Antibiotic Resistance Patterns of Enterobacteriaceae Isolated from Patients with Healthcare-Associated Infections

Background@#There have been recent proposals to categorize healthcare-associated infections (HCAIs) separately from community-acquired infections (CAIs). The aim of this study was to compare the antibiotic resistance of pathogens causing CAIs, HCAIs, and hospital-acquired infections (HAIs) in Korea, and to investigate the need for different empirical antibiotics therapy for CAIs and HCAIs. @*Materials and Methods@#This prospective study was conducted in a university hospital between March and December 2019. Inpatients who underwent a bacterial culture within 2 days of hospitalization, with a Enterobacteriaceae strain identified at the infection site and available antibiotic susceptibility results, were included in the analysis. Infections were classified as CAIs, HCAIs or HAIs, depending on the source. @*Results@#Of the 146 patients included in the analysis, the prevalence of fluoroquinoloneresistant Enterobacteriaceae was 18.8%, 38.5%, and 55.0%; the prevalence of pathogens showing third-generation cephalosporins resistance was 8.3%, 50.0%, and 60.0%; and the prevalence of pathogens showing piperacillin-tazobactam resistance was 8.3%, 7.7%, 15.0% in the CAIs, HCAIs, and HAIs groups, respectively. The prevalence of extended-spectrum beta-lactamase-positive pathogens was 6.3%, 47.3%, and 55.0% in the CAIs, HCAIs, and HAIs group, respectively, with no significant difference between the HCAIs and HAIs groups. Resistance patterns of the HCAIs group more closely resembled those of the HAIs group than those of the CAIs group. @*Conclusion@#The pathogens isolated from patients with HCAIs showed resistance patterns that were more similar to those of patients with HAIs than those with CAIs. Thus, CAIs and HCAIs should be distinguished from each other when selecting antibiotic agents.

Antibiotic Resistance Patterns of Enterobacteriaceae Isolated from Patients with Healthcare-Associated Infections

Background@#There have been recent proposals to categorize healthcare-associated infections (HCAIs) separately from community-acquired infections (CAIs). The aim of this study was to compare the antibiotic resistance of pathogens causing CAIs, HCAIs, and hospital-acquired infections (HAIs) in Korea, and to investigate the need for different empirical antibiotics therapy for CAIs and HCAIs. @*Materials and Methods@#This prospective study was conducted in a university hospital between March and December 2019. Inpatients who underwent a bacterial culture within 2 days of hospitalization, with a Enterobacteriaceae strain identified at the infection site and available antibiotic susceptibility results, were included in the analysis. Infections were classified as CAIs, HCAIs or HAIs, depending on the source. @*Results@#Of the 146 patients included in the analysis, the prevalence of fluoroquinoloneresistant Enterobacteriaceae was 18.8%, 38.5%, and 55.0%; the prevalence of pathogens showing third-generation cephalosporins resistance was 8.3%, 50.0%, and 60.0%; and the prevalence of pathogens showing piperacillin-tazobactam resistance was 8.3%, 7.7%, 15.0% in the CAIs, HCAIs, and HAIs groups, respectively. The prevalence of extended-spectrum beta-lactamase-positive pathogens was 6.3%, 47.3%, and 55.0% in the CAIs, HCAIs, and HAIs group, respectively, with no significant difference between the HCAIs and HAIs groups. Resistance patterns of the HCAIs group more closely resembled those of the HAIs group than those of the CAIs group. @*Conclusion@#The pathogens isolated from patients with HCAIs showed resistance patterns that were more similar to those of patients with HAIs than those with CAIs. Thus, CAIs and HCAIs should be distinguished from each other when selecting antibiotic agents.

