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The Association of Academic Physiatrists, the home of academic physiatry, is interested in advancing industry partnerships in research among academic physiatrists. There are limited existing resources that outline opportunities for academic physiatrists in engaging the translational research continuum through industry partnerships and the skill sets that academic physiatrists need to successfully navigate these partnerships. In 2019, then President of the Association of Academic Physiatrists, John Chae, MD, ME, assembled a group of interested physician-scientists in physical medicine and rehabilitation to form the Research and Industry Partnerships Task Force to address this problem. The Task Force implemented a live educational session titled "Collaborating with industry" at Physiatry '19, the Annual Meeting of the Association of Academic Physiatrists held in Puerto Rico. To extend the reach of this valuable information, the Task Force is creating resources that can be easily distributed and accessed by all physiatrists. The goal of this white paper is to provide a roadmap to help academic physiatrists begin to navigate the field of academia-industry relationships with the ultimate goal of accelerating discovery for the benefit of physiatry and rehabilitation patients.

Cryotherapy is the use of cold temperatures and has been used for thousands of years to reduce pain. More recently, cryotherapy has been modernized as an interventional technique to provide long-term pain relief for various pain conditions, such as craniofacial pain secondary to trigeminal neuralgia. This chapter will review the history, description of the procedure as well as provide a review of literature on the efficacy of cryotherapy on trigeminal neuralgia.

Trigeminal Neuralgia is a painful condition affecting the trigeminal nerve which transmits sensory information from the face to the brain. Symptoms range from mild to severe pain or abnormal sensation in the face. This chapter will discuss non-pharmacologic treatments for trigeminal neuralgia. This will include a discussion of home remedies, vitamin supplementation (particularly B vitamins), acupuncture, and laser therapy. Other common treatments include oral medications, local injections, surgeries, psychological interventions, and physical therapy. These treatments will be discussed in other chapters.

Chronic pain is increasingly recognized as a public health problem. We assessed the effectiveness of a multi-modal, interprofessional educational approach aimed at empowering healthcare professionals to make deliberative changes, especially in opiate prescribing practices. Education activities included enduring webcasts, regional interprofessional roundtable events, and state-level conference presentations within targeted Kentucky and West Virginia regions of the United States. Over 1,000 participants accessed the various activities. For the live events, the largest groups reached included nurses (38.1%), nurse practitioners (31.2%), and physicians (22.1%). In addition to our reach, higher levels of educational effectiveness were measured, specifically, learner's intentions to change practice patterns, confidence in meeting patient's needs, and knowledge of pain management guidelines. The majority of the conference (58%) and roundtable (69%) participants stated they intend to make a practice change in one or more areas of chronic pain patient management in post-event evaluation. Differences in pre- and post-activity responses on the measures of confidence and knowledge, with additional comparison to a control population who were not in attendance, were analyzed using non-parametric tests of significance. While neither activity produced significant changes in confidence from pre-activity, participants were more confident post-activity than their control group peers. There were significant changes in knowledge for both live event and webcast participants. Impactful chronic pain continuing the education that emphasizes collaborative care is greatly needed; these results show that the approaches taken here can impact learner's knowledge and confidence, and hold potential for creating change in how opioid prescribing is managed.

Background CD9, a member of the tetraspanin superfamily, is a tumor suppressor in many malignancies. The aim of this study was to evaluate the immunohistochemical expression of CD9 in colorectal carcinomas (CRCs) and determine clinicopathological and prognostic significance of its expression. Methods The CD9 expression status of 305 CRCs was evaluated using a semi-quantitative scoring system in tumor cells (T-CD9) and immune cells (I-CD9) by classifying the results as high and low expression. Results High T-CD9 (T-CD9 [+]) expression was detected in 175 samples (57.6%) and high I-CD9 (I-CD9 [+]) expression was detected in 265 samples (86.9%). Using Kaplan- Meier survival analysis, the T-CD9 (+) group showed a tendency for better disease-free survival (DFS) (p = .057). In left-sided tumors, DFS was significantly longer in the T-CD9 (+) group (p = .021) but no statistical significance was observed with right-sided tumors (p = .453). I-CD9 (+) CRCs significantly correlated with well/moderately differentiation (p = .014). In Kaplan-Meier analysis, the I-CD9 (+) group had a tendency towards worse DFS compared to the I-CD9 (-) group (p = .156). In combined survival analysis of T-CD9 and I-CD9, we found that the longest DFS was among patients in the T-CD9 (+)/I-CD9 (-) group, whereas the T-CD9 (-)/I-CD9 (+) group showed the shortest DFS (p = .054). Conclusions High expression of T-CD9 was associated with a favorable DFS, especially in left-sided CRCs. Combined evaluation of T-CD9 and I-CD9 is required to determine the comprehensive prognostic effect of CD9 in CRCs.

Persistent human papillomavirus type 16 (HPV16) is the major risk factor for cervical cancer. HPV16 intratypic variants differ in their geographical distribution and oncogenic potential. This study aimed to analyze the distribution of HPV16 variants and their association with cervical lesion histopathology in Korean women. In total, 133 HPV16-positive cervical samples from women admitted to Seoul National University Boramae Hospital were analyzed by sequencing E6, E7, and L1 genes and the long control region (LCR), and the variant distribution according to cervical lesion grade was determined. Isolates were grouped into a phylogenetic lineage, and A1-3, A4, C, and D sublineages were detected in 54.1, 37.8, 0.7, and 7.4% of samples, respectively. The most commonly observed LCR variations were 7521G>A (91.5%), 7730A>C (59.6%), and 7842G>A (59.6%). Furthermore, A4 or D sublineage-positive women had a higher risk for cervical cancer than women who were positive for A1-3. Among HPV phylogenetic clusters, A1-3 was the predominant sublineage, and within A1-3, the 350G polymorphism was highly frequent. These results differed from those of previous studies in Korea and other Asian countries. The findings suggest that cervical neoplasia incidence in HPV16-infected patients could be affected by the distribution of HPV16 variants in the population.

Cervical epidural anesthesia (CEA) is used for pain control and surgical procedures of the head and neck or upper arm areas. However, the failure rate of CEA is reported to be high, is the failure rate being quite higher than other sites, because of the anatomical differences of the cervical spine. We hypothesized that the loss of resistance (LOR) method combined with the drip infusion method for confirmation of the cervical epidural space can reduce the failure rate. This study investigated the usefulness of the drip infusion method.One hundred chronic renal failure patients undergoing arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. In the cervical epidural puncture, we identified the cervical epidural space using a combination of the LOR method with the drip infusion method. After confirmation of the epidural space with LOR method, we decided it was the true epidural space when fluid dripping to the space was present. Otherwise, if fluid dripping was not present, we designated it was pseudo LOR, and we found the true epidural space using the drip infusion method only.In all cases, the combined LOR with drip infusion method, identify the epidural space.Combined LOR with drip infusion method is an efficacious method for the confirmation of the cervical epidural space.

