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Background/Aims@#To identify changes in symptoms and pulmonary sequelae in patients with coronavirus disease 2019 (COVID-19). @*Methods@#Patients with COVID-19 hospitalized at seven university hospitals in Korea between February 2020 and February 2021 were enrolled, provided they had ≥ 1 outpatient follow-up visit. Between January 11 and March 9, 2021 (study period), residual symptom investigations, chest computed tomography (CT) scans, pulmonary function tests (PFT), and neutralizing antibody tests (NAb) were performed at the outpatient visit (cross-sectional design). Additionally, data from patients who already had follow-up outpatient visits before the study period were collected retrospectively. @*Results@#Investigation of residual symptoms, chest CT scans, PFT, and NAb were performed in 84, 35, 31, and 27 patients, respectively. After 6 months, chest discomfort and dyspnea persisted in 26.7% (4/15) and 33.3% (5/15) patients, respectively, and 40.0% (6/15) and 26.7% (4/15) patients experienced financial loss and emotional distress, respectively. When the ratio of later CT score to previous ones was calculated for each patient between three different time intervals (1–14, 15–60, and 61–365 days), the median values were 0.65 (the second interval to the first), 0.39 (the third to the second), and 0.20 (the third to the first), indicating that CT score decreases with time. In the high-severity group, the ratio was lower than in the low-severity group. @*Conclusions@#In COVID-19 survivors, chest CT score recovers over time, but recovery is slower in severely ill patients. Subjects complained of various ongoing symptoms and socioeconomic problems for several months after recovery.
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Background@#Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrugresistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions. @*Methods@#This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated. @*Results@#A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days).Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13–2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20–2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23–2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15–2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing. @*Conclusion@#A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.
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Background@#We evaluated the household secondary attack rate (SAR) of the omicron and delta severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, according to the vaccination status of the index case and household contacts; further, in vaccinated index cases, we evaluated the effect of the antibody levels on household transmission. @*Methods@#A prospective cross-sectional study of 92 index cases and 197 quarantined household contacts was performed. Tests for SARS-CoV-2 variant type and antibody level were conducted in index cases, and results of polymerase chain reaction tests (during the quarantine period) were collected from contacts. Association of antibody levels in vaccinated index cases and SAR was evaluated by multivariate regression analysis. @*Results@#The SAR was higher in households exposed to omicron variant (42%) than in those exposed to delta variant (27%) (P = 0.040). SAR was 35% and 23% for unvaccinated and vaccinated delta variant exposed contacts, respectively. SAR was 44% and 41% for unvaccinated and vaccinated omicron exposed contacts, respectively. Booster dose immunisation of contacts or vaccination of index cases reduced SAR of vaccinated omicron variant exposed contacts. In a model with adjustment, anti-receptor-binding domain antibody levels in vaccinated index cases were inversely correlated with household transmission of both delta and omicron variants.Neutralising antibody levels had a similar relationship. @*Conclusion@#Immunisation of household members may help to mitigate the current pandemic.
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Background@#The proportion of antimicrobial-resistant Enterobacteriales as a causative pathogen of community-acquired acute pyelonephritis (APN) has been increasing. The aim of this study was to quantitatively evaluate the impact of antimicrobial resistance on medical costs and length of hospital stay for the treatment of APN. @*Materials and Methods@#A single-center retrospective cohort study was conducted between January 2018 and December 2019. All hospitalized patients aged ≥19 years who were diagnosed with community-acquired APN were recruited, and those diagnosed with Enterobacteriales as a causative pathogen were included. Log-linear regression analysis was performed to determine the risk factors for medical costs and length of hospital stay. @*Results@#A total of 241 patients participated in this study. Of these, 75 (31.1%) and 87 (36.1%) had extended-spectrum beta-lactamase (ESBL)-producing pathogens and ciprofloxacinresistant pathogens as the causative pathogen, respectively. Based on the log-linear regression model, ESBL-producing Enterobacteriales is a causative pathogen that is, on average, 27.0%, or United States Dollar (USD) 1,211 (P = 0.026) more expensive than non-ESBL-producing Enterobacteriales. A patient who is a year older would incur USD 23 (P = 0.040) more, those having any structural problems in the urinary tract would incur USD 1,231 (P = 0.015) more, and those with a unit increase in the Pitt bacteremia score would incur USD 767 (P <0.001) more, with all other variables constant. Having a case in which ESBL-producing Enterobacteriales is a causative pathogen would explain staying 22.0% longer or 2 more days (P = 0.050) in the hospital than non-ESBL-producing Enterobacteriales. A patient who is 10 years older would, on average, would have to stay for half a day longer (P = 0.045). Any structural problems in the urinary tract explain a longer stay (2.4 days longer; P = 0.032), and moving from 0 to 5 on the Pitt bacteremia score would explain four more days (P = 0.038) in the hospital. @*Conclusion@#Patients with community-acquired APN with ESBL-producing Enterobacteriales as the causative pathogen would incur, on average, 27.0% higher medical costs and 22.0% longer hospitalization days than patients detected with non-ESBL-producing pathogens.