Positivity of Carbapenemase-producing Enterobacteriaceae in Patients Following Exposure within Long-term Care Facilities in Seoul, Korea

Background@#Carbapenemase-producing Enterobacteriaceae (CPE) are emerging as a worldwide threat. Long-term care facilities (LTCFs) are considered a reservoir for CPE and play a central role in transmission to acute care hospitals. We investigated the CPE positivity in patients exposed to CPE in LTCFs. Furthermore, we analyzed the CPE positivity rates in the environment exposed to CPE. @*Methods@#We collected rectal swab specimens from patients residing in LTCFs who were exposed to CPE. Environmental sampling was performed by infection control practitioners from sites classified as patient private space, common space in the patient room, common space other than patient rooms, and nursing station. Each sample was cultured on a Chrom KlebsiellaF pneumoniae carbapenemase (KPC) agar for CPE screening. The positive isolates were subjected to a polymerase chain reaction to identify the presence of bla KPC , bla VIM , bla IMP , bla OXA-48 , and bla NDM and determine CPE genotype. @*Results@#From 65 index cases, a total of 24 hospitals and 481 patients were enrolled; 414 patients who had resided in the same patient room as a patient with confirmed CPE and 67 patients who were newly admitted to that patient room. A total of 117 (24.3%) patients were positive for CPE among which 93 (22.5%, 93/414) were already admitted patients and 24 (35.8%, 24/67) were newly admitted patients. A total of 163 CPEs were detected and K. pneumoniae (n = 104, 63.8%) was the most common bacteria followed by Escherichia coli (n = 43, 26.4%) and Citrobacter koseri (n = 11, 6.7%). Environmental sampling was performed in 24 hospitals and 604 sites. A total of 12 sites (2.0%) were positive for CPE and sink in the nursing station (n = 6, 4.2%) was the most contaminated space. @*Conclusion@#CPE colonization rates in patients exposed to CPE in LTCFs were higher than those found in acute care hospitals. Proper infection control measures for detecting and reducing CPE colonization in patients residing in LTCFs are required. Newly admitted patients could also be carriers; therefore, infection control for newly admitted patients also needs to be thorough.

The Analgesic Effect of Different Dosing Methods When Using Transdermal Fentanyl Patches after Laparoscopic Cholecystectomy

BACKGROUND: The advances in surgical technology, anesthesia and perioperative care have made it possible to perform laparoscopic cholecystectomy on an outpatient basis. This study was conducted to assess the analgesic effect and the adverse events of different dosing methods when using transdermal fentanyl patches (TDFPs) after laparoscopic cholecystectomy. METHODS: Sixty patients who were to undergo laparoscopic cholecystectomy under general anesthesia were divided into two groups. Group 1: 2 TDFPs that released 12microgram/h were applied after the induction of anesthesia and these 2 patches were removed after 24 hours. Group 2: 2 TDFPs that released 12microgram/h were applied after the induction of anesthesia and one patch was removed after 7 hours and the other patch was removed after 24 hours. The intensity of the postoperative pain was assessed by using a visual analogue scale (VAS) and assessing the adverse events, including dizziness, pruritus and nausea/vomiting, were recorded for 48 hours postoperatively. RESULTS: The VAS score of postoperative pain was not significantly different between the two groups at all times. The incidence of dizziness in groups I and II was 10 and 3, respectively, and the incidence of nausea/vomiting in group I and II was 4 and 0, respectively. The incidences of dizziness and nausea/vomiting in group II were significantly lower than those of group I (P < 0.05). CONCLUSIONS: A dosing method that removes half of the TDFPs (24microgram/h) after 7 hours of application caused a lower incidence of dizziness and nausea/vomiting without any significant difference of postoperative analgesic efficacy, as compared to leaving on both the TDFPs (24microgram/h) for 24 hours after laparoscopic cholecystectomy.

Bispectral index monitoring to assess the level of consciousness in patients with brain injury / 대한마취과학회지

