A Proactive Testing Strategy to COVID-19 for Reopening University Campus during Omicron Wave in Korea: Ewha Safe Campus (ESC) Project / 이화의대지

Objectives@#Ewha Womans University launched an on-campus Coronavirus disease-19 (COVID-19) response system called Ewha Safety Campus (ESC) Project in collaboration with the Seegene Inc. RTPCR diagnostic tests for COVID-19 were proactively provided to the participants. This study examines the effectiveness of the on-campus testing strategy in controlling the reproduction number (Rt ) and identifying student groups vulnerable to infection. @*Methods@#The ESC project was launched on March 2, 2022, with a pilot period from Feb 22 to March 1, 2022—the peak of the Omicron variant wave. We collected daily data on the RT-PCR test results of the students of Ewha Womans University from Mar 2 to Apr 30, 2022. We daily calculated Rt and compared it with that of the general population of Korea (women, people aged 20–29 years, and Seoul residents). We also examined the students vulnerable to the infection based on the group-specific Rt and positivity rate. @*Results@#A lower Rt was observed about 2 weeks after the implementation of the ESC Project than that of the general population. The lower Rt persisted during the entire study period. Dormitory residents had a higher Rt . The positivity rate was higher in students who did not comply with quarantine guidelines and did not receive the second dose of the vaccine. @*Conclusion@#The study provides scientific evidence for the effectiveness of the on-campus testing strategy and different infection vulnerabilities of students, depending on dormitory residence, compliance with the quarantine guidelines, and vaccination.

Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs

The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.

Clinical Prediction Score for Community-Onset Bloodstream Infections Caused by Extended-Spectrum Beta-Lactamase-Producing Escherichia coli and Klebsiella Species

BACKGROUND: This study aimed to identify the predictors and build a prediction score for community-onset bloodstream infections (CO-BSIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species. METHODS: All CO-BSIs caused by E. coli and Klebsiella species from 2012 to 2015 were grouped into derivation (BSIs from 2012 to 2014) and validation (BSIs in 2015) cohorts. A prediction score was built using the coefficients of the multivariate logistic regression model from the derivation cohort. RESULTS: The study included 886 CO-BSIs (594 and 292 in the derivation and validation cohorts, respectively). The independent predictors of CO-BSIs caused by ESBL-producing E. coli and Klebsiella species included: 1) identification of ESBL-producing microorganisms from any clinical culture within one year of admission, 2) beta-lactam or fluoroquinolone treatment within 30 days (with 2 or more courses within 90 days; with 1 course within 90 days), 3) hospitalization within one year, 4) the presence of an indwelling urinary catheter at the time of admission. The area under the curve (AUC) of the clinical prediction score was 0.72 (95% confidence interval [CI], 0.68–0.77). In the validation cohort, the AUC was 0.70 (95% CI, 0.63–0.77). CONCLUSIONS: The results of this study suggest a simple and easy-to-use scoring system to predict CO-BSIs caused by ESBL-producing E. coli and Klebsiella species.

Serotype Distribution and Antimicrobial Susceptibilities of Invasive Streptococcus pneumoniae Isolates from Adults in Korea from 1997 to 2012

In Republic of Korea, a 7-valent pneumococcal conjugated vaccine (PCV7) was licensed for use in infants in 2003, and 13-valent PCV (PCV13) replaced it since 2010. We investigated trends in serotype distribution and antibiotic susceptibility of pneumococcal isolates from adult patients with invasive pneumococcal diseases (IPD). Invasive pneumococcal isolates from adult patients of ≥ 16 years of age were collected from 1997 to 2012. Serotypes of the isolates were determined by the Quellung reaction. Distribution of serotypes was analyzed according to the vaccine types. Antibiotic susceptibility was tested by using E-test strips. A total of 272 invasive pneumococcal isolates were included. The most common serotypes were serotype 19F (8.5%, 23/272), and serotype 3 (8.1%, 22/272), and 24.6% (67/272) of the isolates were of non-vaccine serotypes. Of the 272 isolates, 2.6% (7/272) were penicillin MICs of ≥ 4 µg/mL. The proportion of the PCV13 serotypes decreased from 63.3% (50/79) in 1997-2003 to 48.6% (17/35) in 2011-2012, whereas that of non-vaccine serotypes was 26.6% (21/79) and 25.7% (9/35), respectively, for the same periods. The proportion of the PCV13 serotypes showed a decreasing trend among adult patients with IPD over the study period.

