Search

Kidney transplant (KT) recipients have an increased risk of herpes zoster (HZ) and its complications. Although recombinant zoster vaccine is favoured over zoster vaccine live (ZVL), ZVL is also recommended to prevent HZ for KT candidates. We aimed to evaluate the clinical effectiveness of ZVL in KT recipients immunized before transplantation. Adult patients who received kidney transplantation from January 2014 to December 2018 were enrolled. Patients were observed until HZ occurrence, death, loss of allograft, loss to follow-up, or 5 years after transplantation. The inverse probability of the treatment-weighted Cox proportional hazard model was used to compare the incidence of HZ after transplantation between vaccinated and unvaccinated patients. A total of 84 vaccinated and 340 unvaccinated patients were included. The median age was higher in the vaccinated group (57 vs. 54 years, p 0.003). Grafts from deceased donors were more frequently transplanted in the unvaccinated group (16.7% vs. 51.8%, p < 0.001). Five-year cumulative HZ incidence was 11.9%, which translated to 26.27 (95% CI, 19.33–34.95) per 1000 person-years. The incidence in the vaccinated and unvaccinated groups was 3.9% and 13.7%, respectively. After adjustment, vaccination showed significant protective effectiveness against HZ (adjusted hazard ratio, 0.18, 95% CI, 0.05–0.60). In addition, all four cases of disseminated zoster occurred in the unvaccinated group. Our study, the first on the clinical effectiveness of zoster vaccines for KT recipients, suggests that ZVL before transplantation effectively prevents HZ. [ABSTRACT FROM AUTHOR]

We aimed to evaluate various aspects of antibiotic therapy as factors associated with candidemia in non-neutropenic patients. A retrospective, matched, case-control study was conducted in two teaching hospitals. Patients with candidemia (cases) were compared to patients without candidemia (controls), matched by age, intensive care unit admission, duration of hospitalization, and type of surgery. Logistic regression analyses were performed to identify factors associated with candidemia. A total of 246 patients were included in the study. Of 123 candidemia patients, 36% had catheter-related bloodstream infections (CRBSIs). Independent factors in the whole population included immunosuppression (adjusted odds ratio [aOR] = 2.195; p = 0.036), total parenteral nutrition (aOR = 3.642; p < 0.001), and anti-methicillin-resistant S. aureus (MRSA) therapy for ≥11 days (aOR = 5.151; p = 0.004). The antibiotic factor in the non-CRBSI population was anti-pseudomonal beta-lactam treatment duration of ≥3 days (aOR = 5.260; p = 0.008). The antibiotic factors in the CRBSI population included anti-MRSA therapy for ≥11 days (aOR = 10.031; p = 0.019). Antimicrobial stewardship that reduces exposure to these antibacterial spectra could help prevent the development of candidemia. [ABSTRACT FROM AUTHOR]

Background: We investigated the trend change in vancomycin-intermediate Staphylococcus aureus (VISA)/heterogeneous VISA (hVISA) prevalence among methicillin-resistant S. aureus (MRSA) bacteremia strains and antistaphylococcal antibiotic use together with mutation studies of vancomycin resistance-related gene loci to evaluate the impact of changes in antibiotic use after new antistaphylococcal antibiotics became available. Methods: Among 850 healthcare-associated MRSA isolates from 2006 to 2019 at a tertiary hospital in South Korea, hVISA/VISA was determined by modified PAP/AUC analysis, and the identified hVISA/VISA strains were genotyped. Gene mutations at vraSR, graSR, walKR, and rpoB were studied by full-length sequencing. Antistaphylococcal antibiotic use in 2005–2018 was analyzed. Results: Two VISA and 23 hVISA strains were identified. The prevalence rate ratio of hVISA/VISA carrying mutations at the two-component regulatory systems among MRSA was 0.668 (95% CI 0.531–0.841; P = 0.001), and the prevalence rate ratio of hVISA/VISA carrying rpoB gene mutations was 1.293 (95% CI 0.981–1.702; 174 P = 0.068). Annual vancomycin use density analyzed by days of therapy (DOT) per 1,000 patient-days did not decrease significantly, however the annual average length of time analyzed by the number of days vancomycin was administered for each case showed a significantly decreasing trend. Conclusions: During the 14-year period when the average length of vancomycin therapy decreased every year with the availability of alternative antibiotics, the prevalence of hVISA/VISA did not decrease significantly. This seems to be because the resistant strains carrying the rpoB mutations increased despite the decrease in the strains carrying the mutations at the two-component regulatory systems. [ABSTRACT FROM AUTHOR]

Intermittent negative blood cultures, known as the skip phenomenon (SP), frequently occur in patients with Staphylococcus aureus bacteremia (SAB), yet the clinical implications of SP in persistent SAB are not well understood. In this retrospective cohort study conducted at four university hospitals, SP was observed in 25 (11.3%) of 221 patients with persistent SAB. Infections involving methicillin-resistant S. aureus (MRSA) were more prevalent in patients with SP, who also experienced longer durations of bacteremia and delayed active antibiotic therapy compared with those without SP. The 30-day in-hospital mortality was lower in patients with SP than in those without SP (12.0% vs. 30.6%, respectively, p = 0.052). The median time from the initiation of active antibiotic therapy to the occurrence of SP was 6 days, and from SP to the last positive blood culture was 7 days. The duration of bacteremia and MRSA were independent predictors of SP. These findings suggest that SP can cause the duration of bacteremia to be underestimated by more than 1 week, indicating that confirmation of serial negative blood cultures might be necessary to reliably rule out SP in patients with prolonged MRSA bacteremia. [ABSTRACT FROM AUTHOR]