Low back pain (LBP) remains one of the most prevalent musculoskeletal disorders, while algorithms that able to recognise LBP patients from healthy population using balance performance data are rarely seen. In this study, human balance and body sway performance during standing trials were utilised to recognise chronic LBP populations using deep neural networks. To be specific, 44 chronic LBP and healthy individuals performed static standing tasks, while their spine kinematics and centre of pressure were recorded. A deep learning network with long short-term memory units was used for training, prediction and implementation. The performance of the model was evaluated by: (a) overall accuracy, (b) precision, (c) recall, (d) F1 measure, (e) receiver-operating characteristic and (f) area under the curve. Results indicated that deep neural networks could recognise LBP populations with precision up to 97.2% and recall up to 97.2%. Meanwhile, the results showed that the model with the C7 sensor output performed the best. Practitioner summary: Low back pain (LBP) remains the most common musculoskeletal disorder. In this study, we investigated the feasibility of applying artificial intelligent deep neural network in detecting LBP population from healthy controls with their kinematics data. Results showed a deep learning network can solve the above classification problem with both promising precision and recall performance.

There have been few clinical studies on the association between the vancomycin 24-h area under the concentration-time curve (AUC24) to minimum inhibitory concentration (MIC) ratio and vancomycin treatment outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infections. To examine this association and to establish a suitable cut-off value for AUC24/MIC, a multicentre prospective observational study was conducted in patients with MRSA bacteraemia. Data were collected on all patients aged ≥18 years with MRSA bacteraemia treated with vancomycin for ≥72 h without dialysis. The MIC was determined by broth microdilution (BMD) and Etest. Treatment failure was defined as (i) 30-day mortality, (ii) persistent bacteraemia (≥7 days) and (iii) recurrence (≤30 days after completion of therapy). AUC24 was estimated by a Bayesian approach based on individual vancomycin concentrations. The AUC24/MIC cut-off value for differentiating treatment success and failure was calculated by Classification and Regression Tree (CART) analysis. In total, 117 patients were enrolled, among which vancomycin treatment failure occurred in 38 (32.5%). In univariate analysis, high vancomycin MIC and low trough levels were unrelated to treatment outcomes. In the CART analysis, low vancomycin AUC24/MIC [392.7 (BMD) and397.2 (Etest)] was associated with treatment failure. In multivariate analysis, low AUC24/MIC was a risk factor for treatment failure [adjusted odds ratio (aOR)=3.50, 95% confidence interval (CI) 1.39-8.82 by BMD; aOR=5.61, 95% CI 2.07-15.24 by Etest]. AUC24/MIC is associated with vancomycin treatment outcomes in MRSA bacteraemia, and seeking individualised AUC24/MIC ratios above target (400) may improve treatment outcomes.

Little is known about the incidence of and risk factors for glucose intolerance after distal pancreatectomy. This study investigated the clinicopathologic factors associated with the development of glucose intolerance or overt diabetes mellitus (DM) after distal pancreatectomy, and the correlation between resected pancreas volume and endocrine function impairment.After excluding patients with preoperative DM, 101 patients who underwent distal pancreatectomy with a minimum of 1-year postoperative follow-up were enrolled in this prospective cohort. Patients were assessed preoperatively and 1 week and 12 months postoperatively by oral glucose tolerance tests and by measures of HbA1c and pancreatic volume.Mean patient age was 54.1 years, mean body mass index (BMI) was 23.3 kg/m(2), and the male-to-female ratio was 1:1.8. Of the 101 patients, 21 (20.8 %) had pancreatic ductal adenocarcinoma. The median percent resected pancreas volume was 28.0 % (range 5.0-71.3 %). One year after distal pancreatectomy, 51 patients (50.5 %) had glucose intolerance, including 26 with impaired fasting glucose and 25 with DM. ROC curve analysis showed that a resected pancreas volume of 25 % showed maximum diagnostic value for development of glucose intolerance. Univariate analysis showed that female sex (58.5 vs. 36.1 %, P = 0.031), BMI (24.1 vs. 22.5 kg/m(2), P = 0.010), larger resected volume (36.5 vs. 28.0 %, P = 0.026), and lower remnant volume relative to BMI (1.7 × 10(-3) vs. 2.1 × 10(-3) m(5)/kg, P = 0.021) were risk factors for postoperative endocrine function impairment. Multivariate analysis revealed that female sex (odds ratio [OR] 5.818, P = 0.003), higher BMI (OR 10.556, P = 0.006), and resected pancreatic volume (OR 3.192, P = 0.035) were independent risk factors for endocrine impairment.About 50 % of patients without preoperative DM developed impaired glucose tolerance or overt DM following distal pancreatectomy. Female sex, higher BMI, and resection of pancreatic volume25 % were risk factors for endocrine function impairment, indicating the need for preoperative evaluation and careful perioperative glucose monitoring in these patients.

At an intensive care unit, four neonates died consecutively within 80 minutes. Citrobacter freundii was isolated from blood samples of the 4 patients. It was also cultured from the leftover SMOFlipid that had been infused intravenously into the patients. In this in vitro study, we evaluated the bacterial growth kinetics and change in size of fat globules in SMOFlipid contaminated with C. freundii. Following the growth of bacteria, pH of SMOFlipid decreased to < 6, and the number of fat globules larger than 5 μm increased. Pulmonary fat embolism is proposed as a possible cause of the sudden deaths as well as fulminant sepsis.

Purpose In 2007, the American Society of Clinical Oncology and the College of American Pathologists had established a human epidermal growth factor receptor 2 (HER2) testing guideline, which was updated in 2013 and subsequently in 2018. We assessed the clinical impact of the recent update by comparing the in situ hybridization (ISH) results based on the 2007, 2013, and 2018 guidelines. Methods We assessed 2 cohorts. The first cohort included 1,161 primary invasive breast cancer (IBC) samples including 18 bilateral IBC cases, with both immunohistochemistry (IHC) and silver-enhanced ISH (SISH) results available for the HER2 status. The second cohort included 160 IBC cases with equivocal HER2 IHC, assessed using SISH. We retrospectively evaluated and compared the HER2 SISH results. Results There were 22 (1.9%) and 20 (12.5%) cases with altered SISH results according to the 2013 guidelines in cohorts 1 and 2, respectively. As per the 2018 guidelines, final HER2 statuses of 16 (1.4%) and 14 (8.5%) cases changed in cohorts 1 and 2, respectively. The 2013 guidelines increased the positive rate compared to the 2007 guidelines, in both cohorts (0.6% and 6.2%, respectively). Most equivocal cases in cohorts 1 (92.3%) and 2 (100%) as per the 2013 guidelines were reclassified as HER2-negative according to the 2018 guidelines. The 2018 guidelines increased the negative rates (1.3% in cohort 1 and 8.7% in cohort 2) and slightly decreased the positive rates (-0.2% in cohort 1 and -3.1% in cohort 2), compared to the 2013 guidelines. With each update, minor changes in the positive and negative rates were observed in whole breast cancer samples (cohort 1). However, the 2018 guidelines affected previously defined HER2-positive IBC with equivocal IHC results. Conclusion Under the 2013 guidelines, the positive and equivocal cases increased. However, the 2018 guidelines eliminated ambiguous cases by reclassifying them as HER2-negative.

