Preventing infections in hematological cancers is critical due to weakened immune systems from chemotherapy or bone marrow involvement. Strict hygiene, protective isolation, and timely vaccinations help reduce infection risk.
Antimicrobial prophylaxis is often prescribed to high-risk patients. Antibiotics, antivirals, and antifungals are used depending on immune status, providing an additional layer of protection against life-threatening infections.
Nutritional support strengthens immunity. A balanced diet, safe food preparation, and avoidance of raw or contaminated foods help minimize exposure to pathogens in vulnerable cancer patients.
Regular monitoring, early detection of fever, and prompt initiation of antibiotics are crucial. Multidisciplinary care ensures that infections are managed quickly, improving survival and quality of life in hematological cancer patients.
What Are the Main Causes of Infections in Hematological Cancers?
The risk of infection in hematological cancers increases as a result of the combination of several factors. The primary reason is that the cancer itself invades the bone marrow, preventing the production of healthy cells. In diseases such as leukemia, while immature or abnormal white blood cells proliferate rapidly, the body’s defense mechanisms are disrupted. Thus, when sufficient quantity and quality of defense cells cannot be produced, resistance to infections decreases.
In addition, chemotherapy or radiotherapy used in cancer treatments can also damage healthy cells while targeting cancerous cells. Especially bone marrow cells are highly affected by the side effects of these treatments. When cells such as neutrophils, lymphocytes, and platelets produced in the bone marrow are damaged, the body’s immune capacity significantly decreases. In some patients, the use of high-dose corticosteroids when necessary can also cause suppression of the immune system. This suppression allows even normally harmless microbes to cause serious health problems.
Another important factor contributing to infection is damage to the body’s various defense barriers. For example, sores (mucositis) that develop in the oral mucosa due to chemotherapy allow bacteria and fungi to enter easily. Cells in the intestinal wall can also be damaged, and this can lead to bacteria from the gut flora entering the bloodstream. The presence of interventions such as central line catheters or ports can also facilitate the entry of microbes into circulation.
When it comes to viral infections, viruses that do not cause significant problems or remain “dormant” (latent) in healthy individuals can become active again when the immune system is weakened. Various viruses in the herpes virus family (HSV, VZV, EBV, CMV, etc.) are included in this group. While they do not cause problems under normal circumstances, they can reactivate and lead to severe infections when the immune system is suppressed.
Fungi and molds can also be dangerous for patients with hematological cancers. Especially opportunistic fungi such as Aspergillus or Candida can cause severe infections in the lungs and bloodstream. While a normal immune system can fight these fungi, with weakened immunity, these microbes can easily cause disease. Considering all these factors, the risk of infection increases or decreases depending on many variables such as the type of cancer, treatment regimen, medications used, personal hygiene habits, and the hospital environment. In conclusion, the main causes of infections include abnormal or insufficient blood cell production, suppression of the immune system, and disruptions in the body’s defense barriers.
How Does Neutropenia Increase the Risk of Infection in Hematological Cancers?
Neutropenia is a condition where the level of white blood cells called neutrophils in the blood is below normal. Neutrophils form the first line of defense against microorganisms such as bacteria and fungi. A deficiency of these cells creates serious gaps in the body’s defense, just like a large hole in a castle wall. In hematological cancers, neutropenia is a common situation. Especially chemotherapy, in its “bombardment” effect to destroy cancer cells, can also suppress the bone marrow’s ability to produce neutrophils.
The most important factor increasing the risk of infection is the duration and depth of neutropenia. If the neutrophil count remains very low for a long time (for example, below 500 cells/microliter), even the smallest microorganism can cause serious infections. For this reason, febrile neutropenia attacks are frequently observed in most patients with hematological cancers. Fever is one of the most prominent responses of the body to infection. When the neutrophil count is low, sometimes fever may not appear even in the presence of infection, or the symptoms may be very vague. Therefore, “afebrile infection” is also possible and close monitoring of patients is essential.
Neutropenia also weakens the body’s “alarm” system for infection sites. Normally, when bacteria or fungi enter a tissue, neutrophils quickly migrate to the area and try to eliminate the infectious agent. However, if there are not enough neutrophils, bacteria or fungi can multiply freely. For this reason, a small sore in the mouth, minor damage on the intestinal surface, or a tiny cut on the skin can turn into serious infections in neutropenic patients.