Background: The epidemiology of bloodstream infection (BSI) is well-established; however, little is known about the contribution of different pathogens to mortality. To understand true burden of BSI, pathogens contributing to mortality were investigated and compared according to where the BSI was acquired.Methods: Data from deceased patients in two teaching hospitals in the Republic of Korea were collected. BSI contributing mortality was defined as BSI within 2-weeks before death. Cases were grouped by acquisition sites: community-acquired (CA)-, healthcare-associated (HCA)-, and hospital-acquired (HA)-BSI. Drug resistance, BSI focus, and appropriateness of empirical antimicrobial therapy were also compared.Results: Among 1849 deceased patients in the hospitals, 280 (15.1%) patients experienced BSI within 2-weeks before death. In all, 71, 53, and 156 patients in the CA-, HCA-, and HA-BSI groups, respectively, with 316 total isolated pathogens were analyzed. The three most common pathogens were Klebsiella pneumoniae (17.1%), Escherichia coli (16.4%), and Staphylococcus aureus (11.4%). While K. pneumoniae and E. coli were the most common pathogens in CA- and HCA-BSI, Acinetobacter baumannii and Candida species were in HA-BSI. 26.3% (41/156) of patients experienced breakthrough HCA-BSI during administration of carbapenem and/or vancomycin. The proportion of central venous catheter-related infection (0%, 3.4% and 28.3%), carbapenem resistant-Gram negative bacilli (0%, 6.9% and 21.9%), and inappropriate empirical antimicrobial therapy (21.1%, 37.7% and 51.9%; all P < 0.001) were more frequently observed in HA-BSI.Conclusion: The epidemiology of BSI related to mortality had unique characteristics according to the acquisition site. Given the epidemiology of HA-BSI, infection control and antibiotics stewardship programs should be emphasized. [ABSTRACT FROM AUTHOR]

Background & Aims: This multicenter cohort study aimed to compare the real‐world biochemical response rates during tenofovir alafenamide (TAF), tenofovir disoproxil fumarate (TDF), and entecavir (ETV) treatment in chronic hepatitis B virus (HBV) infection patients. Methods: Overall, 1282 treatment‐naïve patients with CHB who commenced TAF (n = 270), TDF (n = 617), or ETV (n = 395) were analysed for biochemical response rates during the antiviral treatment using a time‐dependent Cox proportional hazard model after the inverse probability of treatment weighting (IPTW). Results: Patients treated with ETV were older (55.1 ± 11.5 years) than TAF or TDF (P <.0001). ETV was more frequently prescribed to patients with diabetes mellitus (DM, P =.003), hypertension (P <.0001), chronic kidney disease (P <.0001), and negative e‐antigen (P <.0001). Cumulative biochemical response rate was independently lower in patients with radiologic fatty liver (HR, 0.75; 95% CI, 0.61‐0.94) and obese patients without DM (HR, 0.85; 95% CI, 0.68‐0.98) according to multivariable Cox analyses based on time‐dependent variables after IPTW for age, sex, liver cirrhosis, baseline e‐antigen, ALT, and HBV DNA levels. ETV treated patients (HR, 1.38; 95% CI, 1.13‐1.68) showed higher biochemical response rates compared with TAF‐ or TDF‐treated patients after adjusting for similar parameters. Conclusions: In real‐world practice, ETV was preferable for older, hepatitis B e‐antigen negative patients with underlying comorbidities. Biochemical responses in patients treated with ETV, TAF, and TDF were significantly affected by metabolic factors such as fatty liver, obesity, and DM. However, the mechanism behind the higher biochemical response rate in patients treated with ETV should be investigated further. [ABSTRACT FROM AUTHOR]

• We analyzed factors that may predict active TB in liver transplantation recipients. • IGRA positivity itself was not associated with TB development in a TB-endemic area. • IGRA positive predicted active TB when chest images suggested a previous TB infection. • Both IGRA and chest CT should be considered to identify LTBI treatment candidates. We implemented a stratified risk analysis to predict the development of active tuberculosis (TB) in liver transplantation (LT) recipients based on IGRA and chest images in a TB-endemic area. In this retrospective cohort study, LT recipients who tested for IGRA between May 2008 and December 2017 were included. Chest images compatible with old TB lesions were considered as positive images. LT recipients were divided into six groups: LT recipients with history of treated TB, image (+)/IGRA (+), image (+)/IGRA (-), image (-)/IGRA (+), image (-)/IGRA (-) and LTBI treated. The Cox regression model was used to analyze risk groups. Among the 717 eligible LT recipients included in this study, 21 patients developed active TB. Incidence rates of TB were 2,261, 724, and 119 cases/100,000 person-years in the 1st, 2nd, and ≥ 3rd year after transplantation, respectively. History of treated TB (HR 18.92; 95% CI 4.10–87.25) and image (+)/IGRA (+) (HR 10.86; 95% CI 2.75–42.89) were independent risk factors for developing active TB. IGRA (+) with a negative image was not a risk factor. Our findings suggested that both IGRA and chest images should be considered to identify risk groups for LTBI treatment. [ABSTRACT FROM AUTHOR]

