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Invasive bacterial infection (IBI) causes a significant burden in infants. In this study, we analyzed changes in epidemiology of IBI among infants in Korea.A retrospective multicenter-based surveillance for IBIs in infants3 months of age was performed during 2006-2020. Cases were classified as an early-onset disease (EOD) (0-6 days) or late-onset disease (LOD) (7-89 days). The temporal trend change in proportion of pathogens was analyzed.Among 1545 cases, the median age was 28 days (IQR: 12, 53) and EOD accounted for 17.7%. Among pathogens, S. agalactiae (40.4%), E. coli (38.5%), and S. aureus (17.8%) were the most common and attributed for 96.7%. Among EOD (n = 274), S. agalactiae (45.6%), S. aureus (31.4%), E. coli (17.2%) and L. monocytogenes (2.9%) were most common. Among LOD (n = 1274), E. coli (43.1%), S. agalactiae (39.3%), S. aureus (14.9%) and S. pneumoniae (1.3%) were most common. In the trend analysis, the proportion of S. aureus (r s = -0.850, P0.01) decreased significantly, while that of S. agalactiae increased (r s = 0.781, P0.01).During 2006-2020, among IBI in infants3 months of age, S. agalactiae, E. coli, and S. aureus were most common and an increasing trend of S. agalactiae was observed.

Objective Geographic region can be an important source of variation in the immune response to pneumococcal conjugate vaccines (PCV). The aim of this study was to collate data from available PCV clinical trials in order to characterize the differences in antibody responses in different countries. Methods A systematic review and meta-analysis was conducted to examine the difference in antibody responses after primary series of PCVs in infants, associated with geographic regions, compared with each other and with the different PCVs using random-effects models. Results A total of 69 trials were included. Studies conducted in the Western Pacific Region (WPR) showed higher geometric mean concentrations (GMC) compared to studies conducted in Europe. The pooled GMC for serotype 4 after three doses of PCV7 in the WPR was 5.19 μg/ml (95% confidence interval 4.85–5.53 μg/ml), while for studies conducted in Europe this was 2.01 μg/ml (95% confidence interval 1.88–2.14 μg/ml). The IgG GMC ratios among the WPR versus European regions ranged from 1.51 to 2.87 for PCV7, 1.69 to 3.22 for PCV10, and 1.49 to 3.08 for PCV13. Conclusions Studies conducted in the WPR generally showed greater antibody responses than the studies conducted in Europe. Indications of differences among geographic regions highlight the fact that further research is needed to compare the biological factors contributing to immune responses, which may affect vaccination schedules.

Replacement with nonvaccine serotypes (NVTs) among invasive pneumococcal diseases (IPDs) after the introduction of extended-valency pneumococcal conjugate vaccines varies in predominant serotypes across countries. This study analyzed changes in serotype distribution through serotyping, multilocus sequence typing, and antimicrobial susceptibility testing of 168 pediatric IPD isolates obtained from a multihospital-based surveillance system during 2014-2019 in South Korea. Vaccine serotypes (VTs) accounted for 16.1% (19A, 10.1%; 6A, 1.8%; and 19F 1.8%), 82.1% were NVTs (10A, 23.8%; 15A, 8.3%; 12F, 6.5%; 15C, 6.5%; and 15B, 6.0%), and three (1.8%) were nontypeable. Serotype 10A was the most common serotype, with a significant increase from 11.5% in 2014 to 33.3% in 2019 (p < 0.05 for the trend). Other NVTs decreased from 70.4% to 41.7% between 2015 and 2019, most notably in serotype 12F (from 14.8% to 0%). Almost all (95.0%) serotype 10A isolates were ST11189, which were multidrug resistant.

Aims: Acinetobacter baumannii has become an important nosocomial pathogen that causes invasive infections. We conducted a retrospective study to evaluate the risk factors for mortality due to A. ba...