Mycobacterium arupense, a slow-growing nontuberculous mycobacterium (NTM), was first isolated from clinical samples in 2006 [1]. It is a member of the M. terrae complex, which includes M. arupense, M. engbaekii, M. heraklionense, M. hiberniae, M. kumamotonense, M. longobardum, M. nonchromogenicum, M. senuense, and M. terrae [1, 2, 3, 4, 5]. Although the M. terrae complex is generally considered nonpathogenic [6], infections caused by the M. terrae complex have been reported [7, 8, 9]. The pathogenicity of M. arupense is debatable, but a few cases of M. arupense infection involving bacteremia, osteomyelitis, pulmonary infection, and tenosynovitis have been reported [10, 11, 12, 13, 14]. We report a case of M. arupense tenosynovitis in a patient with a history of puncture injury to the finger caused by a crab. A 56-yr-old woman presenting with symptoms of redness, pain, and swelling in the second and fifth fingers of the right hand was admitted to our hospital. One year previously, the patient had suffered from a puncture injury to the right second finger caused by a crab; the injured finger showed swelling and redness 2 months later. She received antibiotics and corticosteroid injections at a local hospital, but the infected finger did not improve and the fifth finger of her right hand also began to show symptoms of infection. The patient had a history of being treated for hypertension and had undergone trans-sphenoidal surgery 4 yr ago for a non-functioning pituitary adenoma. After the surgery, she was treated with prednisolone and levothyroxine, but prednisolone was stopped on the day after admission. On admission, her body temperature was 36.0℃, blood pressure was 117/79 mm Hg, pulse was 56/min, and respiratory rate was 20 breaths/min. Laboratory tests confirmed that the patient's electrolytes, liver function, hormones, and complete blood counts were normal, with the exception of an elevated erythrocyte sedimentation rate (43 mm/hr) and decreased thyroid-stimulating hormone level (0.12 µIU/mL). Magnetic resonance imaging of the right hand revealed synovial hypertrophy with enhancement along the flexor tendons, which was especially evident along the second and fifth flexor tendons. Under suspicion of tuberculous tenosynovitis, her right hand was incised and drained. Histological examination of the resected tissue showed chronic granulomatous inflammation, but no organisms were detected on Gram and Ziehl-Neelsen stainings. Molecular analysis of the resected tissue for M. tuberculosis and NTM by using the AdvanSure TB/NTM real-time PCR kit (LG Life Science, Seoul, Korea) showed a negative result, and direct cultures of the tissue sample for bacteria and fungi were sterile. After the surgical site had healed, the patient was discharged on cephradine. The biopsied tissue was cultured for mycobacteria, and mycobacterial growth was observed on Lowenstein-Jensen medium 27 days later. The colonies were rough and unpigmented in the dark and after light exposure. The mycobacterium was identified as NTM by using the Seeplex MTB/NTM ACE Detection Kit (Seegene Inc., Seoul, Korea). For NTM identification, 16S rRNA and 65-kDa heat shock protein genes (hsp65) of this isolate were sequenced. The primers and PCR setting used to amplify the target regions were as previously described [15, 16, 17]. Sequences were analyzed by using an ABI PRISM 3730 series DNA Analyzer (Applied Biosystems, Foster City, CA, USA). For the first 500 bp of the 16S rRNA gene sequence, the isolate showed a 100% identity match with GenBank sequences {"type":"entrez-nucleotide","attrs":{"text":"NR_043588","term_id":"343198755"}}NR_043588 (M. arupense), a 99.6% identity match with {"type":"entrez-nucleotide","attrs":{"text":"GU084182","term_id":"343796636"}}GU084182 (M. heraklionense), and a 99.1% identity match with {"type":"entrez-nucleotide","attrs":{"text":"DQ058406","term_id":"66932807"}}DQ058406 (M. nonchromogenicum). The 415 bp of hsp65 showed a 100% identity match with {"type":"entrez-nucleotide","attrs":{"text":"AB239922","term_id":"110796715"}}AB239922 (M. arupense) and a 96.9% identity match with {"type":"entrez-nucleotide","attrs":{"text":"JX154109","term_id":"394987442"}}JX154109 (M. engbaekii). The phylogenetic tree of the hsp65 showed that this isolate was most closely related to {"type":"entrez-nucleotide","attrs":{"text":"AB239922","term_id":"110796715"}}AB239922 (M. arupense) and was classified as M. arupense (Fig. 1). Fig. 1 Phylogenetic tree based on 65-kDa heat shock protein gene sequences constructed by using the neighbor-joining method. Nucleotide sequences were used to align the reference panels provided by the National Center for Biotechnology Information Reference ... After the identification of M. arupense, the patient was prescribed clarithromycin, ethambutol, and rifampin empirically. We used Clinical and Laboratory Standards Institute breakpoints for M. kansasii [18] to interpret the results of the drug susceptibility test (DST) performed by using the broth microdilution method, which indicated that the isolate was susceptible to clarithromycin, ethambutol, and linezolid, but resistant to amikacin, ciprofloxacin, moxifloxacin, rifampin, and trimethoprim-sulfamethoxazole (Table 1). Therapy was maintained and the patient was cured without further complications. Table 1 Antimicrobial susceptibility testing results for Mycobacterium arupense M. arupense was first described in 2006 by Cloud et al. [1] as a non-pigmented organism, negative for niacin accumulation and positive for 68℃ catalase and hydrolysis of Tween 80. Although the clinical significance of M. arupense is controversial, infections caused by this organism are occasionally reported [10, 11, 12, 13, 14]. To date, only 6 patients, besides the present case, have been infected with M. arupense, although 1 pulmonary isolate from an immunocompetent patient was classified as colonization according to the American Thoracic Society criteria [6]. The cases include tenosynovitis of the hand (n=2), osteomyelitis of the wrist (n=1), pulmonary infection in an immunocompetent patient (n=1), pulmonary infection in an HIV-positive patient (n=1), and bacteremia in an HIV-positive patient (n=1). In all 4 extrapulmonary M. arupense infections in the immunocompetent patients, there was a predisposing factor such as corticosteroid injection or injury. Accurate identification is important for the treatment of M. terrae complex infection, because a substantial number of patients infected with these organisms show persistent disease owing to misdiagnosis [7]. Using mycolic acid analysis by high-performance liquid chromatography, it is difficult to distinguish M. arupense from M. nonchromogenicum because of their similar mycolic acid patterns [1]. Thus, sequencing of the 16S rRNA gene, 16S-23S internal transcribed spacer region 1 region, and especially the hsp65, is useful for identifying M. arupense [1]. In our case, the hsp65 showed better discriminatory power than 16S rRNA gene. The present strain was susceptible to clarithromycin, ethambutol, and linezolid. Among the 8 isolates studied by Cloud et al. [1], all were susceptible to clarithromycin, ethambutol, and rifabutin, and 1 isolate was resistant to clarithromycin. However, the DST results for amikacin and trimethoprim-sulfamethoxazole were variable, and all isolates were resistant to ciprofloxacin, linezolid, moxifloxacin, rifampicin, and streptomycin. Although the optimal therapy for M. arupense is not well established in the literature, a multiple antibiotic regimen including clarithromycin and ethambutol is a useful initial approach to manage these patients. In conclusion, this is the first case of M. arupense tenosynovitis in Korea. Our findings indicate that M. arupense can be an opportunistic pathogen in patients with a history of corticosteroid injection or injury.

Direct fluorescent antibody (DFA) staining of induced sputum is frequently used to diagnose Pneumocystis pneumonia (PCP) in patients infected with human immunodeficiency virus, although induction can provoke nausea and bronchospasm. Since the diagnostic value of expectorated sputum examined with DFA stain has not been well evaluated, we reviewed the medical records of HIV-infected patients who were clinically diagnosed as having PCP between 1999 and 2011. Over this 13-year period, we found 76 patients whose records included the results of DFA staining of expectorated sputum and noted that 42 (55.3%) were positive. Polymerase chain reaction to detect Pneumocystis in the sputum of 65 of the patients resulted in the finding of 43 (66.2%) who were positive. Our findings suggest that DFA staining of expectorated sputum could be a useful initial diagnostic method in HIV-infected patients with PCP.