Background: Sequence type (ST) 17 vancomycin-resistant Enterococcus faecium (VREF) is frequently isolated in nosocomial settings. The aim of this study was to identify whether ST17 contributes to subsequent bacteremia more often than other STs among hospitalized patients carrying VREF. Methods: A retrospective cohort study was conducted in patients carrying ST17 VREF and those with non-ST17 VREF. Rectal screening according to hospital policy was used to identify patients with VREF. Subsequent VREF bacteremia events within a year of detection of colonization were recorded. Cox regression analysis was used to adjust the covariates involved in determining the association between ST17 and subsequent bacteremia events. Results: The cohorts comprised 52 patients with ST17 and 169 patients with non-ST17 VREF. One-year VREF bacteremia-free rates were 85.9% and 90.2%, respectively. In multivariate analysis, ST17 was associated with subsequent bacteremia at an adjusted hazard risk (aHR) of 4.02 (95% confidence interval [CI], 1.32–12.29). Liver transplantation (aHR, 40.08; 95% CI, 4.87–329.76) and hematologic malignancy (aHR, 20.97; 95% CI, 4.87–87.82) were also significant. All cases of subsequent bacteremia in ST17 VREF carriers were caused by ST17; however, subsequent bacteremia in non-ST17 carriers was often caused by ST17 or another ST variant. Conclusions: A specific genotype, ST17 is a predictor of subsequent bacteremia in hospitalized patients carrying VREF. Patients with a hematologic malignancy and those receiving a liver transplant are also at high risk. More targeted strategies may be needed to prevent VREF infection in hospitals. [ABSTRACT FROM AUTHOR]

[Display omitted] • Antibiotics stewardship program (ASP) in the surgical ICU was implemented. • Comprehensive ASP decreased the use of anti-pseudomonal beta-lactams. • Susceptibilities of anti-pseudomonal beta-lactams were improved during ASP period. • Comprehensive ASP was a factor associated with decreased mortality in surgical ICU. • ASP should be implemented to improve antimicrobial use and patient outcome. We evaluated the effects of a comprehensive antimicrobial stewardship program (ASP) in a surgical intensive care unit (SICU). The ASP was implemented from March 2018 to February 2019 at an SICU in a teaching hospital. An infectious disease physician and a pharmacist visited the SICU 3 times per week for prospective audit and feedback. Outcomes were compared between the ASP period and the same months in the preceding year (pre-ASP period). The primary outcome measure was the use of anti-pseudomonal beta-lactams (APBL). Appropriate antimicrobial de-escalation and ICU mortality rates were also compared. A total of 182 and 149 patients were included in the study for the pre-ASP and ASP periods, respectively. Although disease severity was higher in the ASP group (septic shock 39.0% in pre-ASP vs 65.1% in ASP group, P < 0.001), the use of APBL as a definitive treatment was lower during ASP (68.7% vs 57.7%, OR 0.62, 95% CI 0.40–0.98). Appropriate antimicrobial de-escalation improved (63.2% vs 94.6%, P < 0.001). ICU mortality was comparable (7.7% vs 7.4%) and significantly lower during the ASP, after adjustment (adjusted OR 0.41, 95% CI 0.18–0.92, P = 0.032). A comprehensive ASP decreased the use of APBL and was associated with improved patient outcomes. [ABSTRACT FROM AUTHOR]

Bloodstream infection (BSI) is a common complication after living-donor liver transplantation (LDLT). Some patients develop recurrent BSIs. We evaluated the impacts of early recurrent BSIs (ER-BSIs) on outcomes in LDLT recipients. LDLT cases between 2008 and 2016 were included. Early BSI (E-BSI) was defined as a BSI event that occurred within 2 months after LDLT. ER-BSIs were defined as new-onset BSIs within 2 months due to another pathogen at a ≥ 48-h interval or a relapse of BSIs by the same pathogen at a ≥ 1-week interval, with negative cultures in between. The primary objective was evaluating the all-cause mortality of each group of LDLT recipients (90 days and 1 year). The secondary objectives were analyzing associated factors of each all-cause mortality and risk factors for early single BSI and ER-BSI. Among 727 LDLT recipients, 108 patients experienced 149 events of E-BSI with 170 isolated pathogens. Twenty-eight patients (25.9%, 28/108) experienced ER-BSI. The 1-year survival rates of patients without BSI, with early single BSI event, and with ER-BSIs were 92.4%, 81.3%, and 28.6%, respectively. ER-BSI was the most significant risk factor for 1-year mortality (adjusted HR = 5.31; 95% CI = 2.27–12.40). Intra-abdominal and/or biliary complications and early allograft dysfunction were risk factors for both early single BSI and ER-BSI. Interestingly, longer cold ischemic time and recipient operative time were associated with ER-BSI. LDLT recipients with ER-BSI showed very low survival rates accompanied by intra-abdominal complications. Clinicians should prevent BSI recurrence by being aware of intra-abdominal complications. [ABSTRACT FROM AUTHOR]