To use an analogy, think of neutrophils as the fire brigade. They are the first to arrive to extinguish even the smallest fire. Without fire brigades, even a small spark can turn into a large fire. This is exactly the case in neutropenia. Therefore, any situation showing possible infection symptoms in patients with low neutrophil counts during or after chemotherapy should be taken seriously. Keeping these patients in isolated rooms in the hospital, close monitoring, and providing prophylactic antibiotics or antifungal drugs when necessary are frequently used methods to reduce the risk posed by neutropenia.
Why Is Hand Hygiene Critical in Preventing Infections in Hematological Cancers?
Hands are like a “highway” for microorganisms. We touch hundreds of objects and surfaces during the day and inevitably carry various germs. For many people with a normal immune system, this can be tolerated, but for patients with hematological cancers, it poses a serious danger. Hand hygiene, therefore, has the power to create “big differences with small actions.”
Neglecting hand hygiene in hospitals and at home can cause infectious agents to spread easily, especially in immunocompromised patients. If a nurse or doctor moves from patient to patient without properly disinfecting their gloves or hands, they may carry bacteria or viruses. This is one of the most common mechanisms of hospital-acquired infections. Similarly, if family members providing care at home do not pay attention to hand cleanliness, the patient can be exposed to risky microbes. Even common pathogens such as influenza or cold viruses can have severe consequences in immunosuppressed individuals.
Hand hygiene usually brings to mind washing with soap and water. This method is indispensable, especially if hands are visibly dirty or have contacted organic materials such as blood or body fluids. In addition, alcohol-based hand antiseptics are also very effective at killing germs and are frequently used in hospital settings. The important thing is the correct application of both methods. When washing with soap and water, hands should be scrubbed for at least 20 seconds, and spaces between fingers and under the nails should not be neglected. For alcohol-based antiseptics, it is important to cover all parts of the hand and rub until dry.
There are some simple but vital rules in daily life. For example, washing hands upon entering the house from outside, paying attention to hygiene after using the toilet, always cleaning hands before preparing or eating food, and washing hands after contact with a sick person or pet feces are routines that act as a “protective shield” for immunocompromised patients. Just like wearing a seatbelt while driving, washing hands should become a reflex that is effortless but vital. Especially for patients with hematological cancers, defining hand hygiene as “critical” is by no means an exaggeration.
Which Vaccines Are Recommended to Prevent Infections in Hematological Cancers?
Vaccines are the most important tools to “train” the body’s defense system against infections. In hematological cancers, the importance of vaccines increases because patients’ immune systems are weakened. However, which vaccines will be administered, when, and at what dose are determined by the patient’s general condition, treatment protocol, and immune status.
The most commonly recommended vaccine is the annual influenza (flu) vaccine. Since the influenza virus changes every year, the vaccine should be renewed every autumn to maintain its protective effect for immunocompromised patients. Even in healthy people, the flu can sometimes be severe, and in cancer patients, it can have more serious consequences. The influenza vaccine contains inactivated (killed) virus, and can therefore be safely used in immunosuppressed individuals.
Pneumococcal (pneumonia) vaccines also provide important protection. Infections caused by the bacterium Streptococcus pneumoniae can be dangerous, especially when the spleen’s function is impaired or surgically removed. In some types of hematological cancers, the spleen’s function may be reduced or it may be removed as part of treatment for diseases such as lymphoma. Therefore, the pneumococcal vaccine (both conjugate and polysaccharide types) should definitely be considered and administered according to the schedule recommended by the doctor.
The hepatitis B vaccine is recommended, especially for immunocompromised patients who frequently receive blood transfusions. Hepatitis B, which can be transmitted by blood or various contacts, can cause serious conditions such as chronic liver disease and cirrhosis. In addition, vaccines included in the basic vaccination schedule, such as diphtheria, tetanus, and pertussis (DTaP or Tdap), should also be completed in full. An important point here is that live vaccines (for example, live virus vaccines) are generally not recommended in patients with severely suppressed immunity. These vaccines carry a risk of causing infection because they contain attenuated live viruses. Therefore, the selection and timing of vaccines should always be determined by a specialist physician.