The detection of high-risk (HR) HPV in cervical cancer screening is important for early diagnosis of cervical cancer or pre-cancerous lesions. We evaluated the analytical and clinical performances of 3 HR HPV assays in Gynecology patients. A total of 991 specimens were included in this study: 787 specimens for use with a Hybrid Capture 2 (HC2) and 204 specimens for a HPV DNA microarray (DNA Chip). All specimens were tested using an Abbott RealTime High Risk HPV assay (Real-time HR), PGMY PCR, and sequence analysis. Clinical sensitivities for severe abnormal cytology (severe than high-grade squamous intraepithelial lesion) were 81.8% for Real-time HR, 77.3% for HC2, and 66.7% for DNA Chip, and clinical sensitivities for severe abnormal histology (cervical intraepithelial neoplasia grade 2+) were 91.7% for HC2, 87.5% for Real-time HR, and 73.3% for DNA Chip. As compared to results of the sequence analysis, HC2, Real-time HR, and DNA Chip showed concordance rates of 94.3% (115/122), 90.0% (117/130), and 61.5% (16/26), respectively. The HC2 assay and Real-time HR assay showed comparable results to each other in both clinical and analytical performances, while the DNA Chip assay showed poor clinical and analytical performances. The Real-time HR assay can be a good alternative option for HR HPV testing with advantages of allowing full automation and simultaneous genotyping of HR types 16 and 18.

To investigate the prognostic significance of altered breast cancer susceptibility gene 1 (BRCA1) and p53 expression in triple-negative breast cancer (TNBC). Immunohistochemical expression of BRCA1 and p53 was examined in the tumor tissues of 465 TNBC cases and relations were sought with clinicopathological features and patient survival. Loss of BRCA1 expression was found in 29.5% (137/465) of TNBCs. Positive expression of p53 was observed in 49.9% (232/465). Patients with loss of BRCA1 expression had a tendency to have higher rate of lymph node metastasis (p = 0.075). An association between p53 expression and high histological grade was observed (p = 0.039). TNBC patients with loss of BRCA1 expression had a tendency to have poorer overall survival (OS) than those positive for BRCA1 (p = 0.09). TNBC patients with positive p53 expression showed better OS than those with p53 negativity (p = 0.001). In terms of combined expression patterns, significantly poorer overall survival (OS) was observed for BRCA1-negative/p53-negative TNBCs and best OS for BRCA1-positive/p53-positive TNBCs (p = 0.005). Combined expression patterns of BRCA1 and p53 could serve as useful prognostic markers in TNBC.

Objective.To evaluate the risk factors for surgical site infection (SSI) after gastric surgery in patients in Korea.Design.A nationwide prospective multicenter study.Setting.Twenty university-affiliated hospitals in Korea.Methods.The Korean Nosocomial Infections Surveillance System (KONIS), a Web-based system, was developed. Patients in 20 Korean hospitals from 2007 to 2009 were prospectively monitored for SSI for up to 30 days after gastric surgery. Demographic data, hospital characteristics, and potential perioperative risk factors were collected and analyzed, using multivariate logistic regression models.Results.Of the 4,238 case patients monitored, 64.9% (2,752) were male, and mean age (±SD) was 58.8 (±12.3) years. The SSI rates were 2.92, 6.45, and 10.87 per 100 operations for the National Nosocomial Infections Surveillance system risk index categories of 0, 1, and 2 or 3, respectively. The majority (69.4%) of the SSIs observed were organ or space SSIs. The most frequently isolated microorganisms were Staphylococcus aureus and Klebsiella pneumoniae. Male sex (odds ratio [OR], 1.67 [95% confidence interval (CI), 1.09–2.58]), increased operation time (1.20 [1.07–1.34] per 1-hour increase), reoperation (7.27 [3.68–14.38]), combined multiple procedures (1.79 [1.13–2.83]), prophylactic administration of the first antibiotic dose after skin incision (3.00 [1.09–8.23]), and prolonged duration (≥7 days) of surgical antibiotic prophylaxis (SAP; 2.70 [1.26–5.64]) were independently associated with increased risk of SSI.Conclusions.Male sex, inappropriate SAP, and operation-related variables are independent risk factors for SSI after gastric surgery.

Background: Optimal blood culture performance is critical for successful diagnosis and treatment of sepsis. To understand the sta- tus of blood culture, we investigated several aspects of the procedure at 9 university hospitals. Methods: The process of ordering blood culture sets and sampling volume for adults and children was investigated from January 2010 to April 2010, while the positive rate of detection and growth of skin contaminants were compared in 2009. Microbial growth in aerobic and anaerobic bottles was investigated prospectively. Results: A majority of the hospitals used 2 sets of bottles for adults and 1 bottle for children. The average blood volume in each set was 7.7 mL for adults and 2.1 mL for children. The positive rate of microorganisms was 8.0%, and the isolation rate of the normal flora of the skin was 2.1%. Bacterial growth rates in aerobic and anaerobic bottles only were 31.8% and 24.5% respectively. Conclusions: Ordering blood culture sets and sampling volumes did not comply with CLSI guidelines. However, the rate of positive cultures and skin contamination rates were acceptable. Anaerobic bottles are useful in enhancing the yield of microorganisms.

Given that anti-tuberculosis medication itself has antibacterial activity and that broad-spectrum antibiotics are frequently used, the emergence of multidrug-resistant (MDR) bacteria among patients being treated for tuberculosis (TB) is likely. We used a case-control design to study the clinical predictors of MDR bacterial infection among TB patients. Both cases and controls were selected from among patients who were diagnosed and treated as having TB between 1 January 1996 and 31 August 2006. TB patients with MDR bacterial infection were included as cases and those with non-MDR bacterial infection were included as controls. Multiple logistic regression analysis was performed to elucidate the risk factors for MDR bacterial infection. During the study period 3667 patients were diagnosed with, and treated for, TB. A total of 123 experienced episodes of bacterial infection, of whom 59 (48.0%) were infected by an MDR strain at least once. The presence of chronic renal failure [adjusted odds ratio (OR): 4.96; 95% confidence interval (CI): 1.37-18.01] and the use of antimicrobials other than typical anti-TB drugs within three months (adjusted OR: 4.37; 95% CI: 1.74-10.95) were independent risk factors for MDR bacterial infection. Bacterial infection in TB patients is commonly multidrug resistant. Clinicians should be aware of the possibility of MDR bacterial infection among TB patients with chronic renal failure or recent use of other antimicrobials.

