Current Status of Q Fever and the Challenge of Outbreak Preparedness in Korea: One Health Approach to Zoonoses

Human Q fever, a zoonosis caused by Coxiella burnetii, presents with diverse clinical manifestations ranging from mild self-limited febrile illnesses to life-threatening complications such as endocarditis or vascular infection. Although acute Q fever is a benign illness with a low mortality rate, a large-scale outbreak of Q fever in the Netherlands led to concerns about the possibility of blood transfusion-related transmission or obstetric complications in pregnant women. Furthermore, a small minority (< 5%) of patients with asymptomatic or symptomatic infection progress to chronic Q fever. Chronic Q fever is fatal in 5–50% of patients if left untreated. In South Korea, Q fever in humans was designated as a notifiable infectious disease in 2006, and the number of Q fever cases has increased sharply since 2015. Nonetheless, it is still considered a neglected and under-recognized infectious disease. In this review, recent trends of human and animal Q fever in South Korea, and public health concerns regarding Q fever outbreaks are reviewed, and we consider how a One Health approach could be applied as a preventive measure to prepare for zoonotic Q fever outbreaks.

Erythema Nodosum after Vaccination against Coronavirus Disease 2019 / 대한피부과학회지

Erythema nodosum (EN) is the most common form of panniculitis and may be triggered by a variety of stimuli, including infections, drugs, pregnancy, sarcoidosis, inflammatory bowel disease, and malignancies. Rare cases of vaccination-related EN have been reported, but none due to the coronavirus disease 2019 (COVID-19) vaccine of Pfizer have been documented. We report a case of EN associated with the Pfizer vaccine. A 43-year-old woman presented with acute-onset painful nodular lesions that appeared bilaterally on the extensor surface of the lower legs. These lesions appeared 5 days after the first dose of Pfizer vaccination. The patient reported no recent infectious history other than fever for 3 days after vaccination. Skin biopsy revealed inflammation extending into the subcutaneous fat with a septal distribution. It is important for physicians to be aware of the side effects of the COVID-19 vaccine because more people are bound to be vaccinated.

Etiology, Characteristics, and Outcomes of Community-Onset Pyomyositis in Korea: A Multicenter Study / 감염과화학요법

Background@#Pyomyositis (PM) is a serious soft tissue infection and despite its clinical importance, previous studies have not been able to fully determine the clinical characteristics and microbial epidemiology of PM in Korea, which we therefore aimed to investigate. @*Materials and Methods@#We retrospectively identified 140 adult patients diagnosed with PM from 13 general hospitals between January 2012 and December 2015. We analyzed the clinical and microbial characteristics of community-onset PM and compared them with communityacquired (CA) and healthcare-associated (HCA) PM. @*Results@#One hundred eleven organisms were isolated from 96 (68.6%) patients with PM.Staphylococcus aureus (38 patients) was the most common pathogen, followed by streptococci (24 patients), and enteric Gram-negative organisms (27 patients). Methicillin-resistant S.aureus (MRSA) was identified in four (2.9%) patients and in-hospital mortality reached 8.6% (12/140). Enterococci isolates were identified in the HCA PM subgroup only The proportion of MRSA isolates was not comparable between CA and HCA PM subgroups. In the 83 patients with PM infected by monomicrobial pathogens, isolates of Gram-negative organisms were more commonly found in HCA PM subgroup than in CA PM subgroup (47.6% [10/21] of patients with HCA PM vs. 20.7% [12/58] of patients with CA PM; P = 0.01). @*Conclusion@#Gram-positive cocci such as S. aureus and streptococci were dominant etiologies in community-onset PM, whereas MRSA appears to an uncommon causative organism of PM in Korea. Enteric Gram-negative organisms should also be considered as major etiologies, especially in HCA PM patient population in Korea.

