Clinical Characteristics and Antimicrobial Susceptibility Trends in Citrobacter Bacteremia: An 11-Year Single-Center Experience.

BACKGROUND: Recently, Citrobacter freundii bacteremia outbreak in a neonatal intensive care unit has attracted public attention in Korea. However, Citrobacter bacteremia is uncommon and usually occurs in patients with underlying diseases such as malignancy and hepatobiliary diseases. Increase in resistance and emerging of multidrug resistance among Citrobacter species have gradually been reported. The aim of this study was to investigate the clinical characteristics and outcome of C. freundii and non-freundii bacteremia and antimicrobial susceptibility trends. MATERIALS AND METHODS: We reviewed the medical records of patients with Citrobacter bacteremia at St. Mary's Hospital, from 2007 to 2017. RESULTS: A total of 43 patients with a median age of 72 (24-93) years was identified and 90.7% of them had comorbidities. Twenty-nine (67.4%) patients had C. freundii bacteremia while 14 had non-freundii bacteremia (six of C. braakii, five of C. koseri, two of C. amalonaticus and one of C. youngae). A total of 26 (51.2%) patients had community-acquired infection and intra-abdominal infection including hepatobiliary tract was the most common portal of entry (24/43, 55.8%). Moreover, hepatobiliary tract was the leading primary site of nosocomial infection (9/17, 52.9%). Polymicrobial bacteremia was observed in 21 (48.8%) patients. The percentages of Citrobacter species susceptible to ampicillin, amikacin, aztreonam, cefazolin, cefoxitin, cefotaxime, cefepime, piperacillin-tazobactam, ciprofloxacin, and imipenem were 9.5%, 97.6%, 73.8%, 9.5%, 14.3%, 71.4%, 92.9%, 83.3%, 83.3% and 100%, respectively. The resistance rate did not increase during the study period. Of 39 patients treated with antibiotics, 36 (92.3%) received appropriate empirical antibiotics. Overall mortality was 18.6%. High Charlson comorbidity index and Pitt bacteremia score were significant risk factors for death in univariate analysis and showed trends in the multivariate analysis. No significant difference in clinical features and antimicrobial susceptibility rate was observed between C. freundii and non-freundii bacteremia. CONCLUSION: Citrobacter bacteremia was predominant in the elderly with comorbidities, while no pediatric case was observed. Hepatobiliary tract is the leading primary focus of bacteremia both in community-acquired and nosocomial infection. The rate of susceptibility to antibiotics has not changed in the last 11 years.

Gastrointestinal stromal tumor solitary distant recurrence in the left brachialis muscle.

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gastrointestinal tract that are most commonly found in the stomach. Although GISTs can spread to the liver and peritoneum, metastasis to the skeletal muscle is very rare and only four cases have previously been reported. These cases involved concurrent skeletal metastases of primary GISTs or liver metastases. Here, we report the first case of a distant recurrence in the brachialis muscle after complete remission of an extra-luminal gastric GIST following a wedge resection of the stomach, omental excision, and adjuvant imatinib therapy for one year. Ten months after therapy completion, the patient presented with swelling and tenderness in the left arm. Magnetic resonance imaging revealed a large mass in the brachialis muscle, which showed positivity for c-kit and CD34 upon pathologic examination. This is the first reported case of a solitary distant recurrence of a GIST in the muscle after complete remission had been achieved.

Clinical outcome in patients with chronic antibody-mediated rejection treated with and without rituximab and intravenous immunoglobulin combination therapy.

We previously reported that rituximab (RTX) and intravenous immunoglobulin (IVIg) combination therapy (RIT) is effective in treating patients with chronic active antibody-mediated rejection (CAMR), and the proteinuria level can determine the response to RIT. However, the results were not compared to those of patients who did not receive RIT. Fifty-nine patients with CAMR were divided into 2 groups: an RIT treated group (n = 25) and a historic control (HC) group who had not received RIT (n = 29). The RIT group was treated with RTX (375 mg/m(2)) and IVIg (0.4 g/kg) for 4 days. We compared the decline in glomerular filtration rate/month (ΔeGFR), RIT-related complications, and allograft survival rate in both groups. We also compared the allograft survival rate between patients with high proteinuria (spot urine protein/creatinine [PC] ratio > 3.5 g/g) and low proteinuria (PC ratio < 3.5 g/g). ΔeGFR was significantly decreased in the RIT group compared with the HC group after 6 months (P < 0.05). No serious complications were associated with RIT, and only one case of herpes zoster infection developed. The overall allograft survival rate in the RIT group was significantly higher than in the HC group. In both groups, patients with low proteinuria survived better than patients with heavy proteinuria (P < 0.05). The allograft survival rate was greater in the high proteinuria RIT group than that in the HC group. RIT treatment is recommended for delaying the progression of CAMR without serious complications, and is not limited by the presence of heavy proteinuria.