BACKGROUND: It is important to assess the level of consciousness in patients with brain injuries to determine modes of treatment and prognosis. We evaluated the Bispectral Index (BIS) to determine if it could be used as an objective tool for evaluation of the level of consciousness in brain-injured patients. We also compared the BIS values to clinical sedation scales such as the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), and the Reaction Level Scale (RLS). METHODS: Thirty eight patients with brain injuries that were admitted to the neurosurgery intensive care unit (NSICU) were enrolled in this study. An investigator evaluated the clinical sedation scales (GCS, RASS, RLS), while a blind observer noted the BIS in the same patient. The BIS score was obtained three times at an interval of 5 hours. The BISs were measured for 1 minute at 5 min prior to the nursing assessment, during the nursing assessment, and at 5 min after the nursing assessment. The BISs used in the data analysis were the maximal, minimal, and mean values obtained during 1 min, which were defined as BISmax, BISmin, and BISmean. A Spearman's rank correlation coefficient was used to determine if the clinical sedation scales were correlated with the BIS scores. RESULTS: In 38 patients, the BISmax, BISmin, and BISmean were found to be significantly correlated with the GCS, RASS, and RLS. The BISmean had the highest correlation with GCS (r = 0.445, P < 0.01), while the BIS min had the lowest correlation with RLS (r = -0.278, P < 0.01). CONCLUSIONS: The results of BIS monitoring were found to be significantly correlated with sedation scales in patients with brain injuries. These findings suggest that BIS can be used as an objective and continuous method for assessment of the level of consciousness in patients with brain injury.

Anesthesia for electroconvulsive therapy during pregnancy: A case report / 대한마취과학회지

Electroconvulsive therapy (ECT) is sometimes indicated for the treatment of psychiatric disorders during pregnancy. We describe a patient at 17-26 weeks gestation who took twelve ECT treatments for her bipolar disorder. At third ECT, we changed the induction agent from thiopental sodium to propofol due to her post-ECT delirium. At ninth ECT, there was a brief fetal heart rate deceleration associated with maternal ECT. The patient gradually improved and was discharged in remission after twelve ECT treatments. A healthy boy was born by cesarean section at 38 weeks of gestation. We report this case with a brief review of the relevant literature.

Effect of smoking on bronchial mucus transport velocity under total intravenous anesthesia / 대한마취과학회지

BACKGROUND: The aim of this study was to measure the effect of smoking on bronchial mucus transport velocity with bronchoscope under total intravenous anesthesia. METHODS: Twenty six ASA physical status I male patients (13 smokers and 13 nonsmokers) were enrolled into this study. They scheduled to undergo elective orthopedic surgery and were operated under total intravenous anesthesia using propofol and remifentanil. Single drop (approximately 0.02 cc) of methylene blue was applied to the posterior mucosal surface of right main bronchus 5 cm away from carina by the bronchoscope with epidural catheter 30 minutes after tracheal intubation. Two, four minutes after methylene blue application, the transport of methylene blue was observed. Six minutes after methylene blue application, the distance of methylene blue movement was measured. RESULTS: Mean bronchial mucus transport distance and velocity of methylene blue in smoker group vs nonsmoker group was 9.1 +/- 5.5 mm and 1.5 +/- 1.0 mm/min vs 24.3 +/- 15.2 mm and 4.1 +/- 2.5 mm/min respectively. Mean bronchial mucus transport distance of methylene blue in the smoker group was shorter than that in the nonsmoker group (P value < 0.05). Mean bronchial mucus transport velocity of methylene blue in the smoker group was slower than that in the nonsmoker group (P < 0.05). CONCLUSIONS: Smoking may delay transport of bronchial secretion in terms of bronchial mucus transport velocity under total intravenous anesthesia.

The Comparison of Magnesium Sulfate and Remifentanil in Attenuating Hemodynamic Response to Endotracheal Intubation / 대한마취과학회지