Recently, especially COVID-19 vaccines have become an important layer of protection for patients with hematological cancers. As new variants of viruses emerge, updated forms or booster doses of vaccines come to the fore. Although the protection offered by vaccines in immunocompromised individuals may be lower than in healthy people, it should be remembered that they are still effective in reducing the rates of serious illness and hospitalization. In short, “vaccines are like notebooks that keep the immune system’s memory alive.” Using them regularly is of vital importance in the fight against infections.
How Can Environmental Controls Reduce the Risk of Infection in Hematological Cancers?
The arrangement of the hospital or home environment is very important in limiting the circulation of germs. Especially in hematology wards, hospitals use special filtration systems (such as HEPA filters) and isolation rooms for immunocompromised patients. These systems trap most of the fungal spores and other harmful particles in the air, significantly reducing the likelihood of infection.
Another aspect of environmental control is cleaning and sterilization. High-risk areas include frequently touched surfaces such as door handles, faucet taps, and tables. Especially bacteria and viruses can remain alive on these surfaces for hours or sometimes even days. Regular cleaning significantly reduces microbial density. In hospitals, antiseptic solutions or disinfectants are used for this purpose. At home, it is equally important to frequently wipe surfaces, dust, and keep the air as clean as possible. If there will be renovations at home or if you live near a construction area, the risk of fungal spores mixing with the air increases. During such times, keeping the windows closed or using air purifiers can be considered.
Water sources can also sometimes be a source of contamination. If there is any doubt about water cleanliness, drinking water should definitely be boiled or reliable brands of water should be preferred. Environmental controls also include waste management and hygienic toilet use. Waste, especially items classified as medical waste (used syringes, bloody gauze, etc.), can harbor disease-causing microbes. Safely disposing of these items breaks the possible chain of transmission.
A less visible factor is ventilation. Ensuring clean air circulation prevents the microbial density from increasing in closed environments. However, it is important to control this ventilation; if there is a high level of pollen or fungal spores outside, the method of ventilating the patient’s room should be reconsidered. In addition, materials prone to fungal growth, such as plant soil, should not be kept in the rooms of immunocompromised patients. In short, environmental control covers a wide spectrum, from air quality to surface cleanliness, from water sources to the arrangement of plants at home. Just like “seeing the scenery clearly when you frequently clean the window,” ensuring environmental hygiene greatly reduces the risk of infection.
What Is the Role of Personal Hygiene in Preventing Infections in Hematological Cancers?
Personal hygiene is a basic health criterion for everyone. However, in patients with hematological cancers, these hygiene practices are like building a “personal fortress.” Microbes from the outside world and pathogens from the body’s own flora have the potential to exploit even the smallest gap. Therefore, it is necessary to be meticulous about regular bathing, oral care, nail trimming, and clean clothing.
Oral hygiene has particular importance. Due to chemotherapy and radiotherapy, the oral mucosa may become sensitive and sores similar to aphthae may develop. These sores act as an “open door” for bacteria and fungi. Using a soft-bristled toothbrush, gently brushing with fluoride toothpaste, and using antiseptic mouthwashes recommended by a doctor or dentist reduce this infection risk. Brushing teeth at least twice a day, or gargling briefly after every meal if necessary, is a simple but effective defense method.
Skin cleanliness is also critical to closing microbial entry points. The skin is our largest organ, and when damaged, it loses its function of preventing microbe entry. The soap or body shampoo used in the bath should be selected from products that do not irritate the skin and have balanced pH. Using warm instead of hot water prevents the skin from drying and cracking. Also, especially drying moist areas such as the armpits and groin is important; fungi like moist environments and can easily multiply in these regions.
Nail care and hand hygiene are also among the cornerstones of personal hygiene. Long nails provide a suitable area for microbes to hide. Therefore, nails should be cut regularly and cleaned with a brush. Many microbes can be carried from frequently touched surfaces such as phones, computer keyboards, money, or door handles. If there are small scratches or cracks on the hands, these microbes can easily penetrate the skin. Similarly, washing hands with soap or disinfecting with alcohol-based antiseptics should become a habit after using the toilet or after contact with pets.