Effects of Blood Volume Monitoring on the Rate of Positive Blood Cultures from the Emergency Room / 대한임상미생물학회지

BACKGROUND: Blood cultures are essential in diagnosing and treating sepsis. There are several factors that affect the diagnostic yield of blood cultures such as the number of blood sampling episodes, the incubation period, the type and volume of culture media, and the amount of blood drawn. This study aimed to elucidate whether monitoring the volume of blood drawn with an educational intervention could affect the diagnostic quality of blood cultures. METHODS: We implemented quality monitoring for the blood volume drawn during blood culture testing for adults in an emergency room. We instructed the nurses in the emergency room to draw the optimal amount of blood and to reduce the number of blood culture sets from three to two. We analyzed and compared the amount of blood drawn, the rate of positive blood cultures, the contamination rate, and time to positivity (TTP) between 908 patients pre-intervention and 921 patients post-intervention. RESULTS: The amount of blood drawn increased from 0.7±0.3 mL per bottle (pre-intervention) to 6.5±1.7 mL per bottle (post-intervention) (P<0.0001). The rate of positive blood culture post-intervention (12.14%) was higher than that pre-intervention (6.65%) (P<0.0001). The contamination rate post-intervention (1.82%) was also significantly greater than that pre-intervention (0.60%) (P<0.0001). Except for anaerobes, there was no significant difference in the distribution of microorganisms between the pre- and post-intervention periods. The TTP for anaerobe bottles post-intervention was significantly shorter than that of pre-intervention (16.1±16.3 versus 18.6±18.3 h). CONCLUSION: This study suggests that continuing education about adequate blood volume and aseptic techniques is needed to increase the rate of positive blood cultures and reduce the contamination rate of blood cultures.

Subacute progressive disseminated histoplasmosis in immunocompetent patient

No abstract available.

Infected Aortic Aneurysm caused by Mycobacterium bovis after Intravesical Bacillus Calmette-Guerin Treatment for Bladder Cancer

A 70-year-old man presented with lower back pain and cyanotic changes in his left lower extremity. He was diagnosed with infected aortic aneurysm and infectious spondylitis. He had received intravesical Bacillus Calmette-Guerin (BCG) therapy up to 1 month before the onset of symptoms. The aneurysm was excised and an aorto-biiliac interposition graft was performed. Mycobacterium tuberculosis complex was cultured in the surgical specimens. Real-time polymerase chain reaction (PCR) targeting the senX3-regX3 region, and multiplex PCR using dual-priming oligonucleotide primers targeting the RD1 gene, revealed that the organism isolated was Mycobacterium bovis BCG. The patient took anti-tuberculosis medication for 1 year, and there was no evidence of recurrence at 18 months follow-up.

Low Compliance with National Guidelines for Preventing Transmission of Group 1 Nationally Notifiable Infectious Diseases in Korea

PURPOSE: This study was performed to evaluate the compliance with, and adequacy of, the Korean national guidelines which had been recommended until 2011 for isolation of patients with group 1 nationally notifiable infectious diseases (NNIDs), namely cholera, typhoid fever, paratyphoid fever, shigellosis, and enterohemorrhagic Escherichia coli (EHEC) infection. MATERIALS AND METHODS: We evaluated the clinical and microbiological characteristics of confirmed cases of group 1 NNIDs and compliance with the guidelines in 20 Korean hospitals nationwide in 2000-2010. We also compared the Korean guidelines with international guidelines. RESULTS: Among 528 confirmed cases (8 cases of cholera, 232 of typhoid fever, 81 of paratyphoid fever, 175 of shigellosis, and 32 EHEC infections), strict compliance with the Korean guideline was achieved in only 2.6% to 50.0%, depending on the disease. While the Korean guidelines recommend isolation of all patients with group 1 NNIDs, international guidelines recommend selective patient isolation and screening for fecal shedding, depending on the type of disease and patient status. CONCLUSION: Compliance with the previous national guidelines for group 1 NNIDs in Korea was generally very low. Further studies are needed to evaluate whether compliance was improved after implementation of the new guideline in 2012.