BACKGROUND: Laryngoscopy and endotracheal intubation may cause tachycardia and hypertension. Magnesium directly inhibits the release of catecholamine from the adrenal medulla, with has a vasodilating effect. Remifentanil indirectly decreases the release of catecholamine by increasing the depth of anesthetic. The effects of magnesium sulfate and remifentanil at attenuating the sympathetic responses were compared during laryngoscopy and endotracheal intubation. METHODS: Eighty ASA class 1 or 2 patients, scheduled for elective surgery under general anesthesia, and requiring endotracheal intubation, were divided into four groups. The patient received either normal saline, 50 mg/kg magnesium sulfate, 1.0microgram/kg remifentanil or 25 mg/kg magnesium sulfate and 0.5microgram/kg remifentanil Groups C, M, R and MR, respectively, according to their assigned group. The specific drugs for each group were administered over a 30 second period prior to the induction of anesthesia with 2 mg/kg propofol and 1.5 mg/kg succinylcholine. The Systolic blood pressure, diastolic blood pressure and heart rate were recorded prior to induction (T1), immediately prior to intubation (T2), immediately after intubation (T3), and 1 and 3 minutes after intubation (T4 and T5, respectively). RESULTS: The percentage changes in the systolic blood pressure of groups M, R and MR were lower immediately after intubation than that of group C. The systolic blood pressures of groups M and MR increased from those at the baseline, but the systolic blood pressure of group R decreased from that at the baseline immediately after intubation. The heart rate of group M increased from that at the baseline, but the heart rate of group R decreased from that at the baseline immediately prior to intubation. CONCLUSIONS: The blood pressure immediately after endotracheal intubation was increased by the administration of magnesium sulfate, but the induced change was less than that of group C. The blood pressure was decreased by the administration of remifentanil immediately after endotracheal intubation. Magnesium sulfate caused tachycardia, but remifentanil caused bradycardia.

Spontaneous Rupture of Native Kidney in a Patient Receiving Kidney Transplantation : A case report / 대한마취과학회지

Spontaneous rupture of a kidney can occur as a complication of an acquired cystic kidney lesion. Herein, one case of a spontaneous rupture of a contralateral native kidney, due to the rupture of a cystic lesion during kidney transplantation surgery, is described. The patient was a 24 year old female admitted for left kidney transplantation due to chronic renal failure. During the operation, her arterial blood pressure and central venous pressure gradually decreased after anastomosis of the renal vessel, but without significant bleeding in the operative field or any suspected cause of the decreasing arterial blood pressure. On the first postoperative day, she underwent an abdominal CT, where a retroperitoneal hematoma was found. Therefore, a right nephrectomy was performed. She also had a right perirenal hematoma due to the rupture of cystic lesion in the native kidney. While a spontaneous rupture of the kidney is very rare, especially during the perioperative period, it is important to consider this complication when evaluating the corresponding clinical picture.

Incidence of Paresthesia Related to the Insertion Length of Catheter during the Epidural Catheterization / 대한통증학회지

BACKGROUND: Continuous epidural catheterization is a popular and effective procedure for postoperative analgesia. However, continuous epidural catheterization has associated complications such as venous puncture, dural puncture, subarachnoid cannulation, suboptimal catheter placement, and paresthesia because the tip of the epidural catheter touches thenerves of the dura in the epidural space. In this study, we compared the incidence of paresthesia in two different lengths of epidural catheter insertion. METHODS: One hundred women undergoing gynecologic or orthopedic surgery were enrolled in this prospective, double-blinded, randomized study. All patients were randomly divided into two groups based on the insertion length of the epidural catheter 2 cm (group A) or 4 cm (group B). A Tuohy needle was inserted in the lumbarspinal region with a bevel directed cephalad by use of the median approach, and then the epidural space was confirmed by the loss of resistance technique with air. While the practitioner inserted an epidural catheter into the epidural space, a blind observer checked for paresthesia or withdrawal movement. RESULTS: In 97 included patients, 30.6% of the patients in group A (n = 49) had paresthesia, versus 31.3% in group B (n = 48). Withdrawal movements were represented in 2% and 6% of the patients in group A and group B, respectively. There was no difference in the incidence of paresthesia and withdrawal movement between the two groups. CONCLUSIONS: There is no clear relationship for the incidence of catheter-related paresthesia according to the catheter length inserted into the epidural space for epidural analgesia.

Jugular Bulb Venous Oxygen Saturation Monitoring in Brain Surgery / 대한마취과학회지

BACKGROUND: During intracranial brain surgery, numerous factors may alter cerebral blood flow and the oxygen supply-demend balance. Continuous monitoring of the jugular bulb venous oxygen saturation (SjvO2) may help in the anesthetic management of such procedures. METHODS: Fiberoptic SjvO2 was continuously monitored and recorded 1, 3 and 5 min after the skin incision, skull bone craniotomy, dura open and dura closure in 20 patients. RESULTS: The SjvO2 was increased after the skin (scalp) incision at 1, 3 and 5 minutes and also after endotracheal suctioning for removal of secretions. CONCLUSIONS: Although the accuracy of Fibroptic SjvO2 determination is limited, it allows the detection of cerebral blood flow and oxygen supply-demend imbalance during brain surgery. The frequent occurance of SjvO2 elevations is suggestive of reactive hyperemia mechaniams.