The genus Moraxella comprises approximately 20 species of aerobic, non-motile, oxidase-positive, and gram-negative coccobacilli. Besides M. catarrhalis, a well-known pathogen, M. atlantae, M. canis, M. lacunata, M. lincolnii, M. nonliquefaciens, and M. osloensis are also occasionally isolated from clinical samples [1]. M. osloensis is a commensal microorganism in the human respiratory tract, but has also been reported as a rare causative pathogen in human infections [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12]. Here, we report a case of M. osloensis bacteremia in a patient with a hematologic malignancy. To our knowledge, this is the first report of M. osloensis bacteremia in Korea. A 66-yr-old man with acute myeloid leukemia (AML) was admitted to our hospital for consolidation chemotherapy. Two months prior to this hospitalization, the patient was diagnosed with AML, not otherwise specified, according to the 2008 WHO classification system [13], and he subsequently received cytarabine and idarubicin chemotherapy. After 1 month, follow-up bone marrow examination was performed, and he achieved complete remission. On admission, the patient presented with symptoms of an upper respiratory infection including coughing and chills. He had a temperature of 37.2℃, a blood pressure of 117/57 mmHg, a pulse of 106/min, and a respiration rate of 20 breaths/min. The results of the laboratory investigation were as follows: Hb, 11.7 g/dL; leukocyte count, 5.7×109/L; platelet count, 177×109/L; C-reactive protein level, 6.48 mg/dL; blood urea nitrogen (BUN)/creatinine, 15/1.2 mg/dL; and total protein/albumin, 6.8/3.6 g/dL. A total of four blood culture sets were collected from two separate peripheral veins and central venous catheter. There were no abnormalities in the chest radiographic images, but paranasal sinus radiographic imaging indicated a suspected maxillary sinusitis. Therefore, empirical antibiotic therapy with intravenous ampicillin-sulbactam was administered. Bacterial growth was detected in an aerobic culture bottle that contained the blood from the central venous catheter after 1 day of incubation, and in the other 3 aerobic culture bottles after 2 days of incubation (Fig. 1A). The broths from positive culture bottles were inoculated onto blood agar plates (BAPs) and MacConkey agar plates (MACs) that were subsequently incubated for 24 hr at 35℃ in a 5% CO2 atmosphere. Whereas no colony was observed on the MACs, grey-white colored, non-hemolytic colonies grew on the BAPs (Fig. 1B) and gram-negative coccobacilli were observed from gram stain smear preparations (Fig. 1C). The isolates were oxidase-positive and indole-negative. Fig. 1 Colonial and microscopic morphology of Moraxella osloensis. (A) Gram-negative coccobacilli from positive aerobic blood culture smear preparations (Gram stain, ×1,000). (B) Grey-white colored colonies on blood agar plate. (C) Gram-negative coccobacilli ... Using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS; Bruker Daltonik GmbH, Bremen, Germany) and Vitek2 GN system (bioMerieux, Marcy l'Etoile, France), the organism was suboptimally identified as M. osloensis, with a score of 1.885 in the Bruker system and with a 50% probability in the Vitek2 system. To confirm the identity of the isolate, 16S rRNA sequence analysis was performed on the MicroSeq 500 system (Applied Biosystems, Foster City, CA, USA), using PCR and sequencing kits with universal primers designed to cover all bacteria. The sequences were analyzed with an ABI PRISM 3730 Series DNA Analyzer (Applied Biosystems). The first 500 bp of the 16S rRNA gene sequence from the isolate shared 99.6% identity with the GenBank sequence {"type":"entrez-nucleotide","attrs":{"text":"AY043376","term_id":"21844518","term_text":"AY043376"}}AY043376 (M. osloensis) and 99.0% identity with the GenBank sequence {"type":"entrez-nucleotide","attrs":{"text":"KC494325","term_id":"456371510","term_text":"KC494325"}}KC494325 (Enhydrobacter aerosaccus). Antimicrobial susceptibility was tested with the AST-N222 card from the Vitek 2 system (bioMerieux). Using the CLSI breakpoints for other non-Enterobacteriaceae for the interpretation [14], the isolate was determined susceptible to aztreonam, cefepime, ceftazidime, ciprofloxacin, gentamicin, imipenem, meropenem, piperacillin, and trimethoprim-sulfamethoxazole. Intravenous ampicillin-sulbactam treatment was maintained, and follow-up blood cultures from the peripheral veins and central venous catheter on day 3 were negative. The patient was successfully treated with a 10-day course of intravenous ampicillin-sulbactam and subsequently began consolidation chemotherapy for AML. Despite the unique biochemical characteristics of M. osloensis, which include acetate alkalinization, ethylene glycol acidification, and desferrioxamine resistance, species-level biochemical identification is difficult because of the overall lack of biochemical differences among the Moraxella species [1]. Although only 2 reported isolates besides the present case have been identified by MALDI-TOF MS, this method suboptimally identified M. osloensis; one isolate was identified as M. osloensis with a score of

Background. Persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with high mortality rates, but no treatment strategy has yet been established. We performed this study to evaluate the efficacy of linezolid with or without carbapenem in salvage treatment for persistent MRSA bacteremia. Methods. All adult patients with persistent MRSA bacteremia for 7 days from January 2006 through March 2008 who were treated at Seoul National University Hospital were studied. The results of linezolid salvage therapy with or without carbapenem were compared with those of salvage therapy with vancomycin plus aminoglycosides or rifampicin. Results. Thirty-five patients with persistent MRSA bacteremia were studied. The early microbiological response (ie, negative results for follow-up blood culture within 72 hours) was significantly higher in the linezolid-based salvage therapy group than the comparison group (75% vs 17%; ). Adding aminoglycosides or rifampicin P p .006 to vancomycin was not successful in treating any of the patients, whereas linezolid-based therapy gave an 88% salvage success rate ( ). The S. aureus‐related mortality rate was lower for patients treated with a linezolid P ! .001 salvage regimen than for patients continually treated with a vancomycin-based regimen (13% vs 53%; ). P p .030 Conclusions. Linezolid-based salvage therapy effectively eradicated S. aureus from the blood for patients with persistent MRSA bacteremia. The salvage success rate was higher for linezolid therapy than for vancomycin-based combination therapy.

We report a case of liver cirrhosis caused byExophiala dermatitidisin a previously healthy child. The infecting organism was initially mistaken as capsule-deficientCryptococcus neoformans.

There have been very few multicenter studies of the relationship between the use of antifungals and resistance to them. We investigated the antifungal susceptibility of 1,301 clinical isolates of Candida collected from nine Korean hospitals during a 3-month period in 2006 to explore the existence of this type of relationship. Antifungal usage in the preceding year, defined as the daily dose per 1,000 patient days (DDD/1,000 PD), was calculated for each hospital. Resistance to fluconazole, itraconazole, and amphotericin B was detected in 2, 9, and 0.2% of the isolates, respectively. The MIC(50)/MIC(90) values were 0.03/0.125 mg/L for voriconazole, 0.06/0.25 mg/l for caspofungin, and 0.03/0.125 mg/l for micafungin. The total usage of systemic antifungals varied considerably among the nine hospitals, ranging from 6.1 to 96.2 DDD/1,000 PD. No relationship was found between the use of fluconazole (MICor =64 mg/l) or itraconazole (MICor =1 mg/l) and resistance in the Candida species (P0.05). However, significant correlations were found between the percentage of Candida isolates that were non-susceptible to fluconazole (MICor =16 mg/l) and fluconazole usage (r=0.733, P=0.025) or total antifungal usage (r=0.767, P=0.016).

