated as oropharyngeal contamination. In addition, Corynebacterium spp., Group A beta-hemolytic streptococcus and Neisseriae spp. As it was found in normal throat flora, it was not defined as VAP agent and was considered as contamination.

Statistical Evaluation

After the data were transferred to the computer, SPSS 15.0 package program was analyzed. Frequency, percentage, mean, standard deviation, minimum and maximum values ​​were used as descriptive statistics. The difference between the groups with and without VIP in terms of age and duration of mechanical ventilation was compared with Student-t test and CPIS with Mann-Whitney U test. The chi-square test was used to compare the two groups in terms of gender. The effect of gender, age and duration of mechanical ventilation for VAP development was examined by multivariate logistic regression analysis. Spearman correlation was used to determine whether there was a correlation between ETA and mini-BAL in the VAP group. A p value of <0.05 was accepted for statistical significance.

RESULTS

In the intensive care unit (ICU), between June 2010 and June 2011 due to mechanical ventilation, 18 (60%) of the 30 patients who developed VAP were male and 12 (40%) were female; Of 62 patients who did not develop VAP, 39 (63%) were male and 23 (37%) were female. Table I presents the age, follow-up time and CPIS score characteristics of patients with and without VAP during mechanical ventilation.

Table I

Of the 30 patients diagnosed as VAP, 24 (80%) were mortal during the follow-up and treatment period; Six patients (20%) were discharged from the ICU after completion of their treatment. The rate of VAP development in internal ICU was 18.3 per 1000 ventilator days.

ETA and mini-BAL samples were taken in all 30 patients who developed VAP during mechanical ventilation. The reproduction results of these samples were shown in Table II . Mini-BAL cultures showed higher bacterial growth than ETA cultures; It was determined that contamination which was 27% in ETA cultures was not seen in mini-BAL cultures and Escherichia coli and more than one microorganism growth could not be detected in ETA culture in mini-BAL cultures.

Table II

Acinetobacter baumannii , Klebsiella pneumoniae growth was observed in 6 (75%), 1 (12.5%) of the mini-BAL cultures taken from eight patients whose endotracheal aspirate sample cultures were evaluated as contamination. In the ETA sample, E.coli was isolated in 2 (33%), K.pneumoniae in 2 (33%) and P. aeruginosa in 1 (17%) of six mini-BAL specimens without reproduction. In 1 (17%) sample, mini-BAL culture also showed no growth ( Table III ).

Table III

In the statistical analysis, the mean age (68.23 ± 16.19 years and 52.16 ± 10.41 years; p <0.001) and the duration of mechanical ventilation (29.57 ± 15.78 days and 12.11 ± 6.01 days, respectively; <0.001). When the effect of gender, age and mechanical ventilation duration for VAP development was examined by multivariate logistic regression analysis; It was found that gender was not a risk factor in the development of VAP, whereas mechanical ventilation time and patient age significantly increased the risk of developing VAP independently of each other and gender. OR = 1.205, 95% CI = 1.104-1.316 and p <0.001 for mechanical ventilation time, OR = 1.162, 95% CI = 1.074-1.258 and p <0.001 for age.

The results of Mann-Whitney U test revealed significant differences in CPIS scores (6.8 ± 1.15 and 2.71 ± 1.06, respectively) between the patients with and without VAP (p <0.01).

As a result of statistical evaluation with Spearman test, no significant correlation was found between the culture results of the samples taken by ETA and mini-BAL methods (p = 0.464); The agreement between the culture results of the samples taken by ETA and mini-BAL methods was found to be 50%.

DISCUSSION

VAP is the most important infection seen in patients undergoing mechanical ventilation in ICUs. According to the results of various studies, 28-85% of patients who underwent mechanical ventilation may develop VAP 2 , 7 , 8 , 9 , 10 , 11 , 12 . In our study, 30 (32.6%) of 92 patients who underwent mechanical ventilation developed VAP. This ratio was found to be compatible with other studies conducted in our country and in the world. In studies performed, 2.5-39 VAP development rate was found in 1000 ventilator days in patients who were connected to ventilator 2 , 3 , 8 , 13 , 14 . In our study, the rate of VAP development was found to be 18.3 per 1000 ventilator days, which was consistent with previous studies.

Advanced age is one of the important risk factors that increases the risk of nosocomial pneumonia 2-3 times 2 . Besides, it carries 1-3% risk increase for VAP development every day due to mechanical ventilator 15 . In the 16 studies of Gedik et al., The mean age of the patients who developed VAP was 56 years and the mean duration of mechanical ventilation was 20 days. In the study performed by Khilnani et al. 17 , mean age was 55.6 ± 16.17 years, mean mechanical ventilation time was 34.88 ± 32 days; In another study by Bacakoglu et al. 18 , the mean age was 63.9 ± 19 years and the mean duration of mechanical ventilation was 7.4 ± 6.3 days. In our study, the mean age of patients who developed VAP was 68.23 ± 16.19 years and the mean duration of mechanical ventilation was 29.57 ± 15.78 days. As a result of the multivariate logistic regression analysis of the data obtained in our study, patient age (p <0.001) and duration of mechanical ventilation (p <0.001) were determined as a risk factor for the development of VAP. a correlation was shown.

The most common cause of mortality among hospital-acquired infections is pneumonia. The rate of mortality in VAP cases varies between 24-76% 16 , 17 , 18 , 19 , 20 , 21 , 22 . In our study, the mortality rate was found to be 80% and this rate was higher than the other studies. This was thought to be due to the long mechanical ventilation periods and the advanced age of the patients. In addition, other underlying conditions, ICU stay and increased frequency of A.baumannii infection in ICU during this period may be other causes of mortality.

The major disadvantages of CPIS calculation used in the diagnosis of VAP are the differing interpretation of variables by clinicians and incorrect calculation of scoring 23 . The presence of CPIS above 6 increases the likelihood of pneumonia. In a study, the diagnosis of VAP; The sensitivity of CPIS ≥ 6 was 93% and the specificity was 100% 23 . However, some researchers have indicated that CPIS should be used in the evaluation and management of treatment 24 . Khilnani et al. 17 , mean CPIS score of patients diagnosed with VAP was 6.76 ± 1.67; Bacakoglu et al. 18 reported 7.2 ± 2.1 points. In our study, the mean CPIS score was 6.8 ± 1.15 points in patients with VAP and 2.71 ± 1.06 points in those who did not, and the difference between the two groups was significant (p <0.001). Based on these results, the use of CPIS score may be useful in the diagnosis of VAP in patients with mechanical ventilators. In a study, mini-BAL, bronchoscopic BAL, bronchoscopic brush culture results and CPIS values ​​of CPIS ≥ 6 patients were compared; The correlation between CPIS and mini-BAL was 80%, the correlation with bronchoscopic brush was 86%, and the correlation with bronchoscopic BAL was 76% 17 . In our study, the agreement between CPIS and ETA was 60% and the agreement between mini-BAL was 80%. However, in addition to all these diagnostic criteria, the diagnosis of patients with clinically suspected VAP should be supported by microbiological cultures.