Etiology, Characteristics, and Outcomes of Community-Onset Pyomyositis in Korea: A Multicenter Study / 감염과화학요법

Background@#Pyomyositis (PM) is a serious soft tissue infection and despite its clinical importance, previous studies have not been able to fully determine the clinical characteristics and microbial epidemiology of PM in Korea, which we therefore aimed to investigate. @*Materials and Methods@#We retrospectively identified 140 adult patients diagnosed with PM from 13 general hospitals between January 2012 and December 2015. We analyzed the clinical and microbial characteristics of community-onset PM and compared them with communityacquired (CA) and healthcare-associated (HCA) PM. @*Results@#One hundred eleven organisms were isolated from 96 (68.6%) patients with PM.Staphylococcus aureus (38 patients) was the most common pathogen, followed by streptococci (24 patients), and enteric Gram-negative organisms (27 patients). Methicillin-resistant S.aureus (MRSA) was identified in four (2.9%) patients and in-hospital mortality reached 8.6% (12/140). Enterococci isolates were identified in the HCA PM subgroup only The proportion of MRSA isolates was not comparable between CA and HCA PM subgroups. In the 83 patients with PM infected by monomicrobial pathogens, isolates of Gram-negative organisms were more commonly found in HCA PM subgroup than in CA PM subgroup (47.6% [10/21] of patients with HCA PM vs. 20.7% [12/58] of patients with CA PM; P = 0.01). @*Conclusion@#Gram-positive cocci such as S. aureus and streptococci were dominant etiologies in community-onset PM, whereas MRSA appears to an uncommon causative organism of PM in Korea. Enteric Gram-negative organisms should also be considered as major etiologies, especially in HCA PM patient population in Korea.

Multisystem Inflammatory Syndrome in an Adult after COVID-19 Vaccination: a Case Report and Literature Review

As the number of people vaccinated increases, people who complain of adverse reactions continue to occur. We experienced a case characterized by low blood pressure, persistent fever, edema due to increased systemic vascular permeability, and systemic inflammation confirmed by image and laboratory examinations after ChAdOx1 coronavirus disease 2019 (COVID-19) vaccination. The diagnostic criteria for multisystem inflammatory syndrome (MIS) in adults are known as fever of 3 days or more in adults, 2 or more mucocutaneous/ gastrointestinaleurologic symptoms, elevation of inflammatory markers, and clinical/ imaging diagnosis of heart failure. A 67-year-old man who was medicated for hypertension and diabetes was admitted complaining of fever, maculopapular rash, diarrhea, headache, chills, and dizziness 6 days after the first vaccination of ChAdOx1 nCoV-19 in Korea.The COVID-19 test was negative but with low blood pressure, leukocytosis, skin rash, pulmonary edema, and increased inflammation markers. His lab findings and clinical course were consistent with those of MIS after COVID-19 vaccination. He was medicated with methylprednisolone 1 mg/kg and diuretics and recovered rapidly. He was discharged after 2 weeks and confirmed cure at outpatient clinic. We report an MIS case after COVID-19 vaccination in Korea.

Infectious Diseases Physician Workforce in Korea

This study aimed to evaluate the infectious disease (ID) physician workforce in Korea. We investigated the acquisition of ID physicians from 1992 to 2019 with their current working place in the Health Care System. We defined ID physicians working at general or tertiarycare hospitals as active ID physicians. A total 275 physicians acquired ID as a sub-specialty.Among the 275, 242 were active ID physicians. The density of active ID physicians was 0.47 per 100,000 population. Of all the 17 administrative districts, 11 (64.7%) fell short of 0.47, and 131 medical institutions employed the service of ID physicians. The median number of beds per adult ID physician was 372 (interquartile range, 280–507). It is essential to secure human resources to respond to emerging infectious diseases and perform the inherent work of ID physicians.

Infectious Diseases Physician Workforce in Korea

This study aimed to evaluate the infectious disease (ID) physician workforce in Korea. We investigated the acquisition of ID physicians from 1992 to 2019 with their current working place in the Health Care System. We defined ID physicians working at general or tertiarycare hospitals as active ID physicians. A total 275 physicians acquired ID as a sub-specialty.Among the 275, 242 were active ID physicians. The density of active ID physicians was 0.47 per 100,000 population. Of all the 17 administrative districts, 11 (64.7%) fell short of 0.47, and 131 medical institutions employed the service of ID physicians. The median number of beds per adult ID physician was 372 (interquartile range, 280–507). It is essential to secure human resources to respond to emerging infectious diseases and perform the inherent work of ID physicians.