A 37-year-old healthy man was admitted with fever, skin rash, migratory arthralgia, and headache without preceding urogenital symptoms. Sexual contact history and positive CSF culture for Neisseria gonorrhoeae using BacT/Alert blood culture bottles were diagnostic for gonococcal meningitis. Multilocus sequence typing of this isolate showed sequence type (ST) 7363, the most predominant ST among ceftriaxone-resistant strains. The isolate from this case remained susceptible to ceftriaxone although it was resistant to penicillin, tetracycline, and ciprofloxacin. With the high selective pressure of ceftriaxone for treatment of plasmid-mediated β-lactamase producing N. gonorrhoeae , resistance to ceftriaxone and molecular characteristics should be monitored. [ABSTRACT FROM AUTHOR]

Infections caused by extended-spectrum β-lactamase-producing Enterobacteriales (ESBL-PE) are commonly treated with intravenous antibiotics. This study investigated whether oral antimicrobial therapy (OAT) is as effective as intravenous antimicrobial therapy (IVT) for acute pyelonephritis (APN) caused by ESBL-PE. A retrospective cohort of patients with APN caused by ESBL-PE was studied at a tertiary-care hospital from January 2014 through December 2016. The OAT group comprised patients treated with an appropriate oral antimicrobial agent following 7 days or less of IVT. The primary endpoint was treatment failure defined as clinical and/or microbiological failure. The secondary endpoint was length of hospital stay and recurrences of APN within 2 months and within 1 year. Propensity score matching and multivariable Cox proportional hazard modeling were used to minimize bias. Among 238 eligible cases, Escherichia coli (83.6%) was the most common pathogen. Sixty patients received OAT after a median of four days of appropriate IVT, and 178 patients completed treatment with IVT. Fluoroquinolones (58.3%) were the most commonly prescribed OAT, followed by trimethoprim-sulfamethoxazole and amoxicillin-clavulanate. OAT was not associated with treatment failure (adjusted OR 0.66; 95% CI 0.18–2.44) and hospitalization length was shorter in the OAT group (6.2 days versus 10.7 days; P < 0.01). APN recurrence caused by ESBL-PE infection within 2 months was not associated with OAT (adjusted HR 0.56; 95% CI 0.16–2.00). OAT reduced hospital stay without adverse effects on treatment outcome. OAT could be safely applied as a carbapenem-saving option in treatment of APN. [ABSTRACT FROM AUTHOR]

Therapeutic drug monitoring (TDM) of teicoplanin is aimed at minimizing the clinical impact of pharmacokinetic variability; however, its benefits are still being defined. We performed a retrospective study of teicoplanin TDM focusing on the dose-serum concentration relationship and clinical outcomes in a clinical setting. From January 2017 to December 2018, patients receiving teicoplanin ≥ 72 h with TDM were enrolled. Patients were divided into three groups: non-loading (NL) group, low-dose loading (LD) group (loading dose < 9 mg/kg), and high-dose loading (HD) group (≥ 9 mg/kg). Serum teicoplanin trough concentration (Cmin) and adverse events (AEs) were evaluated in each regimen. A subgroup of patients with bacteremia was analyzed to evaluate clinical efficacy. Among 65 patients, 12, 18, and 35 were grouped in NL, LD, and HD, respectively. Achievement rates of Cmin > 20 mg/L within 10 days were significantly different among the groups (25.0%, 38.9%, and 68.6% in the NL, LD, and HD groups, respectively; P = 0.014). Fourteen patients (21.5%) had AEs, and higher Cmin over 10 days (adjusted odds ratio 2.08 per every 20 mg/L increases, 95% CI 1.13–3.84, P = 0.019) and age ≥ 65 years (P = 0.009) were identified as independent risk factors. In the subgroup analysis, HD regimen (P = 0.050) and high mean Cmin over 10 days (P = 0.025) were significantly associated with treatment success. Although HL regimen could achieve Cmin targets and improve clinical outcome during teicoplanin treatment, high Cmin was associated with AEs during treatment. Routine TDM can be helpful to optimize teicoplanin administration. [ABSTRACT FROM AUTHOR]

To investigate factors for the recurrence of acute pyelonephritis (APN) caused by extended-spectrum β-lactamase–producing Escherichia coli (ESBL-PE), a retrospective cohort study was performed at a tertiary-care hospital from 2014 through 2016. Among 135 patients who had recovered from APN caused by ESBL-PE, the 1-year cumulative recurrence rates of APN caused by any pathogen or by ESBL-PE specifically were 35.6% and 22.1%, respectively. In a multivariate analysis, infectious disease (ID) consultation was associated with decreased recurrence (95% confidence interval [CI] = 0.24–0.96, P = 0.038 for recurrence caused by any pathogen; and 95% CI = 0.15–0.84, P = 0.019 for recurrence caused by ESBL-PE). History of APN within 1 year was a risk factor for recurrent APN caused by any pathogen (P = 0.011). Microbiological cure was a preventive factor for recurrent APN caused by ESBL-PE (P = 0.024). In conclusion, our data show that ID consultation protects against APN recurrence caused by ESBL-PE. • Acute pyelonephritis (APN) caused by extended-spectrum β-lactamase–producing Escherichia coli (ESBL-PE) is increasing. • Data of the factors associated with APN recurrence caused by ESBL-PE were limited. • The 1-year cumulative recurrence rate of APN caused by ESBL-PE was 22.1%. • Infectious disease (ID) consultation was associated with decreased recurrence. • We should encourage physicians to refer patients with APN for ID consultation. [ABSTRACT FROM AUTHOR]