Gram-negative bacteria are most frequently isolated as VAP agents in the studies 16 , 17 , 18 , 22 , 25 , 26 , 27 . In our study, it was observed that the most frequently isolated microorganisms were gram-negative bacteria. Khilnani et al. 17 reported that 88% of pathogenic microorganisms causing VAP were grown in mini-BAL culture and 68% in ETA culture. In our study, A.baumannii , P.aeruginosa and S.aureus (methicillin resistant or susceptible) isolation rates in mini-BAL and ETA cultures were as follows; 53% and 20%, 20% and 10%, 20% and 20% respectively ( Table II ). It was thought that the high A.baumannii ratio in our study may be due to ICU flora. Therefore, it is important to carry out surveillance studies in each hospital and in each ICU in the same hospital, to detect environmental contamination in these units and to determine their resistance profiles. Thus, effective empirical antibiotic therapy for an infection with high mortality can be determined.

Quantitative culture of mini-BAL ( protected telescoping catheter (PTC)) is used instead of bronchoscopic methods for the diagnosis of VAP especially in some centers because of the low level of contamination due to upper respiratory tract flora, not an invasive method and high specificity 26 , 28 . However, the most common method used for the diagnosis of VAP in centers without bronchoscopy is the quantitative culture of ETA. The most important disadvantage of this method is the high level of contamination due to upper respiratory tract flora 29 . In our study, oropharyngeal contamination was detected in 27% of ETA samples, while no contamination was observed in mini-BAL samples. Seven out of eight patients with contamination in the ETA specimen were found to have pathogen bacterial growth in the mini-BAL specimen culture ( Table III ). In the study of Fangio et al. 30 , the sensitivity and specificity of ETA quantitative cultures were reported as 89.5% and 66.7%, respectively. In contrast, Elatrous et al. 26 , when the cut-off value was 10 4 cfu / ml, the sensitivity and specificity of ETA quantitative culture were 92% and 85%, respectively; reported that when the evaluation threshold was taken as 10 5 cfu / ml, these rates were determined as 84% ​​and 90%, respectively. In our study, sensitivity and specificity values ​​of ETA and mini-BAL quantitative culture methods could not be determined due to lack of control group. The clinical and radiological diagnosis of VAP in this patient group led to this limitation.

In the studies, a strong agreement (77-88%) was observed between the results obtained with mini-BAL and bronchoscopic brush methods. 17 , 31 , 32 , 33 . In contrast, Khilnani et al. 17 reported that among the methods used to obtain distal airway specimens, ETA was the most unsuccessful in obtaining the correct specimen; Bacakoglu et al. 18 reported 67% agreement between ETA and mini-BAL. In our study, the agreement between ETA and mini-BAL was found as low as 50%.

Advantages of nonbronchoscopic methods include; less invasive, requiring less experienced personnel, affecting less oxygenation, continued ventilation and respiration during the procedure, less intracranial pressure increase and arrhythmia, less risk of contamination and less expensive 17 , 23 26 , 30 . Although Mini-BAL is a blinding method, it is quite compatible with the results obtained with bronchoscopic brush. Routine application of bronchoscopic methods in ICU patients is not possible in our country and other developing countries. Therefore, evaluation of nonbronchoscopic techniques is important. As a result, in our study, there was no significant correlation between ETA and mini-BAL culture methods, increased risk of contamination in ETA culture method and higher isolation rate from mini-BAL samples. It has been considered.


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URINARY TRACT INFECTIONS IN CHILDREN

Urinary tract infection (UTI) is one of the most common infections in childhood. It is the second most common cause of upper respiratory tract infections. It is the infection of any part of the urinary system (kidneys, ureters and bladder) with germs, especially bacteria.

The infection is called “cystitis se only if it is located in the bladder and iyel pyelonephritis sa if it reaches the kidney. In the first year of life, it is more common in boys, especially in uncircumcised babies, while the frequency increases in later years. It is generally seen in 3-7% of girls under 5 years of age and 1-2% in boys.

WHY IS URINARY TRACT INFECTION IMPORTANT IN CHILDREN?

Urinary tract infection is usually recurrent in childhood and often has an underlying urinary tract anomaly that facilitates the development of UTI. In addition, it may cause kidney damage and cause serious problems such as high blood pressure, pregnancy problems and chronic renal failure in long-term follow-up. The risk of developing kidney damage is higher in patients who develop at an early age (especially in infancy), who are treated late and have recurrent UTIs. For all these reasons, it is very important to define the first UTI, to treat it adequately and timely and to follow it up appropriately.

HOW DOES URINARY TRACT INFECTION IN CHILDREN?

Under normal conditions, urine is sterile and contains no microorganisms. The most common agent of UTI in children is intestinal bacteria and 80-90% is caused by bacteria called Escherichia Coli (E. coli). Less frequently, other bacteria and rarely viruses and fungi also cause UTI. Bacteria that settle and proliferate around the anal and genital area enter the urinary canal, called the urethra, first reach the bladder and then the kidney, and multiply there, causing infection. Less frequently, bacteria can come directly into the urinary tract through blood or infection of neighboring organs.

INCREASING THE RISK OF URINARY TRACT INFECTION IN CHILDREN

1-Newborns and babies are prone to UTI because their immune systems are not fully developed, especially in the first months of life.

2-Because the urethra is shorter in girls, germs reach the urinary tract more easily and UTI develops more easily.

3-In uncircumcised boys, especially in the first year of life, bacteria grow more easily under the foreskin and may pass to the urinary tract and cause infection.

4-Structural disorders of the urinary system disrupt the flow of urine to facilitate the development of UTI. The most common disorder is vesicoureteral reflux (VUR), which is called urinary escape from the bladder to the kidneys. In addition, urinary stenosis and many rare renal anomalies lead to the development of UTI. For this reason, renal disorders detected by ultrasonography performed in the womb should be followed up after birth.

5-Bladder emptying of the urinary disorders or urinary problems in children who hold the urine flow slows down the bacteria can not be sufficiently cleaned and UTI can develop easily. Constipation, which disrupts the emptying of the bladder due to the pressure of the intestines, is one of the reasons facilitating the development of UTI.

WHAT ARE THE SYMPTOMS OF URINARY TRACT INFECTION?