Feasibility of on-line measurement of sewage components using the UV absorbance and the neural network.

The objective of this study was to test the feasibility of a new method to improve the accuracy in the estimation of sewage components. Adding to the regression of sewage components with UV (ultraviolet) absorbance values, a proposed method considered an unclear but existing relationship among characteristic of sewage production. Sewage production showed very defined profiles due to the daily human activities. So the main idea was the combination of measuring the UV absorbance values and analyzing the characteristics of the sewage production. For this purpose, 446 sewage samples taken at every 2-h interval for 51 days at a wastewater treatment plant were statistically analyzed using neural network (NN). NN was trained with 350 data sets (about 29 days) of UV absorbance values, flow rate and time. And as a result, it could predict 96 data (12 days) as a validation, indicating that estimation accuracies were improved to higher level than those of the linear regressions. The proposed method could estimate concentrations of total nitrogen (TN) and total phosphate (TP) within practical accuracies as well as total suspended solid.

Analysis and application of ADM1 for anaerobic methane production.

An anaerobic model for the serum bottle test was developed and analyzed with sensitivities of stoichiometric and kinetic parameters to the components in order to establish a basis for appropriate application of the model. Anaerobic glucose degradation in a serum bottle was selected as an example. The anaerobic model was developed based on the anaerobic digestion model no. 1 (ADM1), which had five processes with 17 kinetic and stoichiometric parameters. Sensitivity analysis showed that the yield of product on the substrate (f) has high sensitivities to model components, and that the methane concentration was the most sensitive component. Important parameters including yield of product on the substrate (f), yield of biomass on the substrate (Y), and half-saturation values (K) were estimated using genetic algorithms, which optimized the parameters with experimental results. The Monod maximum specific uptake rate (k) was, however, so strongly associated with the concentration of biomass, that values could not be estimated individually. Simulation with estimated parameters showed good agreement with experimental results in the case of methane production. However, there were some differences in acetate and propionate concentrations.

Behaviors of intercellular materials and nutrients in biological nutrient removal process supplied with domestic wastewater and food waste.

A four-stage biological nutrient removal (BNR) process was operated to investigate the effect of anaerobically fermented leachate of food waste (AFLFW) as an external carbon source on nutrient removal from domestic wastewater having a low carbon-to-nitrogen ratio. The BNR system that was supplemented with AFLFW showed a good performance at a sludge retention time (SRT) of 30 days, despite low temperature. With this wastewater, average removal efficiencies of soluble chemical oxygen demand (COD), total nitrogen (T-N), and total phosphorus (T-P) were 88 to 93%, 70 to 74%, and 63 to 68%, respectively. In this study, several kinds of poly-hydroxyalkanoates (PHAs) were observed in cells. These included 24% poly-3-hydroxybutyrate (PHB), 41% poly-3-hydroxyvalerate (PHV), 18% poly-3-hydroxyhexanoate (PHH), 10% poly-3-hydroxyoctanoate (PHO), 5% poly-3-hydroxydecanoate (PHD). and 2% poly-3-hydroxydodecanoate (PHDD), indicating that microorganisms could store various PHAs through the different metabolic pathways. However, breakdown of the enhanced biological phosphorus removal (EBPR) mechanism was observed when SRT increased from 30 to 50 days for the enhancement of nitrification. To study the effect of SRT on EBPR, a sequencing batch reactor (SBR) system that was supplied with glucose was operated at various SRTs of 5, 10, and 15 days. Nitrification and denitrification efficiencies increased as SRT increased. However, the content of intracellular materials such as PHAs, glycogen. and poly-P in cells decreased. From these results, it was concluded that SRT should be carefully controlled to increase nitrification activity and to maintain biological phosphorus removal activity in the BNR process.