Appropriateness of Surgical Antibiotic Prophylaxis in a Tertiary Hospital / 병원감염관리

BACKGROUND: This study aimed to evaluate the quality of surgical antibiotic prophylaxis (SAP) in a tertiary hospital. METHODS: Medical, anesthetic, and nursing records from the 27,320 procedures conducted in a tertiary hospital during 2012 were retrospectively reviewed. Three clinical performance indicators of SAP (selection of antibiotic, timing of the first administration, duration of prophylaxis) were included as part of the National Hospital Evaluation Program (NHEP) of the Health Insurance Review and Assessment Service. In addition, 2 other parameters were assessed according to recent guidelines (weight-based initial dosing for obesity, intraoperative re-dosing for excessive blood loss, and prolonged duration of procedures). RESULTS: Prophylactic antibiotics were administered in 19,637 (71.8%) of 27,320 total procedures. Quality of the 3 performance indicators was higher in the types of operations included in NHEP than in other procedures. However, additional doses were administered in 15 (1.2%) of 1,299 surgical procedures that lasted more than twice the half-life of the antibiotic used, and in 9 (3.3%) of 273 procedures with excessive blood loss greater than 1,500 mL. NHEP and non-NHEP results did not differ significantly. CONCLUSION: Three SAP quality indicators showed more improvement in NHEP surgical procedures than in non-NHEP, but the other parameters did not perform well regardless of NHEP assessment. Therefore, more measures to improve the appropriateness of SAP should be developed.

Evidence-based Guidelines for Empirical Therapy of Neutropenic Fever in Korea

Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3 5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers.

Evidence-Based Guidelines for Empirical Therapy of Neutropenic Fever in Korea

Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3-5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers.

A Case of Diabetic Foot Infection due to Mycobacterium mageritense

Diabetic foot infection is one of the important complications in patients with advanced diabetes mellitus. Limb threatening infections such as osteomyelitis, abscess, and necrotizing fasciitis are frequently accompanied by the disease. Non-tuberculous mycobacterium (NTM) is a rare causative organism of diabetic foot infection. Thus, if one is not suspicious or meticulous, infection due to NTM will be easily overlooked and this will result in delayed diagnose and treat. Therefore, it is necessary to consider NTM as the causative organism if the wound does not respond to the conventional antibiotic treatment and the culture from the adequately obtained specimen reveals atypical acid-fast bacilli. We present a case of diabetic foot infection with osteomyelitis and abscess due to Mycobacterium mageritense, one of the rapid growing mycobacteria, that was successfully treated with surgical debridement and appropriate antibiotic treatment.

A Case of Nocardia farcinica Brain Abscess in the Patient Receiving Steroid Treatment

Nocardiosis occurs mostly in the immunocompromised patients. N. farcinica is known to have resistance to some antibiotics and significant increase in morbidity and mortality in patients requiring long-term treatment. Nocardia farcinica infection, especially brain abscess, has not been reported in Korea. Here, we report a case of N. farcinica brain abscess in a patient receiving steroid treatment. The patient was a 64 year-old male with gouty arthritis. He received steroid for more than two months, because of allopurinol-hypersensitivity syndrome with skin rash. After three months of steroid therapy, he visited other hospital with mild fever and left thigh pain and was diagnosed of intramuscular abscess due to gram positive bacilli. One month later, he visited our hospital with right side weakness and was diagnosed as brain abscess. The causative organism turned out to be N. farcinica, which was confirmed by means of 16S rRNA sequencing. Antibiotics were selected by E-test results and treatment was successful

A Case of Tsutsugamushi Disease after Traveling to the Philippines

Infectious diseases imported from other countries have increased as more and more Koreans are going abroad for various purposes. Tsutsugamushi disease from other endemic area such as Southeast Asia is important, because it can occur in any season and eschar may be absent. We report a case of imported tsutsugamushi disease acquired in the Philippines. A patient presented with fever, headache, and maculopapular skin rash. However, eschar was absent. Polymerase chain reaction (PCR) for 56-kDa gene of Orientia tsutsugamushi using buffy coat was positive. Serum indirect immunofluorescent antibody assay was initially negative but became positive with a titer of 1:320 at follow-up. Sequencing analysis revealed the strain to be 100% identical to the TW73R strain identified in Taiwan. After the patient received doxycycline, body temperature normalized in 12 hours. Tsutsugamushi disease is one of the differential diagnoses that should be included for patients with fever who have recently returned from Southeast Asian countries. PCR for O. tsutsugamushi using patient's buffy coat was useful for early diagnosis.