Finally, genital hygiene should not be neglected. In female patients, cleaning of the vaginal area and in male patients, cleaning of the penile and scrotal area should be done with mild, non-irritating products. Fungal or bacterial colonization in these areas can cause infection to spread to other parts of the body. Using protection (such as condoms) during sexual intercourse minimizes the risk of infection. In summary, personal hygiene is vital both for maintaining the strength of the “castle walls” of the body and for minimizing the transmission of microbes.
How Can Patients with Hematological Cancers Avoid Viral Reactivation Infections?
Many viruses can remain “dormant” in the body after infection. The herpes family (HSV-1, HSV-2, VZV, EBV, CMV, etc.) is the best example of this. In healthy individuals, the immune system is strong, so these viruses usually remain silent. However, in patients with hematological cancers, these viruses can become active again with immune suppression. Like “embers under ashes,” they can reignite the infection when the right conditions arise.
The first step in preventing these reactivations involves the use of necessary antiviral drugs during the patient’s treatment plan. For example, in patients prone to herpes simplex virus or those with a history of cold sores or shingles, the doctor may prescribe antiviral drugs at an appropriate dose and duration. Similarly, in those with a high risk of CMV reactivation, regular blood tests are performed to monitor CMV antigen levels, and preventive treatment is started if necessary. This approach is like “monitoring a volcano that can erupt at any moment and intervening when the pressure gets too high.”
Vaccines also play an important role in preventing viral infections. For example, if a person who has not had chickenpox (varicella) has not experienced significant immunosuppression and the doctor deems it appropriate, varicella vaccine can be planned. However, the risks of live vaccines in hematological cancers must always be considered and evaluated together with an infectious diseases specialist. COVID-19 vaccines also have an important place in protecting against viral infections and, given the possibility that the immune response may not be sufficient, sometimes additional doses may be required.
In addition, the patient’s own efforts to avoid sources of viral infection can indirectly reduce the risk of reactivation. Avoiding close contact with people who have flu, colds, or other respiratory infections, wearing masks in crowded environments, and paying attention to hand hygiene are simple practices that are effective in reducing viral load. Stress management and good nutrition can also indirectly support the immune system and help prevent viral reactivations. Just as you need to add wood to the fire to keep warm in cold weather, taking good care of the body helps to keep the “fire” of the immune system alive.
What Are the Best Practices for Preventing Bloodstream Infections in Hematological Cancers?
Bloodstream infections are particularly dangerous for immunocompromised patients. These infections are usually caused by bacteria, fungi, or rarely parasites and can quickly lead the patient to sepsis. In patients with hematological cancers, the use of medical devices such as central venous catheters or ports is common, making prevention of such infections highly important.
The first practice here is strict adherence to vascular access and catheter care protocols. Strict hand hygiene, use of sterile gloves and masks, and regular cleaning of the catheter insertion site with antiseptic solutions are the most basic protection methods. Catheter dressings should not be changed too frequently, but if they become dirty, wet, or loose, they should be replaced without delay. It is essential that materials used during dressing changes (gauze, tape, antiseptic solution) are clean and sterile.
Antimicrobial lock solutions can also be used in some cases. For example, in patients with long-term catheters, an antimicrobial solution can be instilled into the catheter lumen and left for a certain period to prevent microbial growth inside the catheter. In addition, fluids and medications administered through the catheter can increase the risk of contamination while keeping the catheter open. Therefore, it is necessary for the fluids and medications to be sterile and the connection points to be made using “aseptic technique.”
It is important to properly educate patients and their relatives about catheter care. Early detection of signs such as redness, discharge, or pain at the catheter site and immediate communication with the healthcare team can prevent a possible bloodstream infection from becoming severe. In addition, when necessary, prophylactic antibiotic or antifungal treatments, especially in patients with prolonged neutropenia, can reduce the incidence of bloodstream infections. Just like “repairing a leaking pipe in advance,” paying attention to catheter care helps to catch bloodstream infections early.
How Important Is Regular Monitoring in Preventing Infections in Hematological Cancers?
Regular monitoring is one of the most effective ways to detect infection risk in advance and intervene quickly when necessary. For patients with hematological cancers, this often involves monitoring blood values and clinical examinations. Being “alert and attentive” is critical at this point; because even a small change can be a sign of a serious infection.