Study of Lengths from the Upper Incisor to Left and Right Mainstem Bronchial Carina in Korean Adults Using a Fibroptic Bronchoscope / 대한마취과학회지

BACKGROUND: Accurate knowledge of mainstem bronchial lengths are required to prevent malpositioning of double lumen endobronchial tubes (DLT). Therefore we evaluated the length of the mainstem bronchus in Korean adults who had no abnormalities in both mainstem bronchus. METHODS: Two-hundred Thirty-seven patients were composed of One-hundred one males and One- hundred Thirty-six females who underwent elective surgery. After an endotracheal tube was placed, we measured the length from the upper incisor to the tracheal carina, the right mainstem bronchial carina, and the left mainstem bronchial carina using a fiberoptic bronchoscope. RESULTS: The lengths from the upper incisor to the carina of a male and female were 26.8 +/- 1.8 cm and 23.6 +/- 1.9 cm respectively, and the correlations between their length and height are significant for male and female (r = 0.32, P < 0.01 and r = 0.56, p < 0.0001). The lengths from the upper incisor to the right mainstem bronchial carina of male and female were 29.0 2.0 cm and 25.3 2.2 cm respectively, and the correlations between their length and height are significant for male and female (r = 0.39, P < 0.0001 and r = 0.59, P < 0.0001). The lengths from the upper incisor to the left mainstem bronchial carina of male and female were 32.0 2.1 cm and 28.5 2.1 cm respectively, and the correlations between their length and height are significant for male and female (r = 0.45, P < 0.0001 and r = 0.60, P < 0.0001). CONCLUSIONS: We found that as the height of patients increased, the length from the upper incisor to the carina, the right mainstem bronchial carina, and the left mainstem bronchial carina increased. Nevertheless,it should be understood that the length of DLT insertion at any given height is still normally distributed, and correct DLT positioning should always be confirmed fiberoptically after the initial placement.

Comparison of Oxygen Saturation of Pulmonary Artery and Superior Vena Cava during Mitral Valve Replacement / 대한마취과학회지

BACKGROUND: Mixed venous oxygen saturation (SO2) has been considered as an important parameter during therapy of critically ill patients. But pulmonary artery catheterization for monitoring of SO2 involves risks and sometimes may be contraindicated. The purpose of this study was to evaluate whether SO2 could be replaced by oxygen saturation of superior vena cava (SvcO2). METHODS: We inserted pulmonary artery catheter in 38 patients scheduled for undergoing mitral valve replacement. Blood samples for SO2 were drawn from PA ports of pulmonary artery catheter, blood samples for distal SvcO2 were drawn from CVP ports of pulmonary artery catheter and blood samples for proximal SvcO2 were drawn from distal ports of sheat introducer. RESULTS: There was no significant difference between SO2 and SvcO2 (79.6% and 79.9%, 78.0%), and also no significant difference between distal and proximal SvcO2 (79.9%, 78.0%). Correlation of SO2 and SvcO2 was good (r=0.69: PA and SVCD, r=0.62: PA and SVCP). CONCLUSION: We conclude that mixed venous oxygen saturation might be replaced by oxygen saturation of superior vena cava during mitral valve replacement.

Comparison of Effects of Nitroglycerin and Diltiazem on Venous Capacitance in Rats / 대한마취과학회지