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Background@#It is necessary to develop a roadmap for antimicrobial usage monitoring in order to perform monitoring of antimicrobial use at the national level properly. Therefore, this study aimed to develop a roadmap for establishing surveillance and monitoring of antimicrobial use in medical institutions at the national level. @*Materials and Methods@#A modified Delphi study was conducted, including 3 rounds of an online survey and a virtual meeting with 16 expert panels. The survey items were developed based on a literature review of the surveillance systems for antimicrobial use in 12 countries and interviews with experts. The questionnaire was designed to include both the surveillance and benchmarking systems. @*Results@#Regarding the scope of target institutions to be included in the surveillance system, medical institutions for sentinel surveillance had the highest proportion of agreement among the panels (75.0%, 9/12). For the benchmarking system, “tertiary- and secondarycare hospitals” were accepted as the scope of target institutions at the current moment.Furthermore, the National Health Insurance claims and prescription data of individual hospitals were considered appropriate data sources for the surveillance system. As for the measures to promote the participation of hospitals in the benchmarking system, “compensation through the establishment of antimicrobial management fees” and “set the participation in the program as a quality evaluation or accreditation index for hospital evaluation” were accepted. @*Conclusion@#This study provides a roadmap for establishing an antimicrobial use monitoring and benchmarking system for medical institutions at a national level in Korea.
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Identifying inappropriately prescribed antibiotics for infectious diseases by monitoring the quality of antibiotics use is essential for effective implementation of antibiotic stewardship. Qualitative assessment of the use of antibiotics has been conducted in some countries, including Korea, since the 2000s. The qualitative assessment generally involves an assessment of each component of the antibiotics prescription process, based on specific criteria. However, there is no standardized assessment method or cycle, and infectious diseases or antibiotics included in the assessments vary from country-to-country.According to the results reported in the United States, Europe, Australia, and Korea so far, approximately 20 - 55% of all antibiotics prescriptions are inappropriate. In this review, we describe the current progress in the quality assessment of the use of antibiotics on a global scale. Further, we highlight the future directions to improve antibiotic stewardship activities and the quality assessment of the use of antibiotics in Korea.
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Currently, antimicrobial resistance (AMR) is a major threat to global public health. The antimicrobial stewardship program (ASP) has been proposed as an important approach to overcome this crisis. ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, administration duration, and administration routes. In Korea, efforts are being made to overcome AMR using ASPs as a national policy. The current study aimed to develop core elements of ASP that could be introduced in domestic medical facilities. A Delphi survey was conducted twice to select the core elements through expert consensus.The core elements for implementing the ASP included (1) leadership commitment, (2) operating system, (3) action, (4) tracking, (5) reporting, and (6) education. To ensure these core elements are present at medical facilities, multiple departments must collaborate as teams for ASP operations. Establishing a reimbursement system and a workforce for ASPs are prerequisites for implementing ASPs. To ensure that ASP core elements are actively implemented in medical facilities, it is necessary to provide financial support for ASPs in medical facilities, nurture the healthcare workforce in performing ASPs, apply the core elements to healthcare accreditation, and provide incentives to medical facilities by quality evaluation criteria.