This study was performed to evaluate the relationship among the Nugent score for the diagnosis of bacterial vaginosis (BV), the results of vaginal fluid culture for genital mycoplasmas, and the subsequent occurrence of preterm birth.The Nugent score and culture for genital mycoplasmas were performed in vaginal fluid obtained from 977 pregnant women (gestational age 13-30 weeks). Vaginal samples were obtained with sterile cotton swabs. The relationship among the Nugent score, vaginal fluid culture results and the occurrence of spontaneous preterm birth was examined.(1) Of the 977 women, 14% (137) had a Nugent score ofor=8; (2) The prevalence of a positive vaginal culture for genital mycoplasmas was 30% (288); Ureaplasma urealyticum was isolated in 252 (88%), Mycoplasma hominis in 9 (3%), and both in 27 (9%) women; (3) Cases with a Nugent score ofor=8 had a higher rate of a positive vaginal culture for genital mycoplasmas than those with the lower Nugent score (55%vs. 25%; p0.001); (4) Women with a Nugent score ofor=8 had a significantly higher rate of spontaneous preterm birth37 (10%vs. 4%),34 (5%vs. 2%), and32 (4%vs. 1%) weeks of gestation than those with the lower Nugent score (at each gestational age, p0.05); (5) In contrast, a positive vaginal culture for genital mycoplasmas was not associated with an increased risk for spontaneous preterm birth; (6) Among patients with a positive culture and a Nugent score ofor=8, the frequency of spontaneous preterm delivery (37 weeks) was 10% (7/72); (7) There was no difference in the incidence of spontaneous preterm delivery according to the results of vaginal culture in patients with a Nugent score ofor=8, as well as in those with a lower Nugent score.A high Nugent score (or=8) for the detection of BV but not a positive vaginal culture for genital mycoplasmas is a risk factor for spontaneous preterm birth.

A 13-year-old girl exhibited rapid deterioration in mental status 15 days after surgery for craniopharyngioma. Serial CT scanning detected progression of a low-density lesion on the left frontotemporal lobe. The serum level of C-reactive protein was elevated and polymerase chain reaction identified herpes simplex virus DNA in the cerebrospinal fluid. Antiviral therapy with high-dose acyclovir (10 mg/kg 3 times daily) was begun. She recovered and could speak short sentences, but dysphasia and right hemiparesis remained. Early diagnosis and active treatment of herpes simplex encephalitis is essential for improving prognosis and saving lives.

Objective.To control an outbreak ofShewanella algaeandS. putrefaciensinfections by identifying the risk factors for infection and transmission.Design.Matched case-control study.Setting.A university-affiliated tertiary acute care hospital in Seoul, Republic of Korea, with approximately 1,600 beds.Patients.From June 20, 2003, to January 16, 2004, a total of 31 case patients withShewanellacolonization or infection and 62 control patients were enrolled in the study.Interventions.Requirement to use single-use measuring cups and standard precautions (including hand washing before and after patient care and use of gloves).Results.S. algaeorS. putrefacienswas isolated from blood, for 9 (29.0%) of 31 patients who acquired one of the organisms; from bile, for 8 (25.8%), and from ascitic fluid, for 8 (25.8%). The attack rate of this outbreak was 5.8% (31 patients infected or colonized, of 534 potentially exposed on ward A) and the pathogenicity of the two species together was 77.4% (24 patients infected, of 31 who acquired the pathogens). The estimated incubation period forShewanellaacquisition was 3–49 days. Using logistic analysis, we identified the following risk factors: presence of external drainage catheters in the hepatobiliary system (odds ratio [OR], 20;P< .001), presence of hepatobiliary disease (OR, 6.4;P< .001), admission to the emergency department of the hospital (OR, 2.9;P= .039), wound classification of “contaminated” or “dirty or infected” (OR, 16.5;P= .012), an American Society of Anesthesiologists score of 3 or higher (OR, 8.0;P= .006), duration of stay in ward A (OR, 1.1;P< .001), and, for women, an age of 60–69 years (OR, 13.3;P= .028). AShewanellaisolate was recovered from the surface of a shared measuring cup, and 12 isolates ofS. algaeshowed the same pulsed-field gel electrophoresis pattern.Conclusions.ThisShewanellaoutbreak had a single-source origin and spread by contact transmission via a contaminated measuring cup.Shewanellaspecies are emerging as potentially serious human pathogens in hospitals and could be included in hospital infection surveillance systems.

The prevalence of toxigenic Clostridium difficile in Korea has been reported to be approximately 60–80 %. Although the prevalence of the tcdA−tcdB+ C. difficile strain was less then 5 % prior to the year 2000, it has become an emerging nosocomial pathogen in Korea. Therefore, we have attempted to determine the multicentre nationwide prevalence of tcdA+tcdB+ and tcdA−tcdB+ C. difficile for epidemiological purposes. C. difficile strains (n=724, 30 from 2000, 80 from 2001, 74 from 2002, 76 from 2003, 179 from 2004, 285 from 2005) were obtained retrospectively from January 2000 to December 2005 from in-patients at 6 hospitals, all of whom were suspected of having C. difficile-associated disease (CDAD), colitis or pseudomembranous colitis. The numbers of participating hospitals varied yearly (1 in 2000, 2 in 2001–2003, 3 in 2004, 5 in 2005). The hospitals were located in Seoul (n=4), Kyunggi Province (n=1) and Busan (n=1), Korea. PCR assays for tcdA and tcdB genes were conducted using 724 unduplicated C. difficile isolates. The mean prevalence of tcdA+tcdB+ and tcdA−tcdB+ C. difficile strains over the 6 years was 51.8 % (38.4–59.3 %) and 25.8 %(10–56.0 %), respectively. The mean prevalence of tcdA−tcdB+ C. difficile strains was less than 7 % until 2002, but began to increase in 2003 (13.2 %) and achieved a peak in 2004 (50.3 %). In 2005, the mean prevalence of tcdA+tcdB+ and tcdA−tcdB+ C. difficile strains was 47.7 % (30.9–60.3 %) and 27.0 % (17.6–54.8 %), respectively. This nationwide epidemiological study showed that tcdA−tcdB+ C. difficile strains have already spread extensively throughout Korea, and our results provide basic data regarding the controversies currently surrounding the toxigenicity of tcdA−tcdB+ C. difficile. The use of enzyme immunoassays capable of detecting both TcdA and TcdB is strongly recommended for the diagnosis of CDAD in microbiology laboratories, in order to control the spread of the tcdA−tcdB+ strains of C. difficile.

Human papillomavirus (HPV) infection is an important etiologic factor in cervical carcinogenesis. Various HPV DNA detection methods have been evaluated for clinicopathological level. For the specimens with normal cytological finding, discrepancies among the detection methods were frequently found and adequate interpretation can be difficult. 6,322 clinical specimens were submitted and evaluated for real-time PCR and Hybrid Capture 2 (HC2). 573 positive or “Not Detected but Amplified” (NDBA) specimens by real-time PCR were additionally tested using genetic analyzer. For the reliability of real-time PCR, 325 retests were performed. Optimal cut-off cycle threshold (CT) value was evaluated also. 78.7% of submitted specimens showed normal or nonspecific cytological finding. The distributions of HPV types by real-time PCR were not different between positive and NDBA cases. For positive cases by fragment analysis, concordance rates with real-time PCR and HC2 were 94.2% and 84.2%. In NDBA cases, fragment analysis and real-time PCR showed identical results in 77.0% and HC2 revealed 27.6% of concordance with fragment analysis. Optimal cut-off CT value was different for HPV types. NDBA results in real-time PCR should be regarded as equivocal, not negative. The adjustment of cut-off CT value for HPV types will be helpful for the appropriate result interpretation.

