A Prospective, Multicenter, Randomized Trial for Duration of the Prophylactic Antibiotics after Elective Colorectal Surgery: 3 Days versus 5 Days

PURPOSE: The use of prophylactic antibiotics in elective colorectal surgery is essential. Although postoperative prophylactic antibiotics are recommended within 24 hr, the optimal duration of the use of prophylactic antibiotics after colorectal surgery has not yet been fully proven in Korea. The aim of this study was to compare infectious outcomes in elective colorectal cancer surgery between postoperative 3-day antibiotic therapy and 5-day therapy. METHODS: We conducted a multicenter, randomized trial of a 3-day use vs. a 5-day use of the second-generation cephalosporin cefotetan after elective colorectal surgery. The main outcome measures were the incidences of surgical site infection and all other infectious complications within 21 days after surgery. RESULTS: A total of 306 patients were enrolled. Fifty-one patients were excluded because they received additional surgery or dropped out during the study. Two-hundred fifty-five patients were analyzed in this study. The two groups were similar in terms of demographics, ASA score, tumor location, tumor stage, surgical approach (conventional open vs. laparoscopy-assisted vs. robotic-assisted), and type of operation. The incidences of surgical site infection were not significantly different between the 3-day use group (4/130 or 3.1%) and the 5-day use group (3/125 or 2.4%) (P=1.000). Incidences of overall infectious diseases did not differ significantly between the two groups. Postoperatively, both groups had similar values in their white blood cell count, absolute neutrophil count, and C-reactive protein levels. However, the number of patients is small to draw a definite conclusion in this study. CONCLUSION: Three-day cefotetan administration may be not inferior in preventing surgical site infection compared to 5-day antibiotic administration. However, further studies with a large number of patients are needed before a definite conclusion can be drawn.

Metabolic Complications in Korean HIV/AIDS Patients Receiving Highly Active Anti-retroviral Therapy / 감염과화학요법

BACKGROUND: Since the introduction of HAART (Highly Active Anti-Retroviral Therapy), metabolic com- plications have been reported with varying prevalence. We performed a retrospective study to evaluate the incidence and risk factors of metabolic complications arising in Korean HIV/AIDS patients. MATERIALS AND METHODS: 66 HIV positive patients on combination therapy between 1998 June to 2002 June with at least 1 protease inhibitor (PI) or/and Non-nucleoside reverse transcriptase inhibitors (NNRTI) were reviewed. Hyperglycemia was defined as serum glucose >140 mg/dL on 2 or more occasions; diabetes as any random serum glucose >200 mg/dl; hypercholesterolemia as serum cholesterol >240 mg/dL; hypertriglyceridemia as serum triglyceride >200 mg/dL. We used SPSS version 9.0 for statistical analysis. One way ANOVA was used to compare the treatment groups. Multinominal logistic regression analysis was used for risk factor analysis. RESULTS: 66 patients were analyzed and total duration of follow up was 138 patient-years. The incidence of metabolic complication was 20.3%. Incidence of hypertriglyceridemia, hypercholesterolemia, hyperglycemia, and diabetes were 12.3%, 5.8%. 1.4%, 4.3% respectively. On risk factor analysis, factors contributing to the development of metabolic complication were age>35 years (P= 0.020) and baseline serum triglyceride >140 mg/dL (P=0.001). Baseline CD4 count 6 months (P=0.055) were associated with development of metabolic complications with borderline significance. CONCLUSION: The incidence of metabolic complication among Korean HIV/AIDS patients receiving HAART is 20.3%. Older age and high baseline triglyceride were risk factors for development of metabolic complications.

Metabolic Complications in Korean HIV/AIDS Patients Receiving Highly Active Anti-retroviral Therapy / 감염과화학요법

BACKGROUND: Since the introduction of HAART (Highly Active Anti-Retroviral Therapy), metabolic com- plications have been reported with varying prevalence. We performed a retrospective study to evaluate the incidence and risk factors of metabolic complications arising in Korean HIV/AIDS patients. MATERIALS AND METHODS: 66 HIV positive patients on combination therapy between 1998 June to 2002 June with at least 1 protease inhibitor (PI) or/and Non-nucleoside reverse transcriptase inhibitors (NNRTI) were reviewed. Hyperglycemia was defined as serum glucose >140 mg/dL on 2 or more occasions; diabetes as any random serum glucose >200 mg/dl; hypercholesterolemia as serum cholesterol >240 mg/dL; hypertriglyceridemia as serum triglyceride >200 mg/dL. We used SPSS version 9.0 for statistical analysis. One way ANOVA was used to compare the treatment groups. Multinominal logistic regression analysis was used for risk factor analysis. RESULTS: 66 patients were analyzed and total duration of follow up was 138 patient-years. The incidence of metabolic complication was 20.3%. Incidence of hypertriglyceridemia, hypercholesterolemia, hyperglycemia, and diabetes were 12.3%, 5.8%. 1.4%, 4.3% respectively. On risk factor analysis, factors contributing to the development of metabolic complication were age>35 years (P= 0.020) and baseline serum triglyceride >140 mg/dL (P=0.001). Baseline CD4 count 6 months (P=0.055) were associated with development of metabolic complications with borderline significance. CONCLUSION: The incidence of metabolic complication among Korean HIV/AIDS patients receiving HAART is 20.3%. Older age and high baseline triglyceride were risk factors for development of metabolic complications.