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Background@#The Korea National Antimicrobial Use Analysis System (KONAS), a benchmarking system for antimicrobial use in hospitals, provides Korean Standardized Antimicrobial Administration Ratio (K-SAAR) for benchmarking. This article describes K-SAAR predictive models to enhance the understanding of K-SAAR, an important benchmarking strategy for antimicrobial usage in KONAS. @*Methods@#We obtained medical insurance claims data for all hospitalized patients aged ≥ 28 days in all secondary and tertiary care hospitals in South Korea (n = 347) from January 2019 to December 2019 from the Health Insurance Review & Assessment Service. Modeling was performed to derive a prediction value for antimicrobial use in each institution, which corresponded to the denominator value for calculating K-SAAR. The prediction values of antimicrobial use were modeled separately for each category, for all inpatients and adult patients (aged ≥ 15 years), using stepwise negative binomial regression. @*Results@#The final models for each antimicrobial category were adjusted for different significant risk factors. In the K-SAAR models of all aged patients as well as adult patients, most antimicrobial categories included the number of hospital beds and the number of operations as significant factors, while some antimicrobial categories included mean age for inpatients, hospital type, and the number of patients transferred from other hospitals as significant factors. @*Conclusion@#We developed a model to predict antimicrobial use rates in Korean hospitals, and the model was used as the denominator of the K-SAAR.
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The emergence of hypervirulent Clostridioides difficile strains has decreased the efficacy of metronidazole in the treatment of C. difficile infection (CDI). Therefore, revised guidelines no longer recommend the use of metronidazole as a first-line regimen for CDI and restrict its use for non-severe CDI, only when vancomycin and fidaxomicin are unavailable. In Korea, an epidemic caused by a hypervirulent C. difficile strain or the emergence of metronidazole resistant C. difficile strains have not been reported. This review article aims to compare the treatment outcomes and adverse effects of vancomycin and metronidazole and discuss the validity of the guidelines of various agencies, which restrict the use of metronidazole, for Korean patients. There are no substantial adverse effects of metronidazole, and its clinical outcomes against non-severe CDI are similar to those of vancomycin. Based on these findings, we recommend that the use of metronidazole for the treatment of non-severe CDI is still an appropriate option in Korea.
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Background@#Throughout the coronavirus disease 2019 (COVID-19) pandemic, not only medical personnel but also paramedics or emergency medical technicians (EMT) have faced multiple physical and psychological challenges while performing their duties. The current study aimed to evaluate the psychological effects of managing patients with COVID-19 on the paramedics and EMT. @*Materials and Methods@#A survey targeting paramedics and EMT in Korea was conducted in December 2020. An official letter requesting participation and with the link to an onlinebased survey was sent to the Public Emergency Medical Services. Only one response was accepted from each participant. @*Results@#A total of 326 paramedics and EMT responded to the survey. Among them, 66.3% (216/326) had experience in managing patients with COVID-19. No differences in the distribution of sex, age, working area, duration of working experience, and underlying comorbidities were observed between those who did (COVID-19 group) and did not (nonCOVID-19 group) experience managing patients with COVID-19. The percentage of participants who showed severe posttraumatic stress disorder (PTSD) symptoms was significantly higher in the COVID group than in the non-COVID group (11.1% vs. 3.6%P = 0.029). The participants in the COVID group had a significantly higher mean Global Assessment of Recent Stress Scale score than those in the non-COVID group (18.7 ± 11.1 vs. 16.1 ± 9.9, P = 0.042). The proportion of paramedics and EMT willing to leave their job if given a chance was higher in the COVID group than the non-COVID group (24.1% vs. 9.1%, P = 0.001). Additionally, paramedics and EMT in the COVID group tended to show concern regarding exposure to COVID-19 infection. @*Conclusion@#The experience of managing patients with COVID-19 resulted in psychological distress among paramedics and EMT in Korea.