In infants under two years of age, the findings are not specific to the disease. UTI should be investigated in every baby with high fever. The baby's intermittent urination, crying while urinating, male baby's urine can not gush, the smell of urine to be warned families are signs. However, in addition to these, prolonged jaundice, tendency to sleep, decrease in movements, crying, moodiness, restlessness, loss of appetite, malnutrition, diarrhea, vomiting, and inability to gain weight constitute the UTI symptoms.

Older children may express their complaints. In urinary tract infection, ie cystitis, symptoms such as burning while urinating, frequent urination, urgent urination, bad smelling urine, incontinence, and bloody urination are observed. Infections involving the kidney are accompanied by symptoms such as fever, vomiting, side pain, and abdominal pain. These patients may also have complaints such as growth retardation and inability to gain weight.

HOW IS THE DIAGNOSIS OF URINARY TRACT INFECTION?

The presence of white cells and bacteria in the urine test may suggest UTI. The definitive diagnosis is made by the growth of bacteria in urine culture. For the urine culture, the beginning and end of the urine is thrown out and the mid-stream urine sample is taken in older children. In children and infants who have not yet been able to tell the urine, the most commonly used method is to connect the bladder after the necessary cleaning. As this method is highly likely to contaminate, the bag should be replaced frequently. In some cases, urine can be taken from the urethra with a urinary catheter or a needle under the umbilicus to enter the bladder. Urine specimens reach the laboratory immediately, preventing the possibility of contamination and providing a more reliable result.

HOW TO TREAT AND TREAT URINARY TRACT INFECTION?

Urinary tract infection is treated with appropriate antibiotics for 7-14 days. In addition to UTI treatment in children, it is very important to examine risky patients with various imaging methods and to apply preventive treatment in order to prevent the development of new infections. Renal ultrasonography is the most commonly used method for research purposes. If necessary, urinary cystography can be performed by attaching a catheter to the bladder for VUR detection. The scintigraphic examinations performed in the departments of Nuclear Medicine can be used to investigate the damage and functions of the kidney. Adequate fluid intake and hygiene as a preventive treatment, frequent emptying of the bladder, prevention of constipation, correction of voiding disorder, if any, and circumcision of boys are recommended. Apart from these precautions, some selected patients should be put on continuous preventive antibiotic treatment.

As a result, it can be ensured that the risk of kidney damage can be minimized by the good cooperation of the family and physician, the initiation of appropriate and timely treatment, and the necessary preventive measures by taking adequate precautions in the necessary patients.


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What is dysentery disease? What is bacillary dysentery?

Dysentery is an infectious and epidemic large bowel disease associated with diarrhea. Bacilli dysentery is spread as a result of human faecal contamination of water sources and foods. People suffering from bacillary dysentery should receive appropriate antibiotics and fluid-electrolyte supplements as well as easy-to-digest foods and plenty of water. So, what is Basilli dysentery?

Bacilli Dysentery; It is an acute gastrointestinal infection caused by Shigella species. Because human is the only source of active bacteria in nature, the disease is spread by human faecal contamination of fecal sources of water and food in society.

How is it transmitted?

Even a small number of Shigella group bacteria (only 10 bacteria) can cause the disease to occur. The disease is transmitted through contaminated water and nutrients. Fecal-oral spreading occurs rapidly in environments where cleaning conditions are inadequate, inadequate and safe domestic water is not available and hands are not washed. Waterborne outbreaks occur, especially when sewage is mixed with water. Transmission can also be person to person. It passes directly or indirectly from the patient or carrier by fecal-oral route.

What are the symptoms?

The onset of symptoms usually begins 2-4 days after oral ingestion of the microorganism, but may also extend up to a week. The disease usually lasts for a few days, but sometimes it can last for weeks. Shigella; It causes diarrhea by irritating the intestinal mucosa. Headache, nausea and vomiting, fever rapidly rising to 38 ° C, cramp-like abdominal pain, tenesmus (painful defecation) with bloody diarrhea begins. The stool may contain blood, mucus or pus. However, in one-third of cases, only watery stools may occur. In rare cases (young children), referral may occur. The healing process of the disease lasts 4-7 days.

How is it diagnosed?

Since the clinical picture caused by shigellas cannot be distinguished from other dysentery-like conditions, especially amoebic dysentery, the diagnosis is based on laboratory examination. Laboratory outcome is critical, especially in the direction of treatment (for the differentiation of antibiotic or antiparasitic drug administration). In addition to clinical findings, the diagnosis is made by the production of agents in culture made from stool samples taken from the patient. Antibiotic resistance should also be investigated.

The disease is spread by human faecal contamination of water resources and food in the community, and people living in these areas are most affected.

What is the treatment?

Appropriate antibiotic and liquid-electrolyte support, as well as easy to digest foods and plenty of water should be given. Sick persons should consult their physician as soon as possible.

What are the ways of protection?

There is no vaccine for the disease. Control of drinking and potable water, adapting living conditions to hygiene conditions and paying attention to hygiene rules are the basic protection measures. It is practically impossible to prevent the spread of the disease in the community, in the absence of an improved sewage system and safe drinking water. Therefore, national public health strategies should include improvement of sewerage systems, water and food hygiene, public education and the use of antibiotics.


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Blood Cultures and Clinical Importance

SUMMARY

Detection of microorganism in the patient's blood is very important not only for diagnosis but also for treatment and prognosis. Bacteria are present in the blood in three ways: temporary, intermittent or continuous. In order to make the most of the blood cultures in the clinic, timing, number of cultures, amount of blood, content of the culture medium and the method used are very important, starting with skin antisepsis. In addition, the patient's immune deficiency or presence of an intravascular catheter should be considered carefully. Not all positive blood cultures may be clinically relevant. In the interpretation of leather flora elements, it can sometimes be misleading to comment only on the number of cultures. Good communication between the clinician and the laboratory increases the usefulness of blood cultures.

Keywords: Blood cultures, Bacteremia

SUMMARY

Blood Cultures and Clinical Significance

The detection of a microorganism in the blood of a patient. Bacteria can persist in three manners in blood; transiently To provide a benefit from blood cultures, including skin antisepsis, timing and frequency of culture, amount of blood taken, content of culture and culture method used. In addition, the patient with immunodeficiency or intravascular catheter needs to be evaluated carefully. Every positive blood culture may not be clinically significant. In particular, in interpretation of skin flora elements, evaluation of the number of cultures taken into account. Good communication between the clinician and microbiology laboratory increases the usefulness of blood cultures.

Key Words: Blood Cultures, Bacteremia

Presence and Clinical Meaning of Bacteria in Blood

Detection of microorganism in the patient's blood is important not only for diagnosis but also for treatment and prognosis. It has been shown that the risk of death is 12 times higher in patients with positive blood culture during hospitalization than in patients with negative blood culture (1).