Extended-spectrum β-lactamase-producing Enterobacteriales (ESBL-PE) are often associated with inappropriate empirical therapy (IAT). The aim of this study was to investigate whether IAT of acute pyelonephritis (APN) caused by ESBL-PE is related to adverse outcomes. A retrospective cohort study was performed at a tertiary-care hospital from 2014 through 2016. Patients who had APN caused by ESBL-PE and were definitely treated with appropriate antibiotics for at least 7 days were enrolled. IAT was defined as when inappropriate empirical antibiotics were given 48 h or longer after initial diagnosis of APN. Primary endpoint was treatment failure defined as clinical and/or microbiologic failure. Secondary endpoints were length of hospital stay and recurrence of APN. Propensity score matching was used to adjust heterogeneity of each group. Among 175 eligible cases, 59 patients received IAT and 116 patients received appropriate empirical antimicrobial therapy (AT). Treatment failure was observed in five (8.4%) patients and nine (7.8%) patients in each group, respectively. After matching, the treatment failure rate was similar between both groups (adjusted odd ratio [aOR] 1.05; 95% confidence index [CI] 0.26–4.15). The length of hospital stay (median 11 days in the IAT group versus 11 days in the AT group; P = 0.717) and absence of recurrence within 2 months (90.3% in IAT and 86.7% in AT; P = 0.642) were also similar. IAT did not adversely affect the clinical outcome. In this regard, clinicians should be more cautious about indiscriminate prescription of broad-spectrum antibiotics such as carbapenem empirically for treatment of APN possibly caused by ESBL-PE. [ABSTRACT FROM AUTHOR]

Hemorrhagic pneumonia (HP) is known as the clinical manifestation of Stenotrophomonas maltophilia infection, while catheter-related blood stream infection (CRBSI) is the common clinical presentation of S. maltophilia bacteremia (SMB). The purpose of this study is to evaluate the risk factors for mortality in hematologic malignancy patients with SMB and to analyze clinical and microbiological characteristics of HP associated with SMB and CRBSI. SMB cases of patients with a hematologic malignancy were collected from 2006 through 2016. The overall 30-day mortality rate and mortality risk factors were assessed. The expression of major virulence-associated genes from S. maltophilia isolates, which included genes encoding type-1 fimbriae (smf-1), proteases (StmPr1 and StmPr2), and esterase (Smlt3773), from the blood of patients with HP and CRBSI was investigated. The phenotypic and genotypic traits were also compared. A total of 118 cases of SMB were included. The overall 30-day mortality rate was 61.0%. A multivariable analysis showed that HP was the most important risk factor for mortality (adjusted OR = 106.41; 95% CI = 5.18-2184.55). Although no statistical significance was observed in microbiological analysis, isolates from HP have a trend toward a higher protease activity (93.8% vs. 73.3%, P = 0.172). Clinical analysis showed that thrombocytopenia (P = 0.037) and prolonged neutropenia (P = 0.043) were significant factors associated with HP. Our data, which includes hematologic malignancy patients with SMB, suggest that HP is the significant risk factor for mortality and that the unique characteristics of patients and microbes contribute to the pathogenesis. [ABSTRACT FROM AUTHOR]

AbstractWe developed a prediction model for cefotaxime resistance in patients with K. pneumoniae bacteremia. Adult patients with K. pneumoniae bacteremia were grouped into derivation (from March 2018 to December 2019) and validation (from January 2020 to August 2020) cohorts. The prediction scoring system was based on factors associated with cefotaxime resistance identified by the logistic regression model. A total of 358 patients were enrolled (256 for derivation, 102 for validation). In the multivariable analysis, age ≥65 years, hospital-acquired infection, prior antimicrobial use, and an updated Charlson comorbidity index ≥3 points were associated with cefotaxime resistance in the derivation cohort. When each variable was counted as 1 point, the values of the area under the curve were 0.761 in the derivation and 0.781 in the validation cohorts. The best cutoff value using the Youden index was ≥2 with 73.6% sensitivity and 67.5% specificity. Our simple scoring system favorably predicted cefotaxime resistance. [ABSTRACT FROM AUTHOR]

Stenotrophomonas maltophilia (SM) has emerged as an important nosocomial pathogen with high morbidity and mortality. Because of its unique antimicrobial susceptibility pattern, appropriate antimicrobial therapy for SM bacteremia is still challenging, especially in immunocompromised patients. The present study was performed to assess clinical predictors of SM bacteremia in adult patients with hematologic malignancy. From 2006 through 2016, a case-control study was performed at a tertiary-care hospital. Case patients were defined as SM bacteremia in patients with hematologic malignancy. Date- and location-matched controls were selected from among patients with gram-negative bacteremia (GNB) other than SM. A total of 118 cases of SM bacteremia were identified and compared to 118 controls. While pneumonia was the most common source of SM bacteremia, centralline-associated infection was most common in the controls. The overall 30-day mortality rate of cases with SM bacteremia was significantly higher than that of the controls (61.0 and 32.2%, respectively; P < 0.001). A multivariable analysis showed that polymicrobial infection, previous SM isolation, the number of antibiotics previously used ≥ 3, and breakthrough bacteremia during carbapenem therapy were significantly associated with SM bacteremia (all P < 0.01). Previous use of trimethoprim/sulfamethoxazole (TMP/SMX) was negatively association with SM bacteremia (P = 0.002). Our data suggest that SM is becoming a significant pathogen in patients with hematologic malignancy. Several clinical predictors of SM bacteremia can be used for appropriate antimicrobial therapy in hematologic patients with suspected GNB. [ABSTRACT FROM AUTHOR]