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Background@#The objective of this study was to evaluate the immunogenicity of coronavirus disease 2019 (COVID-19) vaccination in patients with end-stage renal disease (ESRD) on hemodialysis. @*Methods@#ESRD patients at the hemodialysis center of a tertiary-care university-affiliated hospital and healthy employees at the clinical laboratory center were prospectively recruited between March and June 2021. For severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) antibody analysis, blood samples were collected serially on days 0, 14, 28, and 56 after the first vaccine dose, and on days 7 and 50 after the second dose. Antibodies against the SARS-CoV-2 spike protein were quantified, and SARS-CoV-2 neutralizing antibodies were measured in the serum and plasma. @*Results@#Thirty-one ESRD patients and 55 healthy employees were regularly monitored.Twenty-five (80.6%) ESRD patients on hemodialysis received a mix-and-match strategy with ChAdOx1-BNT162b2 (AZ–Pf group) and six (19.4%) received two doses of ChAdOx1 (AZ–AZ group). ESRD patients on hemodialysis showed lower binding antibody titers and neutralizing antibody activities compared to healthy participants following the first vaccination with ChAdOx1. After the second dose, AZ-Pf group had higher immunogenicity than healthy people on days 7 and 50. The binding antibody titer and neutralizing antibody activities on days 7 and 50 were significantly higher in the AZ–Pf group than in the AZ–AZ group. @*Conclusion@#ESRD patients on hemodialysis receiving the mix-and-match strategy (ChAdOx1–BNT162b2) have COVID-19 vaccine immunogenicity comparable to healthy individuals receiving two doses of ChAdOx1.
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Background@#As the coronavirus disease 2019 (COVID-19) pandemic is ongoing, heavy workload of healthcare workers (HCWs) is a concern. This study investigated the workload of HCWs responding to the COVID-19 outbreak in South Korea. @*Methods@#A nationwide cross-sectional survey was conducted from September 16 to October 15, 2020, involving 16 healthcare facilities (4 public medical centers, 12 tertiary-care hospitals) that provide treatment for COVID-19 patients. @*Results@#Public medical centers provided the majority (69.4%) of total hospital beds for COVID-19 patients (n = 611), on the other hand, tertiary care hospitals provided the majority (78.9%) of critical care beds (n = 57). The number of beds per doctor (median [IQR]) in public medical centers was higher than in tertiary care hospitals (20.2 [13.0, 29.4] versus 3.0 [1.3, 6.6], P = 0.006). Infectious Diseases physicians are mostly (80%) involved among attending physicians. The number of nurses per patient (median [interquartile range, IQR]) in tertiarycare hospitals was higher than in public medical centers (4.6 [3.4–5] vs. 1.1 [0.8–2.1], P =0.089). The median number of nurses per patient for COVID-19 patients was higher than the highest national standard in South Korea (3.8 vs. 2 for critical care). All participating healthcare facilities were also operating screening centers, for which a median of 2 doctors, 5 nurses, and 2 administrating staff were necessary. @*Conclusion@#As the severity of COVID-19 patients increases, the number of HCWs required increases. Because the workload of HCWs responding to the COVID-19 outbreak is much greater than other situations, a workforce management plan regarding this perspective is required to prevent burnout of HCWs.
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Human immunodeficiency virus (HIV) is one of the less common triggers of secondary hemophagocytic lymphohistiocytosis (HLH) in which coagulation disorder is a frequent manifestation. Here, we present a case of HIV-triggered secondary HLH presenting with severe bleeding tendency and fever. Despite high-dose dexamethasone infusion (10 mg/body surface area/day), progressive disseminated intravascular coagulation and thrombocytopenia resulted in massive hemathochezia: the bleeding episode ceased after endoscopic hemoclipping. After then, he took a highly-active antiretroviral therapy (HAART). Eventually, body temperature and overall laboratory findings normalized in response to HAART.Clinicians should not overlook HIV infection as a possible trigger of secondary HLH. In such cases, HAART is the core treatment.