There are three forms of bacteria in the blood. This also reflects the path of the bacterium into the blood.

a. Transient bacteremia: Infected tissues, interventions, cystoscopy, tooth extraction, urethral dilatation, sigmoidoscopy, such as the removal of burns in the blood can be temporarily mixed bacteria. In this case, the amount of bacteria in the blood is very small and the duration of its presence in the blood is very short.

b. Intermittently: Generally, bacteria from tissue and organs with closed lesions (abscess, empyema) or diffuse infections (cellulitis, peritonitis, septic arthritis) first enter the lymphatic tract and occasionally into the blood.

c. Continuous: Endocarditis, intravascular infection foci, where there are infected catheters and separate from them in the early stages of infections such as typhoid fever, brucellosis. However, the source of microorganisms cannot be determined in 1/3 of bacteremia (2).

In order to make the most of the blood cultures in the clinic, the following points should be considered.

How to Get Blood Culture?

1. Hematological, biochemical, etc. Blood tests should not be taken when taking blood for tests such as. The risk of contamination increases with multi-purpose intake.

2. Each blood culture should be taken from a different vein. If the appropriate vein is not available for blood culture collection or catheter-induced sepsis is considered, then it can be removed from the catheter.

3. After the vein to be cultured is palpated, the skin is cleaned from the center to the periphery with 70% ethyl alcohol. Then 30 sec. 1-2% iodine tincture is applied. Excess iodine is removed with 70% alcohol. Poor cleansing of the skin results in coagulase negative staphylococci, Corynebacterium spp. and Propionibacterium spp. It is the most common reason for the growth of skin contaminants such as blood cultures.

4. It is preferable to work with sterile gloves for blood culture. A new set should be used if the first attempt at blood collection has failed.

5. Bottles with blood culture should be disinfected with alcohol or iodine tincture. Iodine tincture should not be used for septum cleaning of BACTEC bottles.

6. There is no need to change the needle at the tip of the syringe during blood culture collection. After the blood is placed in the culture flask, it is mixed by shaking gently to prevent clotting.

7. The blood culture request form must be written on which vein it was taken from, at what time it was taken and whether it was taken from the catheter (3-6).

When and how many blood cultures should be taken?

Ideally, the blood culture should be taken one hour before the fever rises. Usually this is not possible in practice. There was no optimal time for the second culture to be taken within 24 hours of the first culture uptake. This is often determined by the severity of antibiotic treatment (7).

In cases such as sepsis, meningitis, osteomyelitis, arthritis, pneumonia and pyelonephritis, blood cultures should be taken from two or three different veins within 15-20 minutes. In acute endocarditis, samples should be taken from three different veins within the first 1-2 hours. In subacute endocarditis, three samples should be taken at intervals of 15 minutes or more on the first day. In the patient with endocarditis under treatment, two more cultures can be taken after three successful days. In patients receiving antibiotics, six blood cultures should be taken within 48 hours, and antibiotics should be tried at the lowest level (gutter period) (4).

In non-emergency cases, two to three blood cultures can be taken in 24 hours. 80-91.5% of the episodes are detected in the first blood culture and 99.3% are detected in the first two blood cultures (8,9).

If blood cultures taken at baseline are negative and there is no change in the patient's clinical and hemodynamic status, he should avoid taking blood culture at elevated fever several times a day. Repeated blood culture monitoring or monitoring after detection of true bacteremia is often unnecessary. Patients who do not respond to treatment or clinically worsen should be re-cultured (3).

What should be the amount of blood cultures taken?

Blood volume taken is the most important factor affecting the sensitivity of blood cultures. Generally, in 50% of bacteremia, the number of bacteria is 1 CFU or less in mL, and in 20% 0.1 CFU / mL. Each 1 mL of excess blood culture increases the positivity rate by 3% (10).

In adults, the recommended volume of blood for each different blood culture is 10-30 mL. If there is no anaerobic and fungal seeding in the protocol prepared for the patient, it is sufficient to take 10 mL for aerobic seeding. It should not be taken more than thirty mL because it causes nosocomial anemia (3).

The concentration of microorganisms during bacteremia in children is higher than in adults. It is sufficient to take 1-2 mL in newborns, 2-3 mL in infants and 3-5 mL in children (11).

What Should be the Approach in Immunodeficient Patients?

Ideally, aerobic and anaerobic bacteria, fungi, mycobacteria and some viruses (HIV, CMV) should be isolated in the culture to be taken in immunocompromised patients. This is not practical for today and is quite expensive (12).

If blood cultures remain negative despite the possibility of a strong infection in a patient with immunodeficiency, it should first be discussed whether appropriate blood culture techniques are used. It should be remembered that bone marrow and liver biopsy cultures are also very supportive in the diagnosis (13).

The higher the number of microorganisms circulating in the blood in patients with immunodeficiency, leads to an increase in the diagnostic value in direct microbiological examination of blood (14).

Blood Cultures in Catheterized Patients

When catheter-related bacteremia is considered, catheter tip culture should be performed. Maki's semi-quantitative technique is the most commonly used method (15).

Isolation of the same microorganism from both catheter tip and peripheral blood culture is highly supportive for catheter-related bacteremia (16).

For long-term catheters, bacteria are often found in the catheter. In this case, quantitative growth culture or quantitative culture of peripheral blood and catheter blood is more sensitive (17).

Clinical Microbiology Laboratory and Blood Cultures

Non-automated and automated methods for blood cultures are available in clinical microbiology laboratories.

Non-automated methods:

a. Conventional monophasic liquid media

b. Diphasic media (Castenada)

c. Lysis centrifugation method (4).

Conventional liquid media use media such as tryptic soy broth, brain-heart infusion broth, and sodium polyanethol sulfonate (SPS), also an anticoagulant. Here reproduction; turbidity, hemolysis, gas formation, Gram staining from culture or agar plate is detected by culture (18).

In the case of diphasic liquid media, in addition to the liquid culture medium, solid media containing agar is present on one side of the bottle. Thus, the liquid medium is brought into contact with the solid medium by inverting the bottle and thus the colonies are visible to the eye (5).

In the lysis centrifugation method, the blood is placed in a tube containing lysis fluid consisting of saponin, SPS, fluorinert and EDTA and centrifuged at high speed. The supernatant is discarded and the culture is made from the precipitate. It should be noted that contamination rate is high in addition to its important advantages (19).

Automatic methods can be divided into three generations:

1st generation: Radiometric blood culture systems: 14 C with radioactive label in medium. When the microorganism grows, it uses it and 14 CO 2 is formed in the medium. The system is based on radiometric reading of this.

2nd generation: Non-radiometric blood culture systems: The color change caused by the CO 2 released by the microorganism in the sensor dye in the bottle is measured spectrophotometrically or the resulting fluorescence is read.