Although mycobacterial culture and the subsequent drug-susceptibility test (DST) for anti-tuberculosis (TB) drugs take several months to complete using solid media, there are no reports on the turnaround times of these tests under clinical conditions. The aim of this study was to determine the interval between initiation of anti-TB treatment and receipt of DST requested at an outpatient clinic. We prospectively enrolled patients with culture-positive pulmonary TB at Seoul National University Hospital from September 2002 to December 2004. Patients were followed up monthly. Mycobacterial cultures were done using Ogawa media at Seoul National University Hospital. DST were performed at the Korean Institute of Tuberculosis. Of the 104 patients enrolled, 54 were male. The median age was 41 yr. The median interval from initiation of anti-TB treatment to receipt of mycobacterial culture results by clinicians was 37 days (range, 0-89 days). The median interval from initiation of treatment to confirmation of DST by requesting clinicians was 80.5 days (range, 28-145 days). Clinicians only received the results of DST more than two months after initiation of treatment when they followed up patients monthly and mycobacterial culture was performed using solid media.

BACKGROUND Recently, molecular detection of Mycobacterium tuberculosis in a respiratory specimens is accepted as one of the standard procedures for diagnosis of tuberculosis in Korea. When detecting tuberculosis using a real-time polymerase chain reaction (PCR), results showed the repeated near-cutoff values in a specimen make it difficult for the laboratory to give definitive reports as positive or negative. METHODS We retrospectively evaluated clinical state of ninety-eight patients who were not currently taking antituberculosis medications and had near-cutoff values of respiratory specimens using a real-time PCR test. RESULTS Sixty-eight percent of the patients had clinical tuberculosis. In subgroup analysis, patients less than the age of 50, 94.3% had tuberculosis while only 55.6% of the patients with the age of equal and over 50 had tuberculosis (p < 0.001). CONCLUSIONS Setting a gray zone for real-time PCR result and give additional tailored information onto the interpretative report would be suggested for the clinical practice in an intermediate burden of tuberculosis country.

Eleven years ago, a 27-year-old non-drug abuser woman was admitted to the hospital due to a burn injury. During the treatment, she was diagnosed with tricuspid valve infective endocarditis caused by multi-drug resistant (MDR) Pseudomonas aeruginosa (P. aeruginosa). She underwent tricuspid valve replacement (TVR) using a bioprosthetic valve, followed by 6 weeks of meropenem antibiotic therapy. Ten years later, she was again diagnosed with prosthetic valve infective endocarditis caused by MDR P. aeruginosa. She underwent redo-TVR with a bioprosthetic valve and was treated with colistin and ciprofloxacin. Ten months later, she was again diagnosed with prosthetic valve infective endocarditis with MDR P. aeruginosa as a pathogen. She underwent a second redo-TVR with a tissue valve and was treated with colistin. Two months later, her fever recurred and she was again diagnosed with prosthetic valve infective endocarditis caused by MDR P. aeruginosa. She eventually underwent a third redo-TVR using an aortic valve homograft and was discharged from the hospital after additional 6 weeks’ of antibiotic therapy. All the strains of P. aeruginosa isolated from each event of infective endocarditis were analyzed by repetitive deoxyribonucleic acid sequence-based polymerase chain reaction (rep-PCR) deoxyribonucleic acid (DNA) strain typing to determine the correlation of isolates. All of the pathogens in 11 years were similar enough to be classified as the same strain, and this is the first case report of TVR using an aortic valve homograft to treat relapsing endocarditis.

We conducted this study to compare clinical features, outcomes, and clinical implication of antimicrobial resistance in Klebsiella pneumoniae bacteremia acquired as community vs. nosocomial infection. A total of 377 patients with K. pneumoniae bacteremia (191 community-acquired and 186 nosocomial) were retrospectively analyzed. Neoplastic diseases (hematologic malignancy and solid tumor, 56%) were the most commonly associated conditions in patients with nosocomial bacteremia, whereas chronic liver disease (35%) and diabetes mellitus (20%) were the most commonly associated conditions in patients with community-acquired bacteremia. Bacteremic liver abscess occurred almost exclusively in patients with community-acquired infection. The overall 30-day mortality was 24% (91/377), and the mortality of nosocomial bacteremia was significantly higher than that of community-acquired bacteremia (32% vs. 16%, p

The marked increase in the incidence of infections due to antibiotic-resistant gram-negative bacilli in recent years is of great concern, as patients infected by those isolates might initially receive antibiotics that are inactive against the responsible pathogens. To evaluate the effect of inappropriate initial antimicrobial therapy on survival, a total of 286 patients with antibiotic-resistant gram-negative bacteremia, 61 patients with Escherichia coli bacteremia, 65 with Klebsiella pneumoniae bacteremia, 74 with Pseudomonas aeruginosa bacteremia, and 86 with Enterobacter bacteremia, were analyzed retrospectively. If a patient received at least one antimicrobial agent to which the causative microorganisms were susceptible within 24 h of blood culture collection, the initial antimicrobial therapy was considered to have been appropriate. High-risk sources of bacteremia were defined as the lung, peritoneum, or an unknown source. The main outcome measure was 30-day mortality. Of the 286 patients, 135 (47.2%) received appropriate initial empirical antimicrobial therapy, and the remaining 151 (52.8%) patients received inappropriate therapy. The adequately treated group had a 27.4% mortality rate, whereas the inadequately treated group had a 38.4% mortality rate ( P = 0.049). Multivariate analysis showed that the significant independent risk factors of mortality were presentation with septic shock, a high-risk source of bacteremia, P. aeruginosa infection, and an increasing APACHE II score. In the subgroup of patients ( n = 132) with a high-risk source of bacteremia, inappropriate initial antimicrobial therapy was independently associated with increased mortality (odds ratio, 3.64; 95% confidence interval, 1.13 to 11.72; P = 0.030). Our data suggest that inappropriate initial antimicrobial therapy is associated with adverse outcome in antibiotic-resistant gram-negative bacteremia, particularly in patients with a high-risk source of bacteremia.

Objectives:To evaluate the clinical features of ciprofloxacin-resistant Enterobacter bacteremia and to examine the risk factors for ciprofloxacin resistance in Enterobacter species isolates causing bacteremia.Design:A case-control study.Setting:A 1,500-bed, tertiary-care university hospital and referral center.Patients:All patients older than 16 years with Enterobacter species isolated from blood were enrolled. The medical records of 183 patients with clinically significant Enterobacter bacteremia from January 1998 to December 2002 were identified. We compared patients with bacteremia caused by ciprofloxacin-susceptible isolates with patients with bacteremia caused by ciprofloxacin-resistant isolates.Results:Twenty-three (12.6%) of the patients had bacteremia caused by isolates resistant to ciprofloxacin. There were no significant differences in age, gender, underlying diseases, primary site of infection, or Acute Physiology and Chronic Health Evaluation II score between the ciprofloxacin-resistant and the ciprofloxacin-susceptible groups. Broad-spectrum cephalosporin resistance, defined as resistance to cefotaxime or ceftazidime in vitro, was detected in 21 (91.3%) of 23 ciprofloxacin-resistant isolates compared with 65 (40.6%) of 160 ciprofloxacin-susceptible isolates (P < .001). Multivariate analysis revealed that independent risk factors for ciprofloxacin resistance were the prior receipt of fluoroquinolones (P < .001) and broad-spectrum cephalosporin resistance (P < .001).Conclusions:In Enterobacter species isolates causing bacteremia, ciprofloxacin resistance was closely associated with the prior receipt of fluoroquinolones and broad-spectrum cephalosporin resistance. The close relationship between ciprofloxacin resistance and broad-spectrum cephalosporin resistance is particularly troublesome because it severely restricts the therapeutic options for Enterobacter species infection.

