Trends in Microorganisms Isolated from Blood Cultures at a Veterans Hospital from 2012 to 2015

Blood culture is important to detecting bacteremia and fungemia in patients with suspected sepsis. We observed a four-year trend of blood culture isolates in the frequency by age group and in vitro antimicrobial susceptibility patterns obtained at VHS Medical Center, the largest veterans hospital in Korea. Blood cultures collected between 2012 and 2015 were analysed retrospectively. Of 68,352 blood specimens, 7,901 isolates were identified during the study period. Seventy-two percent of the isolates were gram-positive cocci, 18% were gram-negative rods, and 6% were fungi. The frequency of bacteremia/fungemia in patients who were 80–89 years old was 43.8%, the highest rate among all age groups, and the mean age of patients diagnosed by blood culture was 77 years old. Coagulase-negative staphylococcus (52.3%), Staphylococcus aureus (8.3%), enterococci (7.5%), Escherichia coli (6.4%), and Klebsiella pneumoniae (3.9%) were the bacteria most commonly isolated. The percentage of methicillin-resistant S . aureus increased in 2015 (76%) relative to that in 2012–2014 (63%–65%), and that of vancomycin-resistant Enterococcus faecium was 17%–22% with no significant changes through time. Among the gram-negative isolates, the ciprofloxacin resistance rate increased to 51.4% (E. coli ) and 31.1% (K. pneumoniae ) in 2015, but imipenem or ertapenem resistance was still very rare, with resistance rates of less than 0.5%. Acinetobacter baumannii showed a high rate of resistance (over 70%) to imipenem and ciprofloxacin throughout the study. In Pseudomonas aeruginosa , the resistance rates of imipenem and ciprofloxacin increased dramatically over time. This analysis confirmed a decrease in antimicrobial susceptibility of gram-negative rods isolated by blood culture.

Brain Abscess Caused by Vancomycin-Resistant Enterococci

No abstract available.

A Case of Adult Onset Still's Disease with Severe Pneumonitis Treated with Anakinra / 대한내과학회지

Adult onset Still's disease (AOSD) is a systemic autoinflammatory disorder that presents with recurrent fever, extreme fatigue, and joint pain. Pulmonary involvement is not uncommon and, although rare, severe pneumonitis can progress to respiratory failure. Still's disease-associated pneumonitis is generally treated with immunosuppressive agents, but improvement in our understanding of systemic inflammatory processes led us to explore alternative agents. Anakinra is an interleukin-1 receptor antagonist used to treat autoinflammatory disorders resistant to immunosuppressive therapy. Several case reports have demonstrated efficacy of anakinra in treating AOSD, but its relevance in cases complicated with severe pneumonitis has not been examined. Our patient's disease activity was not controlled with systemic steroids and cyclophosphamide. Treatment with anakinra led to a dramatic clinical response. This is the first reported case of AOSD with severe pneumonitis refractory to conventional therapy successfully treated with anakinra.

A Case of Systemic Lupus Erythematosus-Associated Hemophagocytic Lymphohistiocytosis Treated Successfully with an Etoposide Infusion / 대한내과학회지

Hemophagocytic lymphohistiocytosis (HLH) can develop following strong activation of the immune system and the cardinal symptoms are a prolonged fever, hematological abnormalities, hepatosplenomegaly, and hemophagocytosis. HLH can be classified as primary or secondary HLH, associated with infections, malignancy and autoimmune disease. There is no consensus on the primary treatment regimen in systemic lupus erythematosus (SLE)-associated HLH. We experienced a case of SLE-associated HLH in a previously healthy adult. She was initially treated with intravenous immunoglobulin, cyclosporine, and high-dose steroid, but had a poor clinical response. After intravenous etoposide, the patient stabilized and has been followed for 1 year without reactivation of the HLH or SLE.

Necrotizing Fasciitis of the Thigh Secondary to Radiation Colitis in a Rectal Cancer Patient

Necrotizing fasciitis usually occurs after dermal injury or through hematogenous spread. To date, few cases have been reported as necrotizing fasciitis of the thigh secondary to rectal perforation in rectal cancer patients. A 66-year-old male complained of pelvic and thigh pain and subsequently developed necrotizing fasciitis in his right thigh. Four years earlier, he had undergone a low anterior resection and radiotherapy due to of rectal cancer. An ulcerative lesion had been observed around the anastomosis site during the colonoscopy that had been performed two months earlier. Pelvic computed tomography and sigmoidoscopy showed rectal perforation and presacral abscess extending to buttock and the right posterior thigh fascia. Thus, the necrotizing fasciitis was believed to have occurred because of ulcer perforation, one of the complications of chronic radiation colitis, at the anastomosis site. When a rectal-cancer patient complains of pelvic and thigh pain, the possibility of a rectal perforation should be considered.