3rd generation: Blood culture systems that monitor reproduction continuously: An important advantage of this method is the possibility of continuous monitoring of cultures under computer support. In addition, one of the important advantages of automatic methods is that they are very fast (20).

Microscopic Examination of Blood

Microscopic examination of blood blood protozoa, Borrelia and Leptospira can be searched (21).

Direct microscopic screening of blood or y buffy coat bakteri for bacteria is a time-consuming and insensitive method (22).

Gram staining from blood taken from the catheter of patients receiving total parenteral nutrition may help in the diagnosis of sepsis.

The presence of intracellular bacteria in peripheral blood smear taken from central venous catheters in immunosuppressive patients may be significant in terms of catheter infection (23,24).

How should blood culture results be evaluated in the clinic?

Not all positive blood cultures are clinically relevant. Even under optimal conditions, 2-3% contamination occurs. It is not always easy to distinguish true positivity from false positivity (3).

The following points should be observed to separate contaminant bacteria.

a. Type of microorganism

b. Compliance with the clinic

c. Reproduction time

D. How many blood cultures are produced

to. Presence of microorganisms belonging to many skin flora

f. Whether blood culture was taken during effective antibiotherapy

g. The number of non-reproductive blood cultures (25).

Generally, contaminant bacteria are skin flora elements. They do not exist in other or followed cultures. They are isolated after a long incubation (3,10).

Skin flora bacteria such as coagulase negative staphylococci, Corynebacterium spp, Propionibacterium acnes are considered contaminants when isolated from one of several blood cultures. However, accepting coagulase-negative staphylococci as contaminant in this way may also lead to the omission of a clinically significant episode (3,8).

Coagulase negative staphylococci are considered significant when isolated from two or more blood cultures. However, it is not always possible to say that this is true bacteremia without strains typing phenotypically and genotypically. These may be due to unrelated contaminated strains or recontamination. Therefore, when coagulase negative staphylococci are isolated from two or more blood cultures, at least antibiotic susceptibility should be compared. As can be seen, it can be misleading to adhere to the number of cultures in the interpretation of leather flora elements (25).

Generally, isolation of several different microorganisms from the blood culture promotes contamination. However, in one study, polymicrobial bacteremia was reported in 21% of septic episodes and it was shown to have higher mortality compared to monomicrobial bacteremia. Polymicrobial bacteremia is more common in patients with underlying serious disease, intraabdominal infections or obstructions and non-hematologic malignancies (9,26,27).

As a result, blood cultures go through different periods, each of which may have an impact on the diagnosis and treatment of the patient, starting with sampling from the patient, evaluating in the laboratory, monitoring and clinical interpretation of the results. Compliance with the rules and clinical-laboratory cooperation in all these periods increases the usefulness of blood cultures.


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An Important Step in Infection Prevention: Control

In this study, the extent to which the materials such as stretchers and tables in the health centers are the source of infection and the extent to which the controls to be performed on this subject can be investigated.

As a result of the evaluation of swab samples taken from tables and stretchers used in health centers and emergency service vehicles, the number of bacteria reproduction materials was 78.3% before unannounced inspection and 30.4% after informed inspection. The difference was statistically significant (p <0.01). When these bacteria were examined, S. aureus (34.3%), E. coli (15.2%), coagulase negative staphylococci (11.1%) and Klebsiella sp. (11.1%).

Keywords: Control, Infection.

We know that there are plenty and variety of microorganisms in every environment we live. In healthy people, microorganisms in the skin, upper respiratory tract, intestinal and genital systems are called normal flora. Some microorganisms are more susceptible to disease and are called pathogenic microorganisms and when infected, they cause disease. All microorganisms can cause infection when they find the appropriate environment.

It is impossible to create a fully sterile environment to prevent infection. However, it is possible to put protective barriers between the individual and microorganisms. A protective barrier is a physical, mechanical or chemical process that prevents infection from person to person, from healthcare workers or from contaminated tools and equipment. These processes are divided into three main categories: cleaning, disinfection and sterilization. Cleaning; removal of organic and inorganic substances with the help of water, soap and detergent. Sterilization; It is the complete removal of all microorganisms from the environment by using pressurized steam, dry hot, liquid or gas chemicals and gamma radiation. Disinfection; cleaning and sterilization. In high level disinfection, all bacteria, fungi and viruses in the environment are removed except for resistant bacterial spores. In low level disinfection, vegetative forms of many viruses and bacteria die, while spores, M. tuberculosis and some viruses remain alive.
Table: Distribution of Infection Sources by Risk Groups
Risk group Object Required action

High-grade risk Instrument, equipment, liquid Sterilization
Moderate risk In contact with solid skin, disinfection
tools, equipment, bedding surgery
and inspection tables, sliders, bathtubs
Low-grade risk Constant cleaning without contact with patient
surfaces, commode, ground, wall,


It is only possible to decide when and to which objects to perform for the correct application, only by knowing the risk levels of the sources of infection. Table 1 shows the differentiation of infection sources by risk groups. As can be seen in the table, some of the materials used in health centers are at risk for infection.
In-service trainings are provided within health centers to prevent infection in both resident and mobile health units. In our country, the duties related to the prevention of infection are mostly performed by non-physician health workers and assistants. The best way to measure the effectiveness of training on infection prevention is to conduct an audit. From this point of view, we planned to perform inspection of patient examination tables, gynecological tables and injection tables in the middle-risk group. As a result of this audit, we aimed to determine the bacterial species that can be transmitted to the patients from the health center and to determine how the informed and unannounced inspections affect the flora in the environment.

Materials and Methods
On 29.12.1998, swab samples were taken from the patient stretchers in Hızır Emergency Service vehicles and injection, dressing, examination tables and gynecological tables in 10 health centers and examined on blood and EMB media. The same transactions were repeated on 24.2.1999 with prior notice. Results were evaluated by chi-square test in dependent groups.

Results
In this study, swab samples were taken from 46 places, five of which were stretchers of Hızır Emergency Service ambulances and 41 of which were used in various jobs (injection, dressing, examination) in health centers. At least one bacterial growth was observed in 36 (78.3%) of the materials according to the results of the swab samples taken in the unannounced inspection and 14 (30.4%) of the materials taken in the informed inspection. There was a statistically significant difference between the two control results at different times (p <0.01). When the bacteria isolated before the control were evaluated, S. aureus (32.9%), E. coli (14.5%) and Klebsiella sp. (14.5%), S. aureus (39.2%), coagulase negative staphylococci (26.1) and Bacillus cereus (17.5%) were isolated.