A Case of Diabetic Foot Infection due to Mycobacterium mageritense

Diabetic foot infection is one of the important complications in patients with advanced diabetes mellitus. Limb threatening infections such as osteomyelitis, abscess, and necrotizing fasciitis are frequently accompanied by the disease. Non-tuberculous mycobacterium (NTM) is a rare causative organism of diabetic foot infection. Thus, if one is not suspicious or meticulous, infection due to NTM will be easily overlooked and this will result in delayed diagnose and treat. Therefore, it is necessary to consider NTM as the causative organism if the wound does not respond to the conventional antibiotic treatment and the culture from the adequately obtained specimen reveals atypical acid-fast bacilli. We present a case of diabetic foot infection with osteomyelitis and abscess due to Mycobacterium mageritense, one of the rapid growing mycobacteria, that was successfully treated with surgical debridement and appropriate antibiotic treatment.

A Case of Nocardia farcinica Brain Abscess in the Patient Receiving Steroid Treatment

Nocardiosis occurs mostly in the immunocompromised patients. N. farcinica is known to have resistance to some antibiotics and significant increase in morbidity and mortality in patients requiring long-term treatment. Nocardia farcinica infection, especially brain abscess, has not been reported in Korea. Here, we report a case of N. farcinica brain abscess in a patient receiving steroid treatment. The patient was a 64 year-old male with gouty arthritis. He received steroid for more than two months, because of allopurinol-hypersensitivity syndrome with skin rash. After three months of steroid therapy, he visited other hospital with mild fever and left thigh pain and was diagnosed of intramuscular abscess due to gram positive bacilli. One month later, he visited our hospital with right side weakness and was diagnosed as brain abscess. The causative organism turned out to be N. farcinica, which was confirmed by means of 16S rRNA sequencing. Antibiotics were selected by E-test results and treatment was successful

A Case of Tsutsugamushi Disease after Traveling to the Philippines

Infectious diseases imported from other countries have increased as more and more Koreans are going abroad for various purposes. Tsutsugamushi disease from other endemic area such as Southeast Asia is important, because it can occur in any season and eschar may be absent. We report a case of imported tsutsugamushi disease acquired in the Philippines. A patient presented with fever, headache, and maculopapular skin rash. However, eschar was absent. Polymerase chain reaction (PCR) for 56-kDa gene of Orientia tsutsugamushi using buffy coat was positive. Serum indirect immunofluorescent antibody assay was initially negative but became positive with a titer of 1:320 at follow-up. Sequencing analysis revealed the strain to be 100% identical to the TW73R strain identified in Taiwan. After the patient received doxycycline, body temperature normalized in 12 hours. Tsutsugamushi disease is one of the differential diagnoses that should be included for patients with fever who have recently returned from Southeast Asian countries. PCR for O. tsutsugamushi using patient's buffy coat was useful for early diagnosis.

A Case of Good's Syndrome

Good's syndrome is the association of thymoma with immunodeficiency, characterized by hypogammaglobulinemia, B-cell lymphopenia and variably defects in cellular immunity with CD4+ T-cell lymphopenia and an inverted CD4+:CD8+ T-cell ratio. We report a 43-year-old male patient who presented with a 18-month history of productive cough and postnasal drip. One year ago, he underwent the operation for resection of a thymoma. Despite of appropriate management, sinusitis relapsed multiple times. He was found to have hypogammaglobulinemia with nearly absent B cells(4/microliter). The CD4+ T-cell count was 554/microliter with an inverted CD4+:CD8+ T-cell ratio of 0.6. His symptoms and signs improved with antibiotic treatment and monthly administration of intravenous immunoglobulin (IVIG, 400 mg/kg).

A Case of Good's Syndrome

Good's syndrome is the association of thymoma with immunodeficiency, characterized by hypogammaglobulinemia, B-cell lymphopenia and variably defects in cellular immunity with CD4+ T-cell lymphopenia and an inverted CD4+:CD8+ T-cell ratio. We report a 43-year-old male patient who presented with a 18-month history of productive cough and postnasal drip. One year ago, he underwent the operation for resection of a thymoma. Despite of appropriate management, sinusitis relapsed multiple times. He was found to have hypogammaglobulinemia with nearly absent B cells(4/microliter). The CD4+ T-cell count was 554/microliter with an inverted CD4+:CD8+ T-cell ratio of 0.6. His symptoms and signs improved with antibiotic treatment and monthly administration of intravenous immunoglobulin (IVIG, 400 mg/kg).