This study was conducted to evaluate risk factors for mortality and treatment outcome of bloodstream infections due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK). ESBL production in stored K. pneumoniae and E. coli blood isolates from Jan 1998 to Dec 2002 was phenotypically determined according to NCCLS guidelines and/or the double-disk synergy test. A total of 133 patients with ESBL-EK bacteremia, including 66 patients with ESBL-producing K. pneumoniae and 67 with ESBL-producing E. coli , were enrolled. The overall 30-day mortality rate was 25.6% (34 of 133). Independent risk factors for mortality were severe sepsis, peritonitis, neutropenia, increasing Acute Physiology and Chronic Health Evaluation II score, and administration of broad-spectrum cephalosporin as definitive antimicrobial therapy ( P < 0.05 for each of these risk factors). In 117 of the 133 patients, excluding 16 patients who died within 3 days after blood culture sample acquisition, the 30-day mortality rates according to definitive antibiotics were as follows: carbapenem, 12.9% (8 of 62); ciprofloxacin, 10.3% (3 of 29); and others, such as cephalosporin or an aminoglycoside, 26.9% (7 of 26). When patients who received appropriate definitive antibiotics, such as carbapenem or ciprofloxacin, were evaluated, mortality in patients receiving inappropriate empirical antimicrobial therapy was found not to be significantly higher than mortality in those receiving appropriate empirical antimicrobial therapy (18.9 versus 15.5%; P = 0.666). Carbapenem and ciprofloxacin were the most effective antibiotics in antimicrobial therapy for ESBL-EK bacteremia. A delay in appropriate definitive antimicrobial therapy was not associated with higher mortality if antimicrobial therapy was adjusted appropriately according to the susceptibility results. Our data suggest that more prudent use of carbapenem as empirical antibiotic may be reasonable.

A vancomycin-resistant Enterococcus (VRE) outbreak occurred at a hematology/oncology (HO) service in a tertiary acute care hospital, 1 January to 30 April 2002. This study was undertaken to identify risk factors, and to establish relations between seasonal factors and this VRE outbreak. Every patient (n = 82) and health care worker (HCW) (n = 31) at the HO unit was screened by rectal swab and stool culture during the VRE outbreak. Environmental surface culture (n = 35) and pulsed-field gel electrophoresis (PFGE) of VRE isolates were preformed. Among a total of 82 patients, 17 had VRE. All VRE isolates were E. faecium, the 6 studied further were Van A with identical PFGE patterns. Cultures of surfaces and HCWs were negative for VRE. Prolonged hospital stay (p = 0.02), male gender (p = 0.02), and care in a 6-bed room (p < 0.01) were risk factors for acquisition of VRE. An association with the VRE outbreak period was found again for long hospital stay, but also for the antibiotic usage pattern, frequent surgery and a high proportion of new inexperienced staff (52% vs 4% before the outbreak (p < 0.01, Fisher's exact test). Sudden personnel turnover in high-risk units should be avoided.

Objective: To determine the impact of delayed treatment of methicillin-resistant Staphylococcus aureus bacteraemia (MRSA bacteraemia) on mortality. Patients and methods: We used two different and complementary approaches: a retrospective cohort study and a matched case–control study. Of the total of all patients with S. aureus bacteraemia in a tertiary hospital over a 4 year period, 127 patients with MRSA bacteraemia were enrolled in the cohort study. The cases for the case–control study were defined as patients who received appropriate empirical treatment for MRSA bacteraemia; the controls, who were patients who received inappropriate empirical treatment for MRSA bacteraemia, were selected according to the matching variables of age, sex, severity of underlying illness, classification of main underlying disease and prior hospital stay. On the 14-point matching scale that was used to select the best controls, the average score (6 S.D.) of the 30 controls was 11.2 (62.0). Results: In the cohort study, the difference in S. aureus bacteraemia-related mortality between appropriate (30%, 9/30) and inappropriate (39%, 38/97) empirical treatment was not significant (P 5 0.36). In addition, multivariate analysis did not indicate that inappropriate empirical treatment was associated with mortality when independent predictors for mortality were considered (adjusted OR 1.1, 95% CI 0.4–3.1). In the case–control study, S. aureus bacteraemia-related mortality in case patients was 30% (9/30) and in control patients 33% (10/30) (P > 0.99, McNemar’s test). In four of the nine discordant pairs, the case patients died whereas the control patients lived. Conclusions: Our data suggest that an initial delay of 2 days in the use of appropriate antibiotics, especially of vancomycin or other glycopeptides, before the preliminary microbiological report may not adversely affect the outcome in patients with MRSA bacteraemia.

BACKGROUND This study was conducted to evaluate the risk factors for infection and clinical outcomes of bacteremic spontaneous bacterial peritonitis (SBP) due to ESBL-producing E. coli and K. pneumoniae, in patients with advanced liver cirrhosis. METHODS The ESBL production was determined by NCCLS guidelines and/or double-disk synergy tests, on stored E. coil and K. pneumoniae blood isolates collected between 1998 and 2002. Of the patients with advanced liver cirrhosis, 15 case patients, with SBP due to ESBL-producers, were compared with 30 matched controls, with SBP due to non-ESBL-producers. RESULTS There were no significant differences in age, sex, Child-Pugh scores, or APACHE II scores between the two groups. Significant factors associated with infection by ESBL-producing organisms, according to univariate analysis, were: ICU care, indwelling urinary catheter, central venous catheterization, an invasive procedure within the previous 72 hours, and prior use of antibiotics within the previous 30 days. When assessing the clinical response at 72 hours after the initial antimicrobial therapy, the treatment failure rate was significantly higher in the ESBL group (73.3% vs. 16.7%, p

Objective:To evaluate the outcome of attempted Hickman catheter salvage in neutropenic cancer patients withStaphylococcus aureusbacteremia who were not using antibiotic lock therapy.Design:Retrospective cohort study.Setting:A university-affiliated, tertiary-care hospital with 1,500 beds for adult patients.Patients:All neutropenic cancer patients who had a Hickman catheter andS. aureusbacteremia (32 episodes in 29 patients) between January 1998 and March 2002.Methods:Salvage attempts were defined as cases where the Hickman catheter was not removed until we obtained the results of follow-up blood cultures performed 48 to 72 hours after starting treatment with antistaphylococcal antibiotics. Salvage was considered to be successful if the Hickman catheter was still in place 3 months later without recurrent bacteremia or death.Results:Catheter salvage was attempted in 24 (75%) of the 32 episodes. Of the salvage attempts, the success rate was 50% (12 of 24). Salvage attempts were successful in 14% (1 of 7) of the episodes with positive follow-up blood cultures, and in 65% (11 of 17) of those with negative follow-up blood cultures (P= .07). If the analysis is confined to cases with no external signs of catheter infection, salvage attempts were successful in 14% (1 of 7) of the episodes with positive follow-up blood cultures and in 80% (8 of 10) of those with negative follow-up blood cultures (P= .02).Conclusion:In neutropenic cancer patients withS. aureusbacteremia, attempted catheter salvage without antibiotic lock therapy was successful in 50% of the cases.