Discussion
The service provided in health centers is a team service where all health workers take part. The person in charge of this service is the physician. When this is the case, the supervision of the service provided in the health center is among the duties of the physician and the health directorate. The main purpose of the audit is to find out the deficiencies in the service provision, to determine the reasons for this and to take the necessary precautions for these reasons. The health center physician should give the necessary importance to the cleaning of the place where he / she works as well as the services provided. Otherwise, it will endanger the health of both the patients coming to the health center and the staff of the health center.
In this study, dressing, examination, injection tables and swab samples taken from Hızır Emergency Department stretchers were evaluated in two different times, unannounced and informed. In the unannounced inspection, 78.3% of the tables and stretchers were smeared, while the frequency of bacterial isolation decreased to 30.4%. According to this, bacterial contamination was detected in health centers and Hızır Emergency Department tables and stretchers. The reason for this can be explained by the lack of importance given to cleaning, the lack of sufficient number of servants to do the cleaning work, or the lack of adequate training on this subject, and the responsible physician's failure to perform the audit duties.
S. aureus was the most frequently isolated bacteria in the study. More studies on this subject

It is very related to hospital and operating room environments. Staphylococci have been shown to be among the main causes of nosocomial infections, especially in recent studies.
An important feature of staphylococci is that they are common in the community and develop resistance to most antibiotics.
Since it is known that washing with water and detergent removes 80% of the microorganisms from the environment, a simple cleaning process in the health center environment will be effective in fighting infection. The most important task in this regard falls to the health center physician. The physician must first be knowledgeable about the subject. In a study conducted by Naçar et al., They reported that the knowledge of physician candidates about preventing infection was insufficient. Physicians who do not have sufficient knowledge at the time of graduation cannot show the necessary interest in their working life and do not inform their staff enough. However, according to the results of the study, it is sufficient to reduce the bacterial contamination by more than half, even if only the control work is given importance. The decrease in bacterial contamination in the pre-informed inspection can be explained by the fact that health center employees do not perform their duties more than their ignorance.

According to these findings, it is of great benefit to prevent infection in the health center environment by educating our physicians on the subject before graduation, educating physicians with in-service trainings and monitoring them regularly.




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What is Contamination? How Foods Are Contaminated?

As much as possible, I prepare my own bread almost every week and consume it for the rest of the week. As I was interested in pickles , vinegar and compost , as well as bread, I began to think more about the other living things in which we shared the common habitat, and we saw that the scope of what can be done in proportion to awareness increases. Why did I get off the road? As I mentioned on the page, I'm advancing the content in line with a plan and trying to address as many themes as possible. In line with these goals, I had to make some changes in my living space in the near future; In 2017, I will be able to share more detailed and detailed studies on a larger area. The subject I will touch upon in this article is again contamination which I pay special attention to during the change of place and production stage.

In the third month of my Kombucha tea, when the mother and the baby were contaminated with SCOBY , I had to discard them, I cannot tell about my astringency . Although SCOBY is highly resistant to foreign bacteria and fungi, in some cases, contamination can often occur in contact with the surface / lid. It's easy to understand. If the surface of the SCOBY is covered with hair, often colored spots and molds, and the smell has become pungent and unpleasant, then the job has passed. Therefore, I had to move the fermentation area to a suitable point where there would be no entry-exit, except for the areas where there was continuous movement, and to prepare more balanced and restrained foods by considering kombucha and other fermented foods. Of course, there were many arrangements from lighting to the arrangement of shelves, planning the area where the materials will be located and separating the usage areas. Before mentioning these regulations, I will mention the contamination on which the article will be based. Then I can continue with answers to the question of how to conserve food in a healthier way, how to use ingredients and techniques.

First of all, I want to give you a basic knowledge. Roughly, a bacterium can be cleaved again in about 20 minutes under appropriate conditions (warm, moist and nutrient rich). A single bacterium that grew at this rate would have produced a bacterial mass weighing approximately 2000 tons per 24 hours if there were no limiting factors and the process proceeded in a geometric sequence. Luckily, the situation is not so alarming. Because bacteria are consuming water and nutrients in this favorable environment in a very short time. Along with this consumption, alcohol and acidic compounds and other residues that are unfit for bacteria start to form.

These substances, which are formed and accumulated in the environment, serve as a limitation by causing bacteria to become insufficiently fed, damaged and killed. Thus, this increase in bacterial density is compensated by the activities of the bacteria themselves. In some cases, depending on the concentration of toxic substances in the environment, the mortality rate may increase and cause all the bacteria to die. Let me not forget, many bacteria die at + 100 ° C, but endospores (the shape a bacterium takes to protect the environment from external influences) can show long-lasting resistance. (see Control of Microbial Growth ).

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What is Cross Contamination?

Cross-contamination occurs when bacteria and viruses are transferred from a contaminated surface to another surface that has not been exposed to contamination. Cross-contamination is a key word for foodborne diseases and food poisoning. Cross-contamination has four main sources: Foods, people, equipment and work areas.

Food

Raw and spoiled foods may contain harmful bacteria. for example, raw meat may naturally contain high amounts of harmful bacteria that may form the basis of foodborne diseases such as Salmonella, Campylobacter and Listeria.
If careful bacteria are not treated, these bacteria can easily be transmitted from raw food to cooked and ready-to-eat food. Some examples are:
With the wrong preservation, the blood or juice of raw meat may drip onto cooked foods such as salami, sausages, or ready-to-eat foods such as salads, pastries.
If raw and cooked foods are used together to prepare sandwiches and mixed salads, harmful bacteria are easily transported from these greens to other foods (such as meat, cheese and eggs).

People

Harmful bacteria can live in and on the human body. especially in the hands and face area and clothing. However, they do not cause diseases because of their low rates. If these bacteria are contaminated by food from the body or clothing and there are conditions that are susceptible to growth, these foods become unsafe for consumption.

Equipment

Bacteria can survive and multiply in cracks and crevices of equipment. Of these equipment, they can especially live on the surface of cutting boards. After the equipment has been used, some parts of food carrying bacteria may remain on the surface of the equipment. If these equipment are not washed properly, the bacteria can be transported to other foods for later use.

Working places

Work areas such as table surfaces are in constant contact with people, raw foods, uncleaned equipment or other things such as cardboard placed on the floor. If the desks are not cleaned properly, the food placed on them can easily become contaminated.

Types of cross contamination:

- Food contamination from staff

- Food-to-food contamination

- Contamination from the surface in contact with the equipment or food


Especially in the studies carried out in businesses;

- Packages placed on the counter,

- Fridge etc. Refrigeration equipment,

- Simultaneous cutting of more than one type of food on the same cutting board,

- Do not wash hands before using gloves,

- Disinfection of work benches,

- Disinfectant concentrations are not at the correct concentration and

- Cross-contamination caused by failure to reach final rinse temperature.