Treatment of Neurosyphilis with Ceftriaxone in a Patient Infected with Human Immunodeficiency Virus

The optimal and alternative antimicrobial regimens to treat neurosyphilis in human immunodeficiency virus (HIV) infected patients remain controversial. Little is known concerning the efficacy of ceftriaxone. A 75-year-old heterosexual man visited an outpatient clinic due to incidentally detected positive serum Venereal disease research laboratory (VDRL) and Fluorescent treponemal antibody absorbed tests in routine preoperative checkup. Because of benzathine penicillin was unavailable to use, 4-week regimen with doxycycline was started. After 2 weeks doxycycline treatment, a severe headache suddenly occurred. Cerebrospinal fluid (CSF) analysis showed mild lymphocyte-dominant pleocytosis, increased protein, and weakly reactive VDRL test. ELISA for HIV antibody and Western blot assay revealed he is infected with HIV. Initial CD4+ T cell count was 220/mm3 and the load of HIV RNA was 5,200 copies/mL. The most probable diagnosis was deemed to be neurosyphilis, considering the possibilities of Jarisch-Herxheimer reaction or doxycycline-induced pseudotumor cerebri. In the absence of procaine penicillin G in our hospital, intravenous ceftriaxone was administered and highly active antiretroviral therapy was started. After 14days of treatment, the patient no longer had a headache and the CSF profile was improved. Additional follow-up CSF analysis was done 3months after treatment. CSF pleocytosis and protein level were decreased and the CSF VDRL was converted to negative. Ceftriaxone may be a good alternative in the treatment of neurosyphilis in HIV infected patient.

AIDS presenting with severe thrombocytopenia: A case report / 대한내과학회지

The hematologic manifestations of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) are common and may cause symptoms that are life threatening and impair the quality of life in these patients1). The most important of these manifestations is cytopenia. Among cytopenias, thrombocytopenia is caused by immune-mediated destruction of platelets, in addition to inadequate platelet production2). Thrombocytopenia has been reported in 5~15% of HIV-seropositive patients3). Profound thrombocytopenia (< 20,000/mm3) is rare (occurs in only 1.5% of cases) and presents only during advanced AIDS. With the exception of thrombocytopenia associated with advanced AIDS, severe thrombocytopenia in AIDS patients is extremely rare3). There are only a few reports of AIDS patients who first presented with severe thrombocytopenia. Here we report the case study of an AIDS patient who first presented with severe thrombocytopenia, mild abdominal distension, and edema in both lower legs. A brief review of the relevant literature is also presented.

AIDS presenting with severe thrombocytopenia: A case report / 대한내과학회지

The hematologic manifestations of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) are common and may cause symptoms that are life threatening and impair the quality of life in these patients1). The most important of these manifestations is cytopenia. Among cytopenias, thrombocytopenia is caused by immune-mediated destruction of platelets, in addition to inadequate platelet production2). Thrombocytopenia has been reported in 5~15% of HIV-seropositive patients3). Profound thrombocytopenia (< 20,000/mm3) is rare (occurs in only 1.5% of cases) and presents only during advanced AIDS. With the exception of thrombocytopenia associated with advanced AIDS, severe thrombocytopenia in AIDS patients is extremely rare3). There are only a few reports of AIDS patients who first presented with severe thrombocytopenia. Here we report the case study of an AIDS patient who first presented with severe thrombocytopenia, mild abdominal distension, and edema in both lower legs. A brief review of the relevant literature is also presented.

An Outbreak of Scabies in Neurosurgery-Intensive Care Unit of a General Hospital / 병원감염관리

BACKGROUND: Scabies outbreaks have been reported in long-term care facilities, but less commonly in acute care facilities. We experienced an outbreak of scabies that occurred in neurosurgery-intensive care unit of a general hospital, Seoul, Korea. METHODS: An outbreak of scabies was noticed on September 2006 when hospital staffs of NICU were diagnosed with scabies. The infection control nurse reviewed medical records and interviewed all of patient in NICU and health care workers. The epidemic spread of scabies from a patient to other patient, hospital employees and their families and associates was identified from historical, clinical, and microbiologic skin preparation data. RESULTS: Forty-three NICU patients and 22 health care workers were investigated. Five scabies cases were identified in total of 42 cases who are exposed to index case with attack rate of 11.9%. The attack rate of scabies in health care workers and NICU patients were 10% and 13.6%, respectively. Tertiary cases also occurred among the family members of workers, with a tertiary attack rate of 44%. CONCLUSION: The patient of acute care facilities also have chances of being exposed to scabies outbreak, since sensorimotor deficits or cognitive disorders make it difficult for individuals to communicate and understand the implication of risky contacts.