Modified Measles in an Anti-Measles Immunoglobulin G-negative Healthcare Worker who had Received Two Doses of Measles-Containing Vaccine / 감염과화학요법

To date, documentation of two doses of measles-containing vaccine (MCV) has been accepted as confirmation of measles immunity among healthcare workers (HCWs). However, we encountered measles in an HCW who had received two doses of MCV. A patient with measles was admitted to our hospital. Among 62 exposed HCWs, one nurse who had previously received two doses of MCV was shown to be negative for anti-measles immunoglobulin G (IgG), and was confirmed to have measles 14 days after exposure. Based on this experience, we suggest that all HCWs should be tested for anti-measles IgG to confirm their immunity to measles.

Early Intravenous Colistin Therapy as a Favorable Prognostic Factor for 28-day Mortality in Patients with CRAB Bacteremia: a Multicenter Propensity Score-Matching Analysis

BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) infection is associated with high mortality. One of the strategies to reduce the mortality in patients with CRAB infections is to use intravenous colistin early but the effect of this strategy has not been proven. Therefore, we investigated the association of early colistin therapy with 28-day mortality in patients with CRAB bacteremia. METHODS: This retrospective multicenter propensity score-matching analysis was conducted in the Korea by reviewing the medical records of adult patients with CRAB bacteremia between January 2012 and March 2015. Early colistin therapy was defined as intravenous colistin administration for > 48 hours within five days after the blood culture collection. To identify the risk factors associated with the 28-day mortality in CRAB bacteremia, the clinical variables of the surviving patients were compared to those of the deceased patients. RESULTS: Of 303 enrolled patients, seventy-six (25.1%) patients received early colistin therapy. The 28-day mortality was 61.4% (186/303). Fatal or rapidly-fatal McCabe classifications, intensive care unit admission, Sequential Organ Failure Assessment scores ≥ 8, vasopressor use, and acute kidney injury were statistically independent poor prognostic factors. Catheter-related infection and early colistin therapy (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.21–0.94) were independent favorable prognostic factors associated with 28-day mortality in patients with CRAB bacteremia. Early colistin therapy was still significantly associated with lower 28-day mortality in the propensity score-matching analysis (aOR, 0.31; 95% CI, 0.11–0.88). CONCLUSION: This study suggests that early colistin therapy might help reduce the mortality of patients with CRAB bacteremia.

Preserved Efficacy of Oral Metronidazole for Severe Clostridium difficile Infection

OBJECTIVE: Although clinical practice guidelines recommend oral vancomycin for hospitalized patients with severe Clostridium difficile infection (CDI), oral metronidazole is still the preferred regimen due to its tolerability and low cost. In this study, we aimed to compare the clinical efficacy based on clinical cure, recurrence, and 30-day mortality of oral metronidazole and oral vancomycin in treating severe CDI. METHODS: The medical records of patients with the diagnosis of severe CDI in a tertiary hospital in South Korea, between June, 2006 and December, 2013, were analyzed. RESULTS: A total of 162 severe CDI patients were enrolled for this study: 139 received oral metronidazole and 23 received oral vancomycin. The rate of clinical cure was not significantly different between treatments (79.86% for oral metronidazole and 82.61% for oral vancomycin, P>0.99). The rate of recurrence was comparable (20.77% vs. 18.18% for metronidazole and vancomycin, respectively; P>0.99), as was the rate of 30-day mortality (9.35% vs. 4.35%, P=0.69). Risk factors for treatment failure were histamine-2 antagonist treatment (odds ratio [OR], 4.34; 95% confidence interval [CI], 1.64–11.51; P=0.0032) and fever (OR, 2.43; 95% CI, 1.0–5.8; P=0.049). CONCLUSION: The clinical efficacy of oral metronidazole for severe CDI was no difference from oral vancomycin, in a real world setting. Oral metronidazole can be a reasonable option for treating severe CDI.

Case of Staphylococcus schleiferi Vascular Access Infections with a Hemodialysis Patient

Staphylococcus schleiferi has been infrequently reported as a human pathogen. We experienced the case of vascular access infection by Staphylococcus schleiferi in a 65-year-old hemodialysis patient. Metastatic infection occurred despite the removal of infected focus and appropriate antibiotic therapy. This case highlights the importance of considering Staphylococcus schleiferi as a true pathogen in vascular access infection with hemodialysis patients.