At this stage, it is important to prepare standard operating procedures to prevent cross-contamination. The focus should be on;

- Personnel hygiene

- Accept goods

- Storage of food and chemicals

- Preparation

- Equipment and uses

- Cleaning and sanitation


Personnel hygiene: It should be ensured that the personnel should wash their hands especially when the duty or type of work changes, the use of gloves regularly and the use of cloths to wipe the hands or dirty foods should be avoided.

Acceptance of Goods: In this case raw and ready-to-eat foods should be kept separately at the time of delivery.

Storage of Food and Chemicals: Storage of raw meat and cooked or ready-to-eat foods in separate cabinets, if possible, storage of raw meat in the same cupboard under cooked or ready-to-eat foods, such as good wrapping (stretching) of foods, etc. should be kept at least 15 cm above, avoid storing in stacks, and certain persons should be allowed to enter the stores.
Chemicals should be stored in a separate and locked area, if possible, and separated from food, if possible.

Preparation: Frequent work benches and instrument equipment should be cleaned and disinfected. Apart from these, cutting boards should be cleaned between each use, gloves should be changed frequently, hands should be washed properly, food to be stored should be covered and eating should be avoided in working areas.

Equipment: There must be separate cutting boards for raw and cooked or ready-to-eat foods, if this is not possible, the use of different products should include documentation on how to use the same equipment. infrared thermometers should be used, it is recommended to clean high-risk areas before low-risk areas during cleaning. Especially if the same cleaning equipment will be used, employees should use each washbasin in accordance with the intended use to prevent contamination, plastic bags and foils should not be reused.

Cleaning and Disinfection: Buckets designed for cleaning and disinfection should be used, the concentration of sanitation solutions should be checked frequently and the sanitation solution should be changed frequently.

Cross-contamination Rules


- Foods that will be offered for direct consumption should not come together with raw products.

- Foods that will be offered for direct consumption and raw foods should be stored in separate places.

- Separate equipment should be used for direct consumption and raw foods.

- Wash your hands thoroughly if you are going to process food that is offered for direct consumption after touching raw foods or equipment used in raw foods.

- If possible, do not touch the foods that are to be consumed directly, or treat them with a disposable glove.

- Make sure that the equipment you use is clean and sound.

- Do not keep the garbage in the production and storage area for a long time.

- Protect against the entrance of insects, rodents and all kinds of pests in the production and storage area.


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Listeria Disease

Listeriosis is a serious infection caused by ingestion of food contaminated with Listeria monocytogenes bacteria and is a major public health problem in the United States. Every year 1600 people are infected and 260 of them die.
Infection

Listeria monocytogenes are often found in soil and water. Animals can carry the bacteria without getting sick, but food from meat and dairy products can be contaminated. Infection is transmitted to humans by ingesting contaminated food. Babies may be born with Listeriosis if their mothers have consumed contaminated food during pregnancy. Rarely, hospital-acquired transmission of neonates has been reported.

There are many microbes that are transmitted through food. Some of them, like Listeria, can be lethal.
symptoms

People with listeriosis usually have fever and muscle pains, and sometimes diarrhea or gastrointestinal symptoms. In almost every diagnosed patient, bacteria spread to the digestive tract. Symptoms vary according to the infected person:

Pregnant women: Typically, fever occurs, other nonspecific symptoms such as fatigue and pain may accompany. However, exposure to bacteria during pregnancy; abortion, stillbirth, preterm birth or newborn life-threatening infections.
People other than pregnant: In addition to fever and muscle pain; Headache, stiff neck, blurred consciousness, loss of balance and convulsions may occur.

Listeriosis can occur in different ways. Septicemia and meningitis are the most common clinical conditions in the elderly and immunocompromised individuals. People with immune system problems may develop acute febrile gastroenteritis or have no symptoms.

Some cases result in death even if treatment is initiated immediately. This is especially true for older people and risk groups with serious health problems.
Diagnosis and Treatment

Early diagnosis and treatment is very important. According to the patient's clinic, definitive diagnosis is made by the growth of bacteria in CSF (Cerebrospinal Fluid) or blood cultures. Effective antibiotics are used in the treatment. If no symptoms have appeared in a person who has consumed contaminated food, most experts believe that no testing or treatment is needed.
Risk for passengers

Listeriosis can be seen anywhere in the world. The disease is primarily related to the elderly (58%), pregnant women (approximately 1/7 of the cases (14%)), newborns and adults with weakened immune systems (such as cancer, liver and kidney failure, diabetes, alcoholism, AIDS, immunosuppressive treatment). effects. However, it may rarely affect people who are not in the risk group.
Protection

Listeria can survive for years in contaminated food products in food processing factories. Bacterium; uncooked meats and vegetables, non-pasteurized milk and dairy products, cream cheese, processed meats (ready to eat) and smoked fish.

Listeria can be killed by pasteurization and cooking. However, contamination may occur in some processed meats such as hot dogs and delicatessens before packaging. Although pasteurized milk is used, as in Mexican cheeses, it can still be transmitted during the cheese making phase.

The risk of disease can be reduced by recommending safe preparation, consumption and storage of food. The recommended general rules for the prevention of listeriosis are similar to those used in the prevention of other foodborne diseases such as salmonellosis. In addition, there are special recommendations for people in the high-risk group for Listeriosis.

Advice for the prevention of foodborne diseases:

Wash your hands frequently with soap and water. If water and soap are not available, use alcohol-based hand disinfectants,
Avoid consumption of risky foods and beverages,
Drinking water should be either in safe sealed packages or boiled before drinking. The carbonated ones of closed waters are safer than the ones that are not carbonated. Do not use in your drinks unless the ice is prepared with closed water or if it is not known how to prepare it. Your food should be fresh and very well cooked.
Do not buy food or drink from street vendors. Many travelers become ill with food from street vendors.
Do not consume fruits and vegetables without washing or peeling. Especially salad material vegetables should be washed very well with clean water (BOIL, COOK, SOY OR FORGOT).

FDA recommendations on food washing and use:

Rinse thoroughly under running tap water before cutting, cooking and eating raw products such as fruits and vegetables. The product should be washed before peeling off.
Hard products such as melon, cucumber should be brushed with a clean brush.
Dry the products with a clean cloth or paper towel.
Separate prepared foods and cooked foods from vegetables, uncooked meat and poultry.
Keep your kitchen and environment clean and safe.
After preparing and using uncooked food, wash the cutting boards, benches, knives and hands.
Unlike many bacteria, Listeria monocytogenes continue to grow and multiply in some refrigerated foods. The refrigerator must be at zero or lower temperature.
Immediately clean the food spilled in your refrigerator with hot water and liquid soap and rinse.
Thoroughly cook food of animal origin (such as meat, milk).
Do not drink non-pasteurized or raw milk and do not eat foods made from these milk.
Take care to buy and consume safe foods.