Pseudobacteremic Outbreak of Leclercia adecarboxylata and Pseudomons aeruginosa Related to Contaminated Saline Cotton / 병원감염관리

BACKGROUND: During a 1-month period in 2005 , a series of 4 Leclercia adecarboxylata and 8 Pseudomonas aeruginosa bacteremias were reported from patients admitted to the emergency room. METHODS: An outbreak of L. adecarboxylata and P. aeruginosa bacteremia that occurred from February to March 2005 was investigated. The infection control nurse reviewed medical records and observed the procedures of blood cultures at the clinical microbiology laboratory. Specimens were obtained for investigational cultures from alcohol sponge, tray, sink, water of sink, saline cotton, microscope, computer, and telephone. RESULTS: L. adecarboxylata was isolated from 4 patients and P. aeruginosa from 8 patients during a 1-month period. Observation of the culture procedure revealed that saline cotton was used to prevent betadin skin discoloration. The culture of the saline solution yielded a heavy growth of P. aeruginosa, which was not isolated from any other specimens. CONCLUSIONS: This was a pseudoepidemic caused by contaminated saline cotton. The use of the saline cotton was stopped, and during the follow-up period of 3 months, no additional L. adecarboxylata or P. aeruginosa bacteremia were reported.

Current Status of Prophylaxis for Endocarditis

BACKGROUND AND OBJECTIVES: Antibiotic prophylaxis of infective endocarditis is required before high-risk procedures in patient with high-risk heart diseases. Although guidelines for the prevention of infective endocarditis were proposed by the American Heart Association in 1997, compliance to these recommendations has not been evaluated in Korea. SUBJECTS AND METHODS: This was a retrospective, multicentered study in 8 Korean university hospitals. Patients with high-risk heart diseases, having undergone invasive dental procedures between Jan. 1, 2000 and Dec. 31, 2003, were enrolled. The medical and dental records of the patients were reviewed to evaluate whether the prophylaxis had been appropriate. RESULTS: Of the initial 4,912 patients, 184 that had been treated with invasive dental procedures (255 total episodes, mean 1.4/patient) were evaluated. The most common high-risk heart disease was a prosthetic heart valve (233 procedures), followed by a previous history of infective endocarditis (22 procedures), cyanotic heart diseases (5 procedures) and systemic pulmonic venous shunts (2 procedures). Antibiotic prophylaxis was performed in 231 procedures (90.8%). Amoxicillin was the most common antibiotic used for prophylaxis (88.6%); however, the adequate dosage (2 gm) was administered in only 56% of these cases. Therefore, the appropriate prophylaxis, according to the AHA recommendations, was performed in only 14.1% (36 procedures). The mean duration of prophylaxis and number of antibiotic doses were 2.40 days (2.40+/-2.44) and 7.97 doses (7.97+/-7.18), respectively. A previous history of infective endocarditis (p=0.03) and dental extraction (p<0.01) resulted in a longer duration of prophylaxis. CONCLUSION: Only 14.1% of the high risk group procedures were given appropriate antibiotic prophylaxis according to the AHA recommendations. These data suggest that protocol-based education of both doctors and patients is required for appropriate antimicrobial therapy during high-risk procedures for the prevention of infective endocarditis in patients with high-risk heart disease.

Therapeutic Efficacy of Meropenem for Treatment of Experimental Penicillin-Resistant Pneumococcal Meningitis

With the widespread emergence of antimicrobial resistance, combination regimens of ceftriaxone and vancomycin (C+V) or ceftriaxone and rifampin (C+R) are recommended for empirical treatment of pneumococcal meningitis. To evaluate the therapeutic efficacy of meropenem (M), we compared various treatment regimens in arabbit model of meningitis caused by penicillin-resistant Streptococcus pneumoniae (PRSP). Therapeutic efficacy was also evaluated by the final bacterial concentration in the cerebrospinal fluid (CSF) at 24 hr. Each group consisted of six rabbits. C+V cleared the CSF at 10 hr, but regrowth was noted in 3 rabbits at 24 hr. Meropenem monotherapy resulted in sterilization at 10 hr, but regrowth was observed in all 6 rabbits at 24 hr. M+V also resulted in sterilization at 10 hr, but regrowth was observed in 2 rabbits at 24 hr. M+V was superior to the meropenem monotherapy at 24 hr (reduction of 4.8 vs. 1.8 log10 cfu/mL, respectively; p=0.003). The therapeutic efficacy of M+V was comparable to that of C+V (reduction of 4.8 vs. 4.0 log10 cfu/mL, respectively; p=0.054). The meropenem monotherapy may not be a suitable choice for PRSP meningitis, while combination of meropenem and vancomycin could be a possible alternative in the treatment of PRSP meningitis.