Detection and Phylogenetic Analysis of Coxsackievirus A24 Variant Causing Nation-wide Epidemic of Acute Hemorrhagic Conjunctivitis in Korea, 2002 / 감염과화학요법

BACKGROUND: Nation-wide outbreak of acute hemorrhagic conjunctivitis occurred in the summer, 2002 in South Korea. We identified the causative agent of this outbreak through virus culture and molecular biological techniques. METHODS: Polymerase chain reaction (PCR) was carried out with direct conjunctival swab samples and cell culture supernatants. Conjunctival swab was done at a community based-eye clinic in Seoul, September 2002. Initial screening for adenovirus and enterovirus was performed. Nested PCR for adenovirus was done with adenovirus common primers using direct swab sample, and reverse transcription PCR (RT-PCR) for enterovirus was done with enterovirus common primers. RT-PCR with primer 188/222 for VP1 region of enterovirus was done, if initial screening test was positive. PCR product was sequenced, and homology searching, compared to prototype strains, was done for serotyping. Protease 3C region of coxsackievirus A24v was amplified and sequenced with primer D1/U2. The sequence of this region was compared to those of viral isolates, which had been obtained from several Asian outbreaks since 1970. RESULTS: Conjunctival swabs were performed in 88 patients. Thirty nine (44%) samples out of the 88 were culture positive on HeLa or MRC-5 cells. Nine (100%) out of 9 culture supernatants, randomly selected from 39 culture positve samples, were positive for coxsackievirus A24v-specific RT-PCR. Phylogenetic analysis showed that sequences from 14 culture positive supernatants, randomly selected from 39 culture positive samples, clustered into a time-related, but distinct lineage, with Asian strains. CONCLUSIONS: We identified the causative agent of the epidemic hemorrhagic conjunctivits in year 2002 as coxsackievirus A24v.

Detection and Phylogenetic Analysis of Coxsackievirus A24 Variant Causing Nation-wide Epidemic of Acute Hemorrhagic Conjunctivitis in Korea, 2002 / 감염과화학요법

BACKGROUND: Nation-wide outbreak of acute hemorrhagic conjunctivitis occurred in the summer, 2002 in South Korea. We identified the causative agent of this outbreak through virus culture and molecular biological techniques. METHODS: Polymerase chain reaction (PCR) was carried out with direct conjunctival swab samples and cell culture supernatants. Conjunctival swab was done at a community based-eye clinic in Seoul, September 2002. Initial screening for adenovirus and enterovirus was performed. Nested PCR for adenovirus was done with adenovirus common primers using direct swab sample, and reverse transcription PCR (RT-PCR) for enterovirus was done with enterovirus common primers. RT-PCR with primer 188/222 for VP1 region of enterovirus was done, if initial screening test was positive. PCR product was sequenced, and homology searching, compared to prototype strains, was done for serotyping. Protease 3C region of coxsackievirus A24v was amplified and sequenced with primer D1/U2. The sequence of this region was compared to those of viral isolates, which had been obtained from several Asian outbreaks since 1970. RESULTS: Conjunctival swabs were performed in 88 patients. Thirty nine (44%) samples out of the 88 were culture positive on HeLa or MRC-5 cells. Nine (100%) out of 9 culture supernatants, randomly selected from 39 culture positve samples, were positive for coxsackievirus A24v-specific RT-PCR. Phylogenetic analysis showed that sequences from 14 culture positive supernatants, randomly selected from 39 culture positive samples, clustered into a time-related, but distinct lineage, with Asian strains. CONCLUSIONS: We identified the causative agent of the epidemic hemorrhagic conjunctivits in year 2002 as coxsackievirus A24v.