During the 2015 Korean MERS outbreak, we experienced atypical presentations of MERS-CoV infections in three immunocompromised hosts that warranted exceptional management. Case 1 showed delayed symptom development after a four-day asymptomatic period, Case 2 experienced a 20-day incubation period, and Case 3 exhibited persistent viral shedding without clinical deterioration. Recognizing these exceptions is extremely important in the management of MERS-CoV-exposed or -infected patients and for control of potential MERS outbreaks. [ABSTRACT FROM AUTHOR]

Staphylococcal scarlet fever (SSF) is characterized by an exanthem without enanthem, bullae, or exfoliation, and is known to be related to Staphylococcus aureus toxins, especially superantigens. It has been reported in children and young adults. Herein, we report the first case of an elderly patient with SSF caused by staphylococcal enterotoxin M (SEM), associated with otitis externa. The patient presented with maculopapular rashes on both arms, thighs, and abdomen and with erythroderma on the face, ears, neck, chest, and back, all of which was followed by desquamation on the face, ears, and trunk. A culture of ear discharge grew methicillin susceptible S. aureus that was only positive for SEM among the superantigens tested. [ABSTRACT FROM AUTHOR]

Abstract: Background: We evaluated the efficacy of a well-prepared left internal thoracic artery (LITA) auto Y graft for simultaneous left anterior descending artery (LAD) and diagonal artery (DA) re-vascularisation in selected patients for the reduction of the number of required grafts and improved graft patency, while limiting technical problems. Methods: Twenty well-controlled diabetic patients, mean age 62.8±8.3, 17 males and three females, underwent isolated elective off-pump coronary artery bypass grafting using the LITA auto Y graft from July 2003 to August 2004. Results: In-hospital data and angiographic results at 6 months after the surgery showed that there was no early mortality, early graft failure and major morbidity except for two cases of superficial wound infection. The 3-year follow-up results including angiographic findings (mean of 37±3.3-month follow-up) demonstrated that all patients are alive and have excellent graft patency in both the LAD and DA. Only two cases required right coronary artery (RCA) stenting during the follow-up period. Compared with our previous routine LITA composite Y graft technique, it is assumed that LITA auto Y graft technique may reduce the number of mobilised conduits or avoided sequential anastomosis. Conclusions: This small study showed that our technique is technically feasible and may be safely performed to the selective patients. The LITA auto Y graft might be an additional surgical option, in terms of not only preserving the other grafts and maintaining patency in the LAD area bypass, but also preventing the need for sequential anastomoses. [Copyright &y& Elsevier]

Background: Concerns are arising about the simultaneous occurrence of the coronavirus disease 2019 (COVID-19) pandemic and the influenza epidemic, the so-called "twindemic". In this study, we compared clinical characteristics and chest images from patients with COVID-19 and influenza. Methods: We conducted a case-control study of COVID-19 and age- and sex-matched influenza patients. Clinical characteristics and chest imaging findings between patients with COVID-19 and matched influenza patient controls were compared. Results: A total of 47 patients were enrolled in each group. Anosmia (14.9%) and ageusia (21.3%) were only observed in COVID-19 patients. There were 31 (66%) and 23 (48.9%) patients with COVID-19 and influenza who had pulmonary lesions confirmed by chest computed tomography (CT), respectively. The interval between symptom onset and pneumonia was significantly longer in patients with COVID-19. Round opacities were more common in images from COVID-19 patients (41.9% vs. 8.7%, p = 0.007), whereas pure consolidation (0% vs. 34.9%, p < 0.001) and pleural effusion (0% vs. 17.4%, p = 0.028) were more common in images from influenza patients. Notably, the difference in the number of involved pulmonary lobes observed on CT and pulmonary fields observed on radiographic images was significantly higher in COVID-19-associated pneumonia than that in influenza-associated pneumonia (2.32 ± 1.14 vs. 1.48 ± 0.99, p = 0.010). Conclusions: Chest images and thorough review of clinical findings could provide value for proper differential diagnoses of COVID-19 patients, but they are not sufficiently sensitive for initial diagnoses. In addition, chest radiography could underestimate COVID-19 lung involvement because of the lesion characteristics of COVID-19-associated pneumonia. [ABSTRACT FROM AUTHOR]