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Background@#Because persistent fever often occurs in adrenal insufficiency, it might be confused with infectious diseases. This study aimed to identify clinical characteristics and risk factors of patients with adrenal insufficiency and fever. @*Methods@#All adult patients (n = 150) admitted to a tertiary care hospital in South Korea and diagnosed with adrenal insufficiency between 1 March 2018, and 30 June 2019, were recruited. Patients were excluded if they had: 1) proven structural problems in the adrenal or pituitary gland; 2) a history of chemotherapy within 6 months prior to the diagnosis of adrenal insufficiency; and 3) other medical conditions that may cause fever. @*Results@#Among the included patients, 45 (30.0%) had fever at the time of the diagnosis of adrenal insufficiency. The mean C-reactive protein level was higher (11.25 ± 8.54 vs. 4.36 ± 7.13 mg/dL) in patients with fever than in those without fever. A higher proportion of patients with fever changed antibiotics (33.3% vs. 1.0%). On multivariate logistic regression analysis, female sex (odds ratio [OR], 0.32) lowered the risk of adrenal insufficiency with fever, while a history of surgery within 6 months (OR, 4.35), general weakness (OR, 7.21), and cough (OR, 17.29) were significantly associated with that. @*Conclusion@#The possibility of adrenal insufficiency should be considered in patients with fever of unknown origin, especially those with risk factors.
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These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Background@#Because persistent fever often occurs in adrenal insufficiency, it might be confused with infectious diseases. This study aimed to identify clinical characteristics and risk factors of patients with adrenal insufficiency and fever. @*Methods@#All adult patients (n = 150) admitted to a tertiary care hospital in South Korea and diagnosed with adrenal insufficiency between 1 March 2018, and 30 June 2019, were recruited. Patients were excluded if they had: 1) proven structural problems in the adrenal or pituitary gland; 2) a history of chemotherapy within 6 months prior to the diagnosis of adrenal insufficiency; and 3) other medical conditions that may cause fever. @*Results@#Among the included patients, 45 (30.0%) had fever at the time of the diagnosis of adrenal insufficiency. The mean C-reactive protein level was higher (11.25 ± 8.54 vs. 4.36 ± 7.13 mg/dL) in patients with fever than in those without fever. A higher proportion of patients with fever changed antibiotics (33.3% vs. 1.0%). On multivariate logistic regression analysis, female sex (odds ratio [OR], 0.32) lowered the risk of adrenal insufficiency with fever, while a history of surgery within 6 months (OR, 4.35), general weakness (OR, 7.21), and cough (OR, 17.29) were significantly associated with that. @*Conclusion@#The possibility of adrenal insufficiency should be considered in patients with fever of unknown origin, especially those with risk factors.
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These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Coronavirus disease 2019 (COVID-19) vaccination is necessary to prevent infection, morbidity, and mortality. In addition to the usual post-inoculation hypersensitivity reactions including headaches, muscle and joint pain, and fever, especially after the second shot, the mRNA vaccine has risk of inflammation in the heart and heart lining of some recipients, mostly younger people. And the adenovirus vector vaccine can induce rare immune thrombocytopenia. Vaccination should be encouraged according to the information about the effectiveness and safety in individual situation.
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As hospitals cater to elderly and vulnerable patients, a high mortality rate is expected if a coronavirus disease 2019 (COVID-19) outbreak occurs. Consequently, policies to prevent the spread of COVID-19 in hospital settings are essential. This study was conducted to investigate how effectively national and international guidelines provide recommendations for infection control issues in hospitals. After selecting important issues in infection control, we performed a systematic review and analysis of recommendations and guidelines for preventing COVID-19 transmission within medical institutions at national and international levels. We analyzed guidelines from the World Health Organization, Centers for Disease Control and Prevention, European Centre for Disease Prevention and Control, and Korea Disease Control and Prevention Agency. Recent guidelines do not provide specific solutions to infection control issues. Therefore, efforts need to be made to devise consistent advice and guidelines for COVID-19 control.
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This study aimed to evaluate the infectious disease (ID) physician workforce in Korea. We investigated the acquisition of ID physicians from 1992 to 2019 with their current working place in the Health Care System. We defined ID physicians working at general or tertiarycare hospitals as active ID physicians. A total 275 physicians acquired ID as a sub-specialty.Among the 275, 242 were active ID physicians. The density of active ID physicians was 0.47 per 100,000 population. Of all the 17 administrative districts, 11 (64.7%) fell short of 0.47, and 131 medical institutions employed the service of ID physicians. The median number of beds per adult ID physician was 372 (interquartile range, 280–507). It is essential to secure human resources to respond to emerging infectious diseases and perform the inherent work of ID physicians.