Is the Initial Size of Tuberculous Lymphadenopathy associated with Lymph Node Enlargement during Treatment? / 감염과화학요법

There are little data on the changes in lymph node (LN) size during the treatment of tuberculous lymphadenopathy (TB LAP). This study aimed to provide data on LN changes during treatment. Between March 2014 and December 2015, 20 patients who were diagnosed with cervical TB LAP were enrolled. LN enlargement within two months (50%, 4/8 vs. 8.3%, 1/12; P = 0.04) was more frequently observed in patients with initial LN size ≥ 7.5 cm². Enlarged LNs were excised in three patients owing to pain and fistula formation. Initial LN size may be associated with LN enlargement during treatment.

Risk Factors for Mortality in Patients with Acinetobacter baumannii Bacteremia / 감염과화학요법

BACKGROUND: Acinetobacter baumannii, an opportunistic nosocomial pathogen that can cause significant morbidity and mortality, has emerged as a worldwide problem. The aim of this study was to evaluate the risk factors for mortality in patients with A. baumannii bacteremia. MATERIALS AND METHODS: We retrospectively evaluated 118 patients who had A. baumannii bacteremia between July 2003 and December 2011. The aim of this study was to identify the 30-day mortality in patients with A. baumannii bacteremia and relevant risk factors. RESULTS: The bacteremia-related 30-day mortality rate was 34.1%. Univariate analysis revealed that the risk factors for mortality included malignancy, longer hospital stay before bacteremia, intensive care unit (ICU) stay at the time of bacteremia, mechanical ventilation, use of a central venous catheter, unknown origin of bacteremia, bacteremia due to pneumonia, antimicrobial resistance to carbapenems, and elevated Acute Physiology and Chronic Health Evaluation II and Pitt bacteremia scores. Multivariate logistic regression analysis revealed that resistance to carbapenems (odds ratio [OR]: 4.01, 95% confidence interval [CI]: 1.51 to 0.68, P = 0.005), need for mechanical ventilation (OR: 3.97, 95% CI: 1.41 to 11.13, P = 0.005), and presence of malignancy (OR: 4.40, 95% CI: 1.60 to 12.08, P = 0.004) were significantly related to mortality risk. CONCLUSIONS: Risk factors such as resistance to carbapenems, mechanical ventilation, and presence of malignancy were found to be associated with high mortality rates in the patients with A. baumannii bacteremia.

Characteristics of Device-Associated Cerebrospinal Fluid Infection in Adults

OBJECTIVE: Device-associated infections in the central nervous system are serious complications of procedures involving indwelling devices among neurosurgical patients. In this study, the clinical characteristics and outcome of microbiologically confirmed device-associated cerebrospinal fluid (CSF) infection were evaluated. METHODS: We performed a retrospective analysis of adult patients found to have a positive CSF culture result during a hospital admission between 1 January 2005 through 2 October 2010 in Soonchunhyang University Hospital. RESULTS: During the study period, all episodes (n=161 CSF specimens, 87 patients) involving a culture-positive CSF were enrolled. Thirty-two episodes of device-associated CSF infection were included in the analysis among the study group. Most device-associated infections were ventriculo-peritoneal shunt infections (14/32, 44%). Fever (>38degrees C) was present in 17 episodes (53%). Overall, the most common microorganism was coagulase-negative staphylococcus (7/32 [22%]). Gram-negative rods (Pseudomonas aeruginosa 6/32 [19%], Acinetobacter baumannii/haemolyticus 5/32 [16%]) were identified in culture in 16/32 (50%). Device was removed for the control of device-associated infection in 30/32 (94%). Cure rate was 69% (22/32). All patients with treatment failure (10/32, 34%) expired. CONCLUSION: It is difficult to diagnosis device-associated CSF infections early since those are frequently presented with nonspecific clinical signs and symptoms. In our study, gram-negative infections accounted for 50% of cases and the empiric antibiotics initially chosen were found to not be effective against the final identified pathogen in many cases. Device-associated CSF infections should be strongly considered a serious risk factor associated with CSF infections, and prompt initiation of broad coverage antibiotics should be started after appropriate assessment.

Autoimmune Diseases after Autologous Hematopoietic Stem Cell Transplantation in Patients with Non-Hodgkin's Lymphoma / 대한내과학회지

Autologous hematopoietic stem cell transplantation (HSCT) is an effective treatment for patients with relapsed or high-risk Non-Hodgkin's lymphoma (NHL). HSCT fundamentally interferes with the immune system. As a consequence, development of autoimmunity after HSCT has been observed during the past several decades. Most evidence is derived from single case reports or studies on small series of patients who developed novel-onset autoimmune diseases after use of HSCT to treat various conditions. We treated 3 NHL patients with autoimmune disease among 54 NHL patients who received high-dose chemotherapy and autologous HSCT.