Risk Factors for Infection and Treatment Outcome of Bloodstream Infections due to Extended Spectrum beta-Lactamases Producing Klebsiella pneumoniae / 감염과화학요법

BACKGROUND: This study was conducted to evaluate risk factors for infection and treatment outcome of bloodstream infection due to extended spectrum beta-lactamases(ESBL)-producing K. pneumoniae. METHODS: ESBL production was evaluated by NCCLS guidelines and/or double-disk synergy test in K. pneumoniae blood isolates stored from January, 1998 to April, 2002. Sixty patients with bloodstream infection due to ESBL-producing K. pneumoniae (case patients) were compared with 159 matched control patients with bloodstream infection of non-ESBL-producing K. pneumoniae. Retrospective case-control study was performed. RESULTS: There were no significant differences in age, sex, APACHE II score, and the primary site of infection between the case and control groups. In multivariate analysis, significant independent risk factors associated with bloodstream infection due to ESBL-producing K. pneumoniae were urinary catheterization, invasive procedure within previous 72 hours, and the number of antibiotics administered within previous 30 days. In clinical response at 72 hours after initial antibiotic treatment, complete response rate was higher in the controls (13.3% vs. 40.3%, respectively, P<0.001), however, treatment failure rate was higher in the cases (33.3% vs. 11.9%, respectively, P<0.001). Overall 7- day mortality rates in the cases and the controls were was 20% (12/60) and 15.7% (25/159) (P= 0.451), respectively, and overall 30-day mortality rates were 30% (18/60) and 24.5% (39/159), respectively (P=0.410). When the patients with bloodstream infection of ESBL-producing organism were evaluated and the patients who received inadequate definitive antibiotic treatment were excluded, delayed effective antibiotic treatment was found to be not associated with higher mortality. CONCLUSION: In patients infected with ESBL-producing K. pneumoniae bacteremia, clinical response rate at 72 hours after antimicrobial therapy was lower, but the increase of mortality rate was not significant. Delayed effective antibiotic treatment was not associated with higher mortality, when definitive appropriate antibiotic treatment was prescribed.

Risk Factors for Infection and Treatment Outcome of Bloodstream Infections due to Extended Spectrum beta-Lactamases Producing Klebsiella pneumoniae / 감염과화학요법

BACKGROUND: This study was conducted to evaluate risk factors for infection and treatment outcome of bloodstream infection due to extended spectrum beta-lactamases(ESBL)-producing K. pneumoniae. METHODS: ESBL production was evaluated by NCCLS guidelines and/or double-disk synergy test in K. pneumoniae blood isolates stored from January, 1998 to April, 2002. Sixty patients with bloodstream infection due to ESBL-producing K. pneumoniae (case patients) were compared with 159 matched control patients with bloodstream infection of non-ESBL-producing K. pneumoniae. Retrospective case-control study was performed. RESULTS: There were no significant differences in age, sex, APACHE II score, and the primary site of infection between the case and control groups. In multivariate analysis, significant independent risk factors associated with bloodstream infection due to ESBL-producing K. pneumoniae were urinary catheterization, invasive procedure within previous 72 hours, and the number of antibiotics administered within previous 30 days. In clinical response at 72 hours after initial antibiotic treatment, complete response rate was higher in the controls (13.3% vs. 40.3%, respectively, P<0.001), however, treatment failure rate was higher in the cases (33.3% vs. 11.9%, respectively, P<0.001). Overall 7- day mortality rates in the cases and the controls were was 20% (12/60) and 15.7% (25/159) (P= 0.451), respectively, and overall 30-day mortality rates were 30% (18/60) and 24.5% (39/159), respectively (P=0.410). When the patients with bloodstream infection of ESBL-producing organism were evaluated and the patients who received inadequate definitive antibiotic treatment were excluded, delayed effective antibiotic treatment was found to be not associated with higher mortality. CONCLUSION: In patients infected with ESBL-producing K. pneumoniae bacteremia, clinical response rate at 72 hours after antimicrobial therapy was lower, but the increase of mortality rate was not significant. Delayed effective antibiotic treatment was not associated with higher mortality, when definitive appropriate antibiotic treatment was prescribed.

A case of Sweet's syndrome with pulmonary involvement / 대한내과학회지

Sweet's syndrome is a rare disorder presenting with painful erythematous plaques or nodules of the skin with fever, leukocytosis, arthralgia and conjunctivitis.Sweet's syndrome occurs in association with malignant tumors in 10~20% of cases. Eighty five percent of the malignant tumors are hematologic malignancies, acute myelogenous leukemia being most common. Sweet's syndrome occurring in a patient with solid tumor is rare and pulmonary involvement of Sweet's syndrome occurring in a patient with a solid tumor has not been reported in world literature so far. We report a case of Sweet's syndrome presenting with pulmonary nodules in a patient with hepatocellular carcinoma.