The change of venous capacitance has an influence on venous return to the heart and cardiac output, and causes the alteration of preload, cardiac filling pressure and myocardial wall tension. Venous capacitance is assesed by measuring the mean circulatory filling pressure (MCFP), and MCFP is measured during brief periods of circulatory arrest produced by inflating an indwelling balloon in the right atrium It is important to know the effects of vasodilator and anesthetic drugs on venous capacitance. Therefore, this study was performed to know the effects of nitroglycerin and diltiazem on venous capacitance in rats. Rats were anesthetized with ketamine 125 mg/kg given intraperitoneally and added 10 mg/kg every 30 minutes. Their mean arterial pressure (MAP) was lowered to 60 mmHg by intravenous injection of 0.82+/-0.36 mg/kg nitroglycerin and/or 6.7+/-1.5 mg/kg diltiazem. Hemodynamic parameters such as MAP, heart rate, central venous pressure and MCFP were measured before and after drug-injection. Hemodynamic values measured before drug-injection in two groups were little differences statistically. However, the MCFP of nitroglycerin was significantly decreased (p<0.01) from 7.3+/-0.61 mmHg to 5.4+/-0.58 mmHg after drug-injection, and that of diltiazem was not significantly changed from 7.1+/-0.54 mmHg to 6.9+/-0.63 mmHg. The results suggested that nitroglycerin was predominantly a venous dilator in terms of MCFP but diltiazem had little effect of venodilation.

Changes in Arterial and Mixed Venous Carbon Dioxide Tension and Hemodynamic States after Sodium Bicarbonate during Hemorrhagic Shock / 대한마취과학회지

Recently, several investigators have begun to question the routine use of sodium bicsrbonate in metabolic acidosis, based on a failure to clearly demonstrate the efficacy of alkali therapy, which includes the production of carbon dioxide and variability of the effect on hemodynamic state. We studied the use of sodium bicarbonate in a canine model of hemorrhagic shock to determine its effect on arterial, mixed venous blood gases and hemodynamic states. Nine adult mongrel dogs were anesthetized with pentothal sodium and mechanical ventilation was adjusted to maintained the PaCO2 at 30 to 35mmHg. Ar Swan-Ganz catheter was inserted via a right femoral vein and the right femoral artery was cannulated for continuous pressure monitoring and intermittent blood sampling. 30 minutes after hemorrhagic shock, sodium bicarbonate (1mEq/kg) was administered and 1, 5, 15, 30 and 60 minutes after administration of sodium biearbonate we analyzed the arterial, mixed venous blood gases and measured hemodynamic states. The results were as follows, 1) The arterial carbon dioxide tensions(PaCO2) of 1,5,15,30 and 60 minutes after administration of sodium bicarbonate were 44,42,41,42 and 46mmHg which increased significantly compared to control value, 33mmHg. 2) The mixed venous carbon dioxide tensions(PvCO2) ofr 1, 5, 15, 30 and 60 minutes after administration of sodium bicarbonste were 57, 55, 56, 55 and 55mmHg which also increased significantly compared to control value, 46mmHg. 3) The mean arterial pressures of 1, 5, 15, 30 and 60 minutes after administration of sodium bicarbonate were 61, 60, 64, 68 and 70mmHg which increased significantly compared to control value, 50mmHg, but there were no increasements of cardiac output. It is undesirable to use sodium bicarbonate routinely during hemorrhagic shock because the use of sodium bicarbonate in metabolic acidosis increased arterial and mixed venous carbon dioxide tension and did not show the improvement of hemodynsmic derangement.

The Changes of Arterial Ketone Body Ratio and Osmolal Gap during Hemorrhagic Shock in Rabbit / 대한마취과학회지

The ratio of acetoacetate to 8-hydroxybutyrate (ketone body ratio) in the blood may reflects the mitochondrial free NAD+/NADH ratio in the liver. Also arterial ketone body ratio will reflects the energy status of the hepatocytes, because mitochondrial free NAD+/NADH ratio is closely related to oxidative phosphorylation. Arterial ketone body ratio and osmolal gap, the difference between measured osmolality and calculated osmolality, were measured 30 min after the induction of hemorrhagic shock with mean arterial blood pressure at 40 mmHg in ten rabbits. Arterial ketone body ratios decreased significantly (p<0.05) from 0.74+/-0.17 to 0.38+/-0.09 and osmolal gap increased significantly (p<0.05) from 17.7+/-5.9 mOsm/Kg to 32.8+/-12.3 mOsm/Kg at 30 min after the induction of hemorrhagic shock. These results suggest that in hemorrhagic shock, decreased arterial ketone body ratio which reflects the inhibition of the TCA cycle is associated with increase of osmolal gap.