Trip Return Recommendations

If you are feeling sick, especially if you have fever, muscle pain, weakness, diarrhea, nausea, vomiting, contact your doctor or health care provider immediately.
Be sure to tell your doctor about your trip.

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What is cross-contamination, how to prevent it?

Cross-contamination, also called cross-contamination , is the transmission of harmful viruses and bacteria to environments that are not bacterial. The most important cause of food poisoning is cross-contamination. Raw foods, especially spoiled foods, are heavily viruses and bacteria. Therefore, the causes of cross-contamination and the precautions to be taken to prevent this situation should be known.
How does cross-transmission occur?

The equipment used by individuals and the unhygienic nature of the work areas bring about cross contamination. Of course, the use of faulty equipment also contributes to this process. Foods that contain bacteria are the most prone to spoilage, but diseases such as Salmonella and Listeria appear with foods that contain bacteria.

In addition, raw foods made ready for consumption also occur with cross contamination. To give an example in this regard; The addition of salami, sausage or raw broth to cooked foods or the transmission of viruses occurs between the food. This can naturally cause health problems.

People are the most important factor in today's ways of cross-contamination . Bacteria, which can easily multiply in human body, are densely found in hands and face. In addition, these bacteria, which can also be transmitted by clothing, are transmitted to food and cause cross-contamination.

Kitchen utensils used with people are also important. It should be remembered that viruses and bacteria can easily find themselves in cracks in kitchen tools and equipment. Bacteria and viruses can easily multiply on boards which are mostly used for cutting salads or meat.

What are the Cross-Contamination Types?

The cross-contamination process occurs in 3 different ways:

From food to food,
By the hand of the staff,
with equipment.

Especially in a study conducted on enterprises, it was stated that the causes of cross contamination occur due to the following factors. These factors are;

Failure to clean workbenches,
Use of refrigerator
Cutting different food types on the same cutting board,
Personnel do not pay attention to hand cleaning before handling food,
Open packages left on the looms are listed as.

Of course it is possible to avoid cross-contamination. In this process, storage of chemical products and foods should be considered. In addition, the hygiene of the personnel and the foodstuffs in the establishments should be kept in a healthy way. In addition, the preparation stage of foods should also be observed to prevent cross-contamination.

How to Prevent Cross-Contamination?

A number of measures are necessary to prevent cross-contamination. These measures;

Foods to be consumed should be kept in a different environment than raw foods.
Foods to be consumed and raw foods should not be brought together in any way.
Production and storage areas in enterprises should be hygienic.
Waste collected in the production and storage areas of the enterprises should be collected hourly or daily.
The equipment used must remain clean at all times.
Different equipment should be used in the preparation of raw foods and other foods.

In general, ways of preventing cross-contamination are such. In addition, some information about celiac disease, which is widely researched today and associated with the risk of cross contamination, should be obtained. Because the risk of cross-contamination in gluten is quite high.
Cross-Contamination and Gluten Relationship

What is Gluten?

Individuals with hypersensitivity to gluten protein are defined as celiac disease. In other words, gluten-containing foods should not be consumed by celiac patients for a lifetime. Therefore, it is essential that celiac patients take some importance against the risk of cross contamination. Furthermore, the cross-contamination and gluten relationship is a matter of utmost importance in the preparation and delivery of foods.

There is a diet program specially prepared for celiac patients. During the preparation of the foods in this program, attention should be paid to bakery products. Since the workshops cannot consume any floury products, gluten-free and gluten-free flours need to be stored in different areas.

In fact, there is always a risk of cross-contamination for celiac patients. No food should be taken from outside during this process. For example, soups and soups are prepared with oily flours which are intended to be consumed from the outside. For celiac patients, this may lead to many different health problems. For these reasons, it should be noted whether gluten information is available on the food to be purchased from outside.

How should celiac patients be fed?

Food preparation process is also important for celiacs. The food of such patients should be prepared with different kitchen equipment. Both wooden and iron spoons cannot prevent the risk of gluten contamination. Therefore, the kitchen equipment of patients on a gluten-free diet should be stored in a different part of their living space.

The risk of cross-contamination in foods is most likely to be celiac disease. For celiac patients, let food come into contact, even in the same environment. In particular, flour is a volatile substance and is the most risky food category for those who have to live gluten-free.


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Honey storage at home: basic rules

This product has medicinal properties because it is known to everyone about the benefit of honey. It is used in various diseases as an additional treatment. With the continuous use of honey, there is an increase in immunity, restoration of strength and improvement of the general condition of the body. However, when the content of the product is in an unsuitable environment, some useful properties may be lost. In addition, the taste may deteriorate. Honey storage at home requires following certain rules, which are the main points we will try to emphasize in this article.

Product Storage Tanks

honey storage

Honey storage at home means that the product will not lose its properties:

Anti-inflammatory.
Bacteria.
Game Envelope.
Restore and others.

It is recommended to have a natural product in these containers:

Parquet casks.
Tin, aluminum or stainless steel kitchenware.
Ceramic products with glaze coating.
Glass containers.

Honey is not recommended to be placed in containers made of copper, lead, zinc, iron and cannot be stored from oak products.

Room for honey

keep refrigerated honey

Storage of honey in house conditions, preparation of a special room for these purposes. It is better to take these moments into account:

The room should be kept at a constant temperature (0–10 ° C) at a humidity of not more than 70%.
The absence of foreign odors is impossible. In particular, you cannot keep it near fuels, lubricants and other chemicals.
The room should be well ventilated and at the same time the direct rays of the sun should not fall on honey. Therefore, it is better to use opaque packaging.

Because this product is highly hygroscopic, it can rapidly absorb moisture from the environment and other substances. As a result, it is not recommended to store the honey in the refrigerator.

Storage highlights

honey storage rules

Honey in honeycombs can be preserved as long as desired. The fungus and mold are destroyed by substances found in the product itself and in the natural “container” composition. At the same time, the most favorable conditions that determine the honey storage rules are: temperature - about 5 ° C, humidity in the air - about 60%.

It is noted that honey can absorb moisture. The environment, even in closed containers with more than 70% air vapor in the air. If the value of this indicator is less than 30%, the product, by contrast, releases water particles.

It is forbidden to contain honey at a temperature above 15 ° С, because at the same time acid reactions begin to occur in the composition. And when heated to 40 ° C, vitamins and other substances are destroyed and the natural product loses its healing properties.

It is best to store the honey at home under optimal conditions. At the same time, the product does not lose its usefulness as it is a valuable product of the “natural masters” - bees.

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