For example, periodic complete blood counts (CBC) show the levels of white blood cells (especially neutrophils). According to the results of these tests, infection risk can be evaluated and, if necessary, prophylactic antibiotic therapy or growth factors (such as G-CSF) can be introduced. Similarly, regular measurement of infection markers such as CRP (C-reactive protein) or procalcitonin can help detect a silently developing infection early. In cases of viral reactivation, blood levels of CMV or EBV can be monitored. Early increases indicate the need to start antiviral treatment.
The patient’s self-monitoring and close attention to what is happening in their body is also part of regular monitoring. Symptoms such as fever, chills, shortness of breath, rash, changes in urine color or odor, and visual disturbances can be signs of a possible infection. It is valuable for the patient to note these symptoms daily and inform the medical team of any abnormality, acting as an “early warning system.” With advances in digital technology, some patients can closely monitor parameters such as heart rate, body temperature, and oxygen saturation using smart wristbands or watches. These applications are valuable tools for early warning and for determining the right time to seek medical attention.
Furthermore, the regular monitoring process does not only focus on physical values; psychological support and nutritional status are also included in this context. Factors such as appetite, weight changes, sleep pattern, or morale can also indirectly affect the risk of infection. The immune system of patients who are malnourished or psychologically challenged can become more fragile. In a way, “if you neglect your car’s oil, water, and engine check, even a minor malfunction can escalate.” In hematological cancers, regular monitoring is like “keeping all parts of your car running”; it can prevent the development or progression of infections.
What Infection Symptoms Should Patients with Hematological Cancers Pay Attention To?
Infection symptoms in patients with hematological cancers may sometimes not be as clear as in healthy individuals; nevertheless, there are “alarm signs” to be aware of. For example, fever is the most common warning signal. Fever is one of the body’s main responses to infection, but in some immune system disorders, there may be no fever or it may be very low. Therefore, if the neutrophil count is low (neutropenia), even a slight increase in temperature should be taken seriously, even if the patient feels well.
Chills and shivering may indicate a bloodstream infection. This condition, described as “I just can’t get warm, my bones are aching,” can sometimes be a sign of insidious sepsis. Symptoms such as shortness of breath, cough, or chest pain may indicate pneumonia or other lung infections. Especially in cancers such as lymphoma, lung involvement can also be seen, so all respiratory abnormalities should be closely monitored.
Sores in the mouth, gum bleeding, sore throat, or difficulty swallowing may also be a reflection of an infection. Chemotherapy-induced mucositis increases these complaints, and with the addition of opportunistic fungi or bacteria, the situation can become even more severe. Symptoms such as burning during urination, frequent urination, and foul-smelling urine may suggest urinary tract infections.
Abdominal pain, diarrhea, nausea, and vomiting can be signs of gastrointestinal infections. Sometimes, when the gut’s defense mechanisms are weakened, even bacteria in the gut flora can cause serious conditions. Redness, swelling, pain, or discharge on the skin or mucous membranes indicate a local infection focus. Redness and increased temperature at the central venous catheter or port site are similarly important warnings. When all these symptoms come together, they should be interpreted as the “body’s cry.” Since patients with hematological cancers may sometimes have a high pain threshold or use antipyretics, even minor symptoms should not be ignored, as early diagnosis and treatment are critical.
How Can Healthcare Workers Reduce Infection Risks in Hematological Cancer Care?
Healthcare workers are the most important professional group in contact with patients with hematological cancers. Therefore, the precautions they take play a major role in infection control. First, maximum compliance with hand hygiene rules is required. Changing gloves and disinfecting hands before and after each intervention between patients is a “simple but vital” rule. Unfortunately, this rule can sometimes be neglected due to busy schedules; however, when it comes to cancer patients, it must never be ignored.
The use of protective equipment is also very important. Personal protective equipment such as masks, gowns, and gloves protect both the patient and the healthcare worker. Especially in infections transmitted by droplets or through the air, the use of masks and goggles becomes vital. When caring for severely immunocompromised patients in isolation rooms, it is necessary to strictly follow the procedures for donning and doffing protective equipment.