Background Usefulness of β- d -glucan (BDG) testing in high-risk patients for invasive fungal infection (IFI) diagnosis has been well demonstrated. However, data on its usefulness in patients without risk factors are limited. We evaluated differences in the diagnostic performance of BDG testing in patients with varying degrees of susceptibility to IFI. Methods From April 2017 to May 2018, all consecutive patients (≥18year-old) who were performed BDG testing (Beijing Gold Mountainriver Tech) were enrolled. Patients were classified into three groups: Group A for patients with host factors defined by 2008 European Organization for Research and Treatment of Cancer-Mycoses Study Group diagnostic (EORTC-MSG) criteria, Group B for patients with malignancy receiving recent chemotherapy within 1 month without host factors, and Group C for others. Cases of proven and probable IFI defined by EORTC-MSG criteria, Pneumocystis pneumonia and all fungemia were considered as true IFIs. Sensitivity, specificity, positive and negative predictive value (PPV and NPV) were calculated with a cut-off value for positivity ≥80 pg/mL. Results Among 473 eligible patients, 190, 142, and 141 patients were classified into group A, B, and C, respectively. Rates of true IFI were significantly different in each group (57/190, 19/142, and 10/141 in each group, P < 0.001). Sensitivities were 0.83, 0.68, and 0.70 and specificities were 0.62, 0.59, and 0.63 in group A, B, and C, respectively. PPVs were considerably different among three groups (PPV for 0.48, 0.20, and 0.12; NPV for 0.89, 0.92 and 0.97 in each group, respectively). Conclusion The BDG test is a useful assay for IFI diagnosis; however, the clinical interpretation should be different by patient risks. Whereas BDG testing could be considered as a tool for predicting IFI in high-risk patients, it only could be a tool for excluding IFI in patient without risk factors. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Bloodstream infections (BSIs) represent a poor prognosis in living-donor liver transplant recipients (LDLT-Rs). Some patients develop recurrent BSIs. We evaluated the impacts of ER-BSIs on outcomes in LDLT-Rs. Methods All LDLT-Rs with follow-up data between January 2008 and December 2016 were included. Early BSIs (E-BSIs) defined as BSI events within 2 months after LDLT. ER-BSI was defined as new-onset BSI within 2 months due to another pathogen ≥48-hour interval, or relapse of BSI by the same pathogen ≥1-week interval with negative cultures in between. Logistic regression model was used to analyze risk factors for 1-year mortality. An associated factor of E-BSI and ER-BSI were also evaluated. Results Among 727 LDLT-Rs, 108 patients had 149 events with 170 isolated pathogens of E-BSI. Twenty-eight patients (25.9%, 28/108) experienced ER-BSI. Enterococcus (37.6%) was the most common pathogen. Intra-abdominal infection was the most common focus in the first episode of E-BSI and even significantly more common in ≥ second (59.3% vs. 82.9%, P = 0.007). Intra-abdominal and/or biliary complications were risk factors for both E-BSI and ER-BSI. Whereas high MELD score, longer cold ischemic time and longer recipient operative time were associated with E-BSI, longer post-transplant intensive care unit stay and longer donor operative time was associated with ER-BSI. 1-year survival rates of patients with or without single event of E-BSI were 81.3% and 92.4%, respectively. Patients having ER-BSI showed significantly low 1-year survival rates of 28.6% (Figure 1). ER-BSI was the most relevant risk factor for 1-year mortality (adjusted OR = 8.26; 95% CI = 4.30–15.88). Conclusion LDLT-Rs with ER-BSI showed very low survival rates accompanying with intra-abdominal and/or biliary complications. Clinicians should aware to prevent recurrence of BSI focusing on intra-abdominal complications in order to improve clinical outcomes of LDLT-R. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background The South Korean government has been combating the coronavirus disease 2019 (COVID-19) outbreak using public information and extensive viral screening. We describe the application of the Korean response system in Gyeongsangnam-do province and outline the epidemiological features of COVID-19 in the cohort. Methods A Rapid Response Team tracked the patients' activities and identified close contacts. A Patient Management Team made decisions regarding the severity of illness, hospital allocation depending on severity, and time of discharge. A national medical center with 155 beds and 4 university-affiliated hospitals with 48 negative-pressure isolation rooms were dedicated for patients with COVID-19. Results As of 15 April, 17 400 residents were tested, of whom 111 were confirmed positive cases. Of the 111 patients, 78 were cured and discharged, 2 recovered after mechanical ventilation, and none died. One healthcare worker at the national center tested positive for SARS-CoV-2. All 412 staff members at the center were tested, but there were no additional infections. Cough (30.0%) was the most common initial symptom, whereas anosmia and ageusia were the first symptoms in 14.7% and 15.7% of the patients, respectively. Overall, 25 patients (22.5%) reported having no symptoms at admission and 7 (6.3%) remained asymptomatic at discharge. Conclusions A response system that enabled the early detection of COVID-19 cases, including asymptomatic and presymptomatic cases, and timely quarantine of these patients and their contacts, along with efficient allocation of medical resources, was the key to curbing the COVID-19 outbreak in Gyeongsangnam-do Province. [ABSTRACT FROM AUTHOR]