A Case of Cytomegalovirus (CMV) Colitis in a Patient after Splenectomy / 대한소화기내시경학회지

Cytomegalovirus (CMV) is the most common cause of life-threatening opportunistic viral infection in patients with acquired immunodeficiency syndrome (AIDS). However, CMV infection may occur in the immunocompetent individuals. CMV colitis has not been reported in a patient with splenectomy in Korea. Recently, we experienced a case of fatal CMV colitis in a patient with splenectomy. A 69-year-old man complained of bloody mucoid diarrhea and abdominal pain for 2 months. He had the splenectomy 6 months ago. CMV colitis was diagnosed by colonoscopy and pathologic examination. He died of sepsis in spite of antiviral ganciclovir therapy.

Unique alterations in penicillin-binding protein 2B of multidrug-resistant Streptococcus pneumoniae from Korea / 감염

BACKGROUND: Pneumococcal resistance became a global issue during the past decades. Korea is reported to be the hottest spot in the world with regard to the prevalence of penicillin and multidrug resistance. Previous molecular epidemiologic studies strongly suggested that antibiotic-resistant pneumococci from Korea are genetically related. To investigate the molecular characteristics of multidrug-resistant (MDR) pneumococcal isolates in Korea, we performed the DNA sequencing of the gene encoding penicillin-binding protein (PBP) 2B. METHODS: A total of 9 invasive MDR strains which were collected from 1990 to 1995 in various parts of Korea and one internationally epidemic Spanish 23F clone were analyzed. The 1.5 kb transpeptidase-encoding region (TER) of PBP 2B gene was amplified and directly sequenced using ABI PRISM Big Dye Terminator cycle sequencing kit (Perkin Elmer). Sequence data were compared with that of a penicillin-susceptible R6 strain. RESULTS: Alterations in nucleotide sequence (5.4-7.8%) and amino acids (3.0-4.3%) of the PBP 2B gene were relatively uniform among 9 Korean MDR strains. Most alterations in nucleotides (86-94%) and amino acids (86-100%) were noted in the hypervariable region between 408 and 993 bp. All 9 strains possessed 14 common alterations in amino acids, among which Asn-276-->Lys, Arg-285-->Cys and Ser-305-->Phe substitutions were unique to Korean MDR strains. CONCLUSION: Sequence analysis of invasive MDR strains showed that a limited number of amino acid substitutions were noted in the wild-type Korean MDR strains in the transpeptidase domain of the PBP 2B gene. Data strongly suggest the possibility of the spread of a few epidemic clones of resistant pneumococci within Korea, which could partly explain the rapid increase of pneumococcal resistance.

A Case of Pichia ohmeri Fungemia Related to the Central Venous Catheter / 감염

Pichia ohmeri is a very rare pathogen of human infection. To date, two cases of P. ohmeri infection were reported worldwide. We have experienced a case of catheter-related P. ohmeri fungemia. The patient had been admitted due to cerebrovascular accident in rehabilitation center since August 1998. He had been bedridden due to previous cerebrovascular accident and undergone several episodes of nosocomial infection. Multiple antimicrobial agents had been used with central venous catheter for parenteral nutrition. On February 1999, he had developed fever and dyspnea. Vancomycin and imipenem were administered empirically and central venous catheter was removed on the impression of central venous catheter related infection. Blood culture and catheter tip culture grew P. ohmeri. He developed septic shock and finally led to death before the administration of amphotericin B.

A Case of Skin and Soft Tissue Infection Caused by Mycobacterium abscessus / 감염

Mycobacterium abscessus (formerly M. chelonae sub-species abscessus) is an acid-fast bacillus classified as pathogenic "rapid growing" nontuberculous mycobacteria. Even though these organisms are ubiquitous in the environment, it is an uncommon cause of human diseases. M. abscessus can cause skin and soft tissue infection associated with a penetrating wound or a foreign body but it can spread to viscera other than the lungs leading to a variety of infections. The single most important factor determining the course and prognosis of M. abscessus infection is the underlying immune status of the hosts. There have been no reports of skin and soft tissue infection caused by M. abscessus in Korea. We experienced a case of skin and soft tissue infection with M. abscessus. A 43-year-old female patient developed necrotizing infection in the skin, soft tissue and fascia in the lower extremity without a definite preceding cause. She was treated successfully with prolonged drug therapy including clarithromycin, and surgical debridement.