Vaccination of healthcare personnel significantly reduces hospital-acquired infections. For example, during the influenza season, vaccinating healthcare workers limits the circulation of the flu virus in the wards. Similarly, checking healthcare personnel’s immunity to infectious diseases such as hepatitis B and completing missing vaccinations keeps patients safe. In addition, it is a critical rule that healthcare workers with fever or infection symptoms do not come to work and isolate themselves.
The proper storage of sterile and single-use materials in the hospital, regular waste management, and strict adherence to cleaning and disinfection protocols are also effective in breaking the chain of infection. Whenever an infection source is detected, isolation and control measures should be taken quickly. In this context, sharing infection data between departments and holding regular meetings of hospital infection control committees facilitate early intervention. In summary, the conscious and careful approach of healthcare workers is one of the strongest shields that help compensate for the vulnerability of patients with hematological cancers.
What Are the Benefits of Antimicrobial Prophylaxis in Hematological Cancers?
Antimicrobial prophylaxis refers to antibiotics, antivirals, or antifungal drugs given preventively to high-risk patient groups before a clear infection is detected. In patients with hematological cancers, especially during prolonged or deep neutropenia, this approach is frequently used. The aim is like “having the fire brigade ready before a fire breaks out.” Under normal circumstances, if the body had sufficient capacity to defend against microbes, these drugs would not be needed. However, since the defense system is insufficient in hematological cancers, prophylaxis often plays a life-saving role.
For example, giving low-dose quinolone group antibiotics to patients during neutropenic periods can reduce the risk of bacteria from the gut flora entering the bloodstream. This approach is highly considered in patients receiving intensive treatment, such as those with AML (acute myeloid leukemia). In addition, during periods of high risk for fungal infections (for example, patients with prolonged neutropenia or who have had previous invasive fungal infections), prophylactic antifungal drugs (fluconazole, voriconazole, etc.) are used. These drugs can prevent fungal spores from settling in the lungs or other organs.
A similar principle applies to viral infections. In patients with a history of herpes simplex or varicella-zoster virus, prophylaxis can be provided with antiviral drugs such as acyclovir when immunity is suppressed. This approach minimizes the recurrence of infections such as shingles or cold sores. Similarly, in patients with a high risk of CMV, agents such as ganciclovir or valganciclovir can be administered under close monitoring of blood levels.
Of course, antimicrobial prophylaxis also has some risks. Prolonged antibiotic use can disrupt the body’s natural flora and contribute to the development of resistant bacterial species. In addition, the side effects of these drugs can cause complications such as liver or kidney dysfunction. Therefore, the decision to initiate prophylaxis is made according to the “benefit-risk” balance and the patient’s condition. The decision to discontinue or change prophylaxis is also shaped by the results of regular monitoring. Essentially, antimicrobial prophylaxis with the right duration and drug selection is a very powerful tool in preventing severe infections in hematological cancers.
How Can Family Members Support Infection Prevention in Hematological Cancers?
Family members play a critical role as the closest supporters in the daily lives of patients with hematological cancers. The simple precautions they take to protect the patient form the vital line of defense outside the hospital. The first step is to be conscious and educated. When being a patient or a relative, acquiring basic information about the disease, understanding why the risk of infection increases, and knowing which symptoms to watch for make a big difference.
If family members frequently visit the patient, they must comply with hand hygiene rules. Washing hands with soap or using alcohol-based hand sanitizers before and after entering the patient’s room protects the immunocompromised individual. In addition, if a family member has an illness such as the flu or cold, they should temporarily limit visits or wear a mask and keep their distance. Even the natural act of wanting to hug a child with a runny nose can be risky for a patient with a weakened immune system.
Cleaning the home environment is also the responsibility of family members. Common areas should be regularly disinfected, and the room should be carefully ventilated. If there are pets, it is important to ensure that their vaccinations are up to date and external parasite treatments are regularly done. Hygiene rules are also of great importance in food preparation. Vegetables and fruits should be washed thoroughly, and cutting boards used for raw meat and cooked foods should be kept separate.
Family members should also address the emotional and psychological needs of the patient. Stress and low morale can indirectly weaken the immune system. They should also guide the patient in regular nutrition, adequate fluid intake, and exercise as recommended by the doctor. For example, asking “How are you feeling today? Would you like to go for a walk?” is a simple but positive step.
Interventional Radiology and Neuroradiology Speaclist Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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