Summary: Background: Posaconazole is used to prevent invasive fungal infections (IFIs) in patients with haematologic malignancy. In this study, we compared plasma posaconazole concentrations (PPCs) and the incidence of breakthrough IFIs between patients with haematologic malignancy receiving posaconazole oral suspension vs tablet. Methods: We retrospectively collected data on adult patients with haematologic malignancies who received posaconazole prophylaxis during chemotherapy from April 2014 through May 2018. A total of 242 cases with PPCs, 88 in the oral suspension group and 154 in the tablet group, were included in this study. Results: Patients receiving tablets achieved a significantly higher mean PPC than did those on oral suspension (1.631 ± 0.878 μg/mL in the tablet group vs. 0.879 ± 0.585 μg/mL in the oral suspension group). One hundred and thirty‐seven of 154 patients (89.0%) receiving tablets had PPCs of 0.7 μg/mL or more, while only 41 of 88 patients (46.6%) receiving oral suspension attained an optimal level (P <.001). The incidence of breakthrough IFIs was significantly higher in the oral suspension group compared with in the tablet group (14.8% of oral suspension vs. 4.5% of tablet; P =.005). In the analysis including patients receiving posaconazole tablets, hypoalbuminemia (< 3.5 g/dL) was found to be a risk factor associated with suboptimal levels (odds ratio: 8.872; 95% confidence interval: 3.011 ‐ 26.141; P <.001). Conclusions: Suboptimal PPCs in the tablet group were less common than those in the oral suspension group. Therapeutic drug monitoring may be still necessary even in patients receiving posaconazole tablets, especially in those with hypoalbuminemia. [ABSTRACT FROM AUTHOR]

This paper proposes an efficient method to classify inverse synthetic aperture radar (ISAR) images. The proposed method achieves invariance to translation and rotation of ISAR images by using two-dimensional (2D) Fourier transform (FT) of ISAR images, polar mapping of the 2D FT image, and a simple nearest-neighbor classifier. In simulations using ISAR images measured in a compact range, the proposed method yielded high classification ratios with small-sized data regardless of the location of the rotation center, whereas the existing method was very sensitive to the location of it. [ABSTRACT FROM PUBLISHER]

Background Clinically relevant categorization of antimicrobial resistance is critical to mitigating the threat it poses. Difficult-to-treat resistance (DTR) is a recently proposed category defined as nonsusceptibility to all first-line antibiotic agents. Methods A retrospective study was conducted with nonduplicate cases of gram-negative bloodstream infection (GNBSI) caused by 4 major taxa (Escherichia coli , Klebsiella pneumoniae , Pseudomonas aeruginosa , and Acinetobacter species) identified from a nationwide surveillance database. DTR was defined as nonsusceptibility to all the β-lactams and fluoroquinolones tested. Patient characteristics and mortality were compared between DTR GNBSI and GNBSI caused by carbapenem-resistant but not DTR and extended-spectrum cephalosporin–resistant but not DTR isolates using Centers for Disease Control and Prevention definitions. Adjusted odds ratios (aORs) for 30-day in-hospital mortality were examined for DTR in overall and in propensity score–matched cohorts. Results A total of 1167 episodes of monomicrobial GNBSI were identified, and 147 (12.6%) of the isolates were DTR. The majority of DTR isolates were Acinetobacter species (79.6%) and P. aeruginosa (17.7%). DTR infections were associated with previous antibiotic use, healthcare contact, ventilator use, and lower respiratory tract infection. Crude mortality for GNBSI caused by DTR was 50.3%. A multivariable model showed that only DTR, but not other categories, was significantly associated with mortality (adjusted odds ratio [aOR], 3.58 [95% confidence interval {CI}, 1.27–10.19]). DTR was also a significant predictor for mortality in the analysis of propensity score–matched cohorts (aOR, 3.48 [95% CI, 1.82–6.79]). Conclusions In patients with GNBSI, DTR was associated with higher mortality than those in other resistance categories. Our findings suggest that DTR could be useful for surveillance and prognostication. [ABSTRACT FROM AUTHOR]

• COL-R K. pneumoniae was converted to be COL-S after TGC exposure. • Induced TGC-R mutants showed increased expression level of ramA. • COL-R K. pneumoniae was eliminated by low concentration of COL with TGC. This study investigated the effect of tigecycline exposure on susceptibility of colistin-resistant Klebsiella pneumoniae isolates to colistin and explored the possibility of antibiotic combination at low concentrations to treat colistin-resistant K. pneumoniae isolates. Twelve tigecycline-resistant (TIR) mutants were induced in vitro from wild-type, colistin-resistant, and tigecycline-susceptible K. pneumoniae isolates. Antibiotic susceptibility was determined using the broth microdilution method. The deduced amino acid alterations were identified for genes associated with colistin resistance, lipid A biosynthesis, and tigecycline resistance. Expression levels of genes were compared between wild-type stains and TIR mutants using quantitative real-time polymerase chain reaction (PCR). Lipid A modification was explored using MALDI-TOF mass spectrometry. Time-killing assay was performed to assess the efficiency of combination therapy using low concentrations of colistin and tigecycline. All TIR mutants except one were converted to be susceptible to colistin. These TIR mutants had mutations in the ramR gene and increased expression levels of ramA. Three genes associated with lipid A biosynthesis, lpxC, lpxL , and lpxO , were also overexpressed in TIR mutants, although no mutation was observed. Additional polysaccharides found in colistin-resistant, wild-type strains were modified in TIR mutants. Colistin-resistant K. pneumoniae strains were eliminated in vitro by combining tigecycline and colistin at 2 mg/L. In this study, we found that tigecycline exposure resulted in reduced resistance of colistin-resistant K. pneumoniae to colistin. Such an effect was mediated by regulation of lipid A modification involving ramA and lpx genes. Conclusion: Because of such reduced resistance, a combination of colistin and tigecycline in low concentrations could effectively eradicate colistin-resistant K. pneumoniae strains. [ABSTRACT FROM AUTHOR]