This study investigated the roles of β-lactamase and penicillin-binding protein 3 (PBP3) alterations in the development of recent antimicrobial resistance in nontypeable Haemophilus influenzae (NTHi) isolated from Korean children. Nasopharyngeal NTHi isolates from children at a tertiary children's hospital were tested for antimicrobial susceptibility using E-test. β-lactamase production was screened by the paper disc test, and polymerase chain reaction amplification of blaTEM and blaROB-1 was performed. The ftsI gene was amplified to identify PBP3 alteration. Of the 53 NTHi isolates, 69.8% were ampicillin nonsusceptible. The nonsusceptibility rates for cefaclor were 81.1%, cefpodoxime 69.8%, and amoxicillin/clavulanate 32.1%. About 60.3% and 32.1% of the isolates were genetically β-lactamase-nonproducing ampicillin-resistant (gBLNAR) and genetically β-lactamase-producing amoxicillin/clavulanate-resistant (gBLPACR) strains, respectively. Group III amino acid substitutions comprised 65.6% of the gBLNAR strains and 70.6% of the gBLPACR strains. MIC50 for amoxicillin/clavulanate, cefaclor, cefuroxime, cefpodoxime, and cefixime were more than 2-80 times higher in the gBLNAR and gBLPACR strains compared with gBLPAR strains. Group III gBLNAR strains had significantly higher ampicillin, amoxicillin/clavulanate, cefpodoxime, and cefixime minimum inhibitory concentrations than group II strains. Group III gBLNAR and gBLPACR NTHi strains are highly prevalent in Korea, raising the alarm about increasing β-lactam resistance in NTHi.

Escherichia coli sequence type (ST) 131 has emerged as a higher virulent and multidrug-resistant pathogen worldwide. This study aimed to identify the prevalence and characteristics of E. coli ST131 isolated from Korean children with bacteremia at a single center for 16 years. We retrospectively reviewed culture-proven E. coli bacteremia cases of children aged ≤18 years between 2000 and 2015. E. coli isolates were analyzed using multilocus sequence typing, fimH typing, and CTX-M typing. Among 177 children with E. coli bacteremia, a total of 21 (11.9%) ST131 isolates and 37 (20.9%) extended spectrum β-lactamase (ESBL)-producing E. coli were identified. Nineteen (90.5%) isolates of ST131 E. coli had the fimH gene, of which three were assigned to subclone H30. There was a significant difference in prevalence of ESBL production between ST131 (n = 8, 38.1%) and non-ST131 (n = 29, 18.6%) isolates (p = 0.039). Five ESBL-producing ST131 E. coli isolates had the blaCTX-M gene: two carried blaCTX-M-14, two carried b...

Background: During the COVID-19 pandemic, South Korea has achieved a temporary, but nearly perfect universal health coverage model, in terms of the extent of patients and services covered by insurance. The current study investigated whether socioeconomic disparities remained in COVID-19 health outcomes under universal health coverage and sought to determine which factor exerted the greatest effect on disparities in COVID-19 outcomes. Methods: This retrospective, observational study included all 7,590 confirmed COVID-19 patients who tested positive in South Korea through May 15, 2020. We used the official medical database, released from the Ministry of Health and Welfare and Health Insurance Review and Assessment Service in South Korea. Socioeconomic status was estimated by insurance type (National Health Insurance Service [NHIS] beneficiaries and Medical Aid [MA] recipients). Incidence (per 1,000,000), mortality rate (per 1,000,000), and case fatality rate were calculated. To determine the factors associated with incidence and case fatality ratio, multivariable logistic regressions were performed at the national and regional levels. Findings: Nationwide, incidence of COVID-19 was 144·4 per 1,000,000, mortality rate was 4·3 per 1,000,000, and case fatality ratio was 3·0%. MA recipients had higher incidence (424·3 vs 136.3), mortality rate (28·3 vs 3·6), and case fatality ratio (6·7 vs 2·7) than NHIS beneficiaries. After adjustment, older age, male sex, hypertension, higher Charlson comorbidity index score, and region were associated with higher odds of COVID-19 case fatality. Interpretation: We found socioeconomic disparities in COVID-19 related health outcomes in incidence and fatality, despite universal health coverage. However, these disparities were not due to socioeconomic status in and of itself, but rather based on the poor underlying health conditions of the vulnerable. Funding Statement: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors. Declaration of Interests: The authors declare that there are no conflicts of interests. Ethics Approval Statement: The Institutional Review Board of the Seoul Metropolitan Government, Seoul National University, Boramae Medical Center (No. 20200403/07-2020-12/043) approved this study.