Clinical Manifestations and Treatment Outcome of Invasive Aspergillosis / 감염

BACKGROUND: The incidence of invasive aspergillosis has been increasing as the number of severe immunocompromised hosts has increased. We reviewed representative cases of invasive aspergillosis to describe clinical manifestations and treatment outcome. METHODS: We identified 40 cases of invasive aspergillosis on the ground of pathologic and radiologic findings from January 1991 to December 2000 and reviewed medical records and laboratory data. RESULTS: Forty cases of invasive aspergillosis included 28 'definite' cases and 12 'probable' cases. Major involved organs of invasive aspergillosis were lung (n=23, 57.5%), sinus (n=11, 27.5%), brain (n=3, 7.5%), spine (n=1, 2.5%), skull (n=1, 2.5%), and small bowel (n=1, 2.5%). Underlying diseases and risk factors were hematologic malignancies (n=21, 52.5%), high-dose steroid treatment (n=8, 20%), post-transplantation of solid organ (n=2, 5%), and ectopic ACTH syndrome (n=1, 2.5%). Immunocompetent hosts including DM patients were 8 cases (20%) and their major involved sites were sinus (n=4) and brain (n=2). Crude mortality rate of total invasive aspergillosis after 3 months and 12 months were 30% and 47.5%, respectively. 3-month and 12-month mortality rate for pulmonary aspergillosis (n=23) were 39%, 61% and those for extrapulmonary aspergillosis (n=17) were 18 %, 29%. Patients with hematologic malignancy (n=21) were in 33%, 57%, other immunocompromised hosts (n=11) were in 45%, 45%, and immunocompetent hosts (n=8) were in 0%, 25%. Patients with aggravated underlying diseases and sustained risk factors (n=20) were in 60%, 70% and patients with improved underlying diseases and no risk factor (n=20) were in 0%, 20%. CONCLUSION: Invasive aspergillosis mainly developed in severe immunocompromised hosts, but invasive sinus aspergillosis and cerebral aspergillosis occasionally developed in apparently immunocompetent hosts. The degree of immunosuppression and severity of underlying diseases affected the treatment outcome of invasive aspergillosis.

The Effects of Initial Empirical Antibiotics Regimens on the Outcomes of Staphylococcus aureus Bacteremia / 감염

BACKGROUND: Because of the concern for the emergence of resistance, the prudent use of vancomycin is essential. However, it is uncertain whether the initial delay in the effective treatment of Staphylococcus aureus bacteremia adversely affects the outcome. We performed this study to determine the outcome of an initial delay in the use of antistaphylococcal antibiotics for Staphylococcus aureus bacteremia (SAB). METHODS: We conducted a retrospective cohort study of 238 with SAB at a tertiary care hospital. Empirical antibiotics treatment was considered ineffective if the isolated strain was not susceptible, in vitro, to antibiotics given during the first 48 hours. The outcome was measured as SAB-related mortality within 8 weeks from the SAB. RESULTS: The mortality for the patients with ineffective empirical regimen (50/117, 42.7%) showed a trend toward being higher than that with effective empirical regimen (38/121, 31.4%), but it did not reach the statistical significance (OR 1.63 95% CI 0.96~2.77, P=0.07). However, in the subgroups of end-stage renal disease ineffective empirical antibiotics adversely affected the outcomes (OR 5.42, 95% CI 1.25~23.49, P=0.02) On multivariate logistic regression analysis, adjusted OR of ineffective empirical regimen for SAB-related mortality was 2.03 (95% CI 1.08~3.82, P=0.03). CONCLUSION: Our findings suggest that an initial delay in the use of antistaphylococcal antibiotics for the first 2 days might adversely affect the outcome when treating SAB, especially in the patients with end-stage renal disease.

Scrub Typhus in a Pregnant Woman: No Evidence of Intrauterine Infection / 감염

Pregnancy with scrub typhus is a rare condition. A 30-year-old woman was infected with scrub typhus at the 35th week of gestation. She was treated successfully with azithromycin, and delivered her baby uneventfully. The baby developed no signs for scrub typhus, and thrived well. IgM antibodies to O. tsutsugamushi were undetectable in the baby's sera, and titers of IgG antibodies did not rise. The polymerase chain reaction of the cord blood for O. tsutsugamushi was also negative. We concluded that transplacental infection did not occur in this pregnant woman.

A case of Klinefelter's syndrome associated with systemic lupus erythematosus / 대한내과학회지

The incidence of systemic lupus erythematosus (SLE) is known to be affected by sex hormone. Patients with Klinefelter's syndrome were reported to have abnormal sex hormonal metabolism and their chronic estrogenic stimulation seems to affect the pathogenesis of SLE. Therefore, association of SLE and Klinefelter's syndrome has been considered as a clue of the effect of sex hormone on SLE. We report the first case of Klinefelter's syndrome in a patient with SLE in Korea and discuss the association of SLE with Klinefelter's syndrome.