Risk Factors for Mortality in Patients with Candidemia and the Usefulness of a Candida Score / 대한의진균학회지

BACKGROUND: Although effective antifungal agents for the treatment of candidemia have recently been introduced, the mortality rate attributed to candidemia remains high (19~49%). OBJECTIVE: This study aimed at evaluating the risk factors for mortality in patients with candidemia and at assessing the usefulness of a Candida Score in these patients. METHODS: A cohort of patients with positive blood cultures for Candida species was retrospectively analyzed at Soonchunhyang University Hospital, a 750-bed teaching hospital, from May 2003 to February 2012. The Candida Score was calculated by assigning 1 point to any of total parenteral nutrition (TPN), surgery, or multifocal Candida species colonization, and 2 points to severe sepsis. RESULTS: Sixty patients (68.3% men; mean age (standard deviation [SD]), 61.8 [18.9] years) with blood cultures positive for Candida species were identified. Most patients had been admitted to an intensive care unit (48 [80%]), were receiving broad-spectrum antibiotics (37 [61.7%]), had TPN (29 [48.3%]), had diabetes mellitus (23 [38.3%]), and were receiving hemodialysis (10 [16.7%]). The mean (SD) Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 19.60 (8.8). Twenty-three patients (38.3%) had a Candida Score >2.5. The Candida species causing infection included C. albicans (41 [68.3%]), C. tropicalis (7 [11.7%]), C. parapsilosis (4 [6.7%]), C. krusei (3 [5%]), C. glabrata (3 [5%]), C. guilliermondii (1 [1.7%]), and C. catenulata (1 [1.7%]). Only 32 patients (53.3%) received adequate antifungal treatment. The candidemia-related mortality rate was 61.7% (n = 37 patients). Multivariate logistic regression analysis demonstrated that a high APACHE II score (adjusted odds ratio [aOR], 1.2; 95% confidence interval [95% CI], 1.0~1.3; p = 0.01), presence of a malignancy (aOR, 14.8; 95% CI, 2.5~88.0; p = 0.003), and treatment with an antifungal agent (aOR, 0.2; 95% CI, 0.0~1.0; p = 0.048) were associated with disease-related mortality. CONCLUSION: The risk factors for mortality in patients with candidemia are a high APACHE II scores and presence of a malignancy. However, the sensitivity of the Candida Score was not high (38.3%). New methods to rapidly identify candidemia and avoid delays in treatment with appropriate antifungal therapy are needed.

Necrotizing Fasciitis in Three University Hospitals in Korea: A Change in Causative Microorganisms and Risk Factors of Mortality During the Last Decade / 감염과화학요법

BACKGROUND: Necrotizing fasciitis is a life-threatening infectious disease with rapidly progressive involvement of the affected site. Because of the high mortality rate of this disease, early diagnosis, surgical exploration, and administration of appropriate antibiotics are necessary. The present study aimed to further review the changes in the clinical and microbiological characteristics of necrotizing fasciitis using patients' medical records from consecutive databases of 3 hospitals in Korea. MATERIALS AND METHODS: In this study, we retrospectively reviewed the medical records of patients with necrotizing fasciitis who were clinically diagnosed between May 2001 and February 2012 in 3 university hospitals in Korea. In total, the data of 83 patients were analyzed, including those of 20 patients from our previous study in 2006. An organism found in a blood culture or surgical specimen was regarded as a causative organism. RESULTS: Of the 83 patients, 68(81.9%) had community-acquired infections. Ninety microorganism species were indentifed by culture. Streptococcus was the most commonly identified pathogen. Non-fermentative gram-negative bacteria and Candida species have recently emerged, especially in immunocompromised hosts. CONCLUSIONS: Gram-positive organisms are still the most common pathogens of necrotizing fasciitis. However in our study, various gram-negative bacteria with different levels of susceptibility to antibiotics, as well as Candida species, were responsible for the necrotizing fasciitis. Initial empirical antimicrobial agents for necrotizing fasciitis should be considered depending on the individual patient's condition.