Background Understanding the population genetics of pneumococci will allow detection of changes in the prevalence of circulating genotypes and evidence for capsular switching. We aimed to analyze the genetic structure of invasive pneumococcal isolates obtained from children before and after the use of pneumococcal conjugate vaccines (PCVs) in Korea. Methods A total of 285 invasive pneumococcal isolates were analyzed using serotyping, multilocus sequence typing, and antimicrobial susceptibility testing. We classified the isolation year to pre-PCV7 (1995–2003; n = 70), post-PCV7 (2004–2010; n = 142), and post-PCV13 (2011–2013; n = 73) periods. Results Of the 10 clonal complexes (CCs), antibiotic-resistant international clones, CC320 (31.6%), CC81 (14.7%), and CC166 (6.7%) were the main complexes. Serotype 19A was the main serotype of CC320 throughout the periods. Serotypes of CC81 mainly comprised of 23F (53.3%) in pre-PCV7 period and replaced by non-vaccine types (NVTs; 6C [10%], 13 [30%], 15A [40%], and 15B/C [20%]) in post-PCV13 period. The main serotype responsible for CC166 also changed from 9 V (80%) in pre-PCV7 to NVT 11A (50%) in post-PCV13 periods. Non-susceptibility to penicillin (42.3%) was the highest in CC320, increasing from 0 to 76%. Conclusion The genetic structures of invasive pneumococcal isolates in Korean children have changed concomitantly with serotype after the implementation of PCVs.

We report the case of a 12-year-old immunocompromised boy with spondylodiscitis of the thoracolumbar spine caused by Aspergillus terreus. Microbiologic diagnosis was confirmed by inoculation of aspiration fluid into blood culture bottles. Because of noncompliance, the patient was treated with extended voriconazole therapy (23 months) with regular serum drug concentration monitoring and intermittent direct observation therapy in an outpatient clinic. The Aspergillus genus contains species that are important causes of morbidity and mortality in immunocompromised hosts. Although the lung is the main target of invasive Aspergillosis, more severe forms such as Aspergillus osteomyelitis can occur. A. fumigatus is the most common cause of Aspergillus osteomyelitis, causing 55%-61% of all cases, whereas A. terreus causes 2.3%-2.8% of cases. The vertebral bodies are the most commonly affected sites, occurring in 46%-49% of cases., Here, we report the case of an immunocompromised 12-year-old boy with thoracolumbar spondylodiscitis caused by A. terreus.

We investigated the molecular epidemiology of respiratory syncytial virus (RSV) isolated from children during 28 consecutive seasons (1990-2018) and the genetic variability of the duplication region of RSV genotypes ON1 and BA in South Korea. RSV was identified using culture-based methods in Hep-2 cells and was grouped as RSV-A or RSV-B by an immunofluorescence assay. The second hypervariable region of the G gene was sequenced for genotyping. The nucleotide and deduced amino acid sequences of the duplication region of RSV ON1 and BA were analyzed. A total of 670 RSV-A and 233 RSV-B isolates were obtained. For RSV-A, the NA1 genotype predominated during the 2004/2005-2011/2012 seasons. The ON1 genotype was first detected in 2011 and has since replaced all other genotypes. For RSV-B, the GB3 genotype predominated during the 1999/2000-2005/2006 seasons, but the BA genotype also replaced all other genotypes of RSV-B after the first season in which it was isolated (2005/2006). In ON1 and BA genotype RSV strains, novel sequence types of the duplication region of the G gene were identified in 50-95% and 33-80% of the isolates, respectively, in each season. The ON1 and BA9 genotypes are responsible for the current epidemics of RSV infection in South Korea. The sequences in the duplication region of the G gene have evolved continuously and might be sufficient for the identification of specific strains of the RSV-A ON1 and RSV-B BA genotypes.

BACKGROUND Cytomegalovirus (CMV) disease is underrecognized in children with retinoblastoma. This study investigated rates of CMV infection and disease in this specific population receiving chemotherapy. METHODS From a cohort of 164 patients with retinoblastoma diagnosed from 2011 to 2018, 107 patients were evaluated for CMV infection determined by antigenemia assay or real-time PCR. Preemptive CMV screening was implemented in 2013. CMV disease was diagnosed by tissue biopsy, culture, or ophthalmic examination. RESULTS Thirty-seven and 70 patients before and after the screening strategy, respectively, were included. Before screening, 10/37 (27%) were diagnosed with CMV infection during chemotherapy. Among them, 5 (50%) developed CMV disease (hepatitis, pneumonia, and retinitis) and one patient died of CMV pneumonia. During screening, 18/70 (26%) were documented with 36 episodes of CMV infection and 9 patients received 25 preemptive antiviral therapies. Age at chemotherapy tended to be younger in patients with CMV infection, and fewer were seronegative prior to chemotherapy. Patients who started chemotherapy