Cytomegalovirus Infections after Renal Transplantation / 감염

Cytomegalovirus (CMV) infections commonly develop between the second and sixth month after renal transplantation. The incidence of CMV infection in renal transplant recipients, which depends on their serological status regarding CMV antibody and the use of immunosuppressants, is reported to be 38~67%. However, CMV infection after renal transplantation has been rarely reported in Korea. Recently, we experienced 4 cases of symptomatic CMV infection after renal transplantation, which were diagnosed by CMV antigenemia assay. With the development of more sensitive diagnostic methods, CMV infection may become recognized more commonly among renal transplant recipients.

Cryptococcal Meningitis in 25 Non-AIDS Patients / 감염

BACKGROUND: Cryptococcal meningitis is an opportunistic infection common among patients with AIDS. Because of the low incidence of cryptococcal meningitis in Korea, there have been insufficient data on the clinical features of cryptococcal meningitis in non-AIDS Korean patients, particularly in patients with liver cirrhosis (LC). We evaluated the clinical manifestations of cryptococcal meningitis in non-AIDS patients admitted at the Samsung Medical Center and assessed the relationship between LC and cryptococcal meningitis. METHODS: The medical records of 25 non-AIDS patients with cryptococcal meningitis admitted between May 1995 and March 1999 were reviewed. Cryptococcal meningitis was confirmed by positive culture of CSF or compatible clinical features plus a positive cry-ptococcal latex test. The mean age of the 25 patients was 55 years and the median duration of follow-up was 95.5 days. Underlying conditions were:use of immunosuppressants (including steroids) (47.8%), LC (34.8%), diabetes mellitus (34.8%), malignancy (17.4%), alcoholism (8.7%), and none (21.7%, five patients). RESULTS: There were no differences in the clinical manifestations between the LC and non-LC groups, with the exception of mental deterioration, which was more frequent in patients with LC than without LC (P= 0.026). The outcomes were:complete cure in six cases, cure with sequelae in five, and treatment failure in ten. The crude and attributable mortality rates of cryptococcal meningitis were 62.5% (15/24) and 50.0% (12/24), respectively. LC was a significant risk factor for a poor survival rate among patients with cryptococcal meningitis (OR:3.25, 95% CI, 1.02~10.40) (P=0.045). CONCLUSION: In Korea, liver cirrhosis is an important risk factor for cryptococcal meningitis and an attributable factor for its high mortality. Because it is possible to confuse mental obtundation in cirrhotic patients with that of hepatic encephalopathy, cryptococcal meningitis should be considered in any patients with altered consciousness and liver cirrhosis.

A Case of Spontaneous Repture of Renal Artery Aneurysm in Polyarteritis Nodosa / 대한신장학회잡지

Although renal aneurysmal formation in polyarteritis nodosa is common, it is rare to form complication of perirenal hematoma caused by spontaneous rupture of renal aneurysm. It should be differentiated from renal tumor, arterio-venous malforrnation, renal infarction, coagulopathy, and acute hydronephrosis in considering the cause of perirenal hematoma. In addition to that, it is a potential life-threatening complication and its early recognition and prompt treatrnent are emphasized. We describe a patient with polyarteritis nodosa who developed spontaneous perinenal hematoma due to repture of renal aneurysm, who had nonspecific symptoms. We thought polyarteritis nodosa based on present illness and clinical background, then immediately performed angiography and coil embolization. So the patient could be treated with cyclophosphamide and steroid successfully. Polyarteritis nodosa is a relatively rare disease, but should be included as one of the differential diagnosis whenever perirenal hematoma occurs.

A Case of Diabetes Insipidus with Langerhans Cell Histiocytosis in Adult / 대한내분비학회지

In Langerhans cell histiocytosis, diabetes insipidus is the most common endocrinologic complication. We experienced a case of Langerhans cell histiocytosis, involving pituitary stalk and lung. The patient was a 43 year old male with complaint of polyuria and polydipsia. The water deprivation test was carried out to confirm the diagnosis of diabetes insipidus. We found multiple small cysts and nodules in HRCT of lung, and diagnosed Langerhans cell histiocytosis by transbronchial lung biopsy, The patient was managed conservatively with DDAVP nasal spray. The polyuria,polydipsia was relieved completely. After that, we follow up and observe closely the patients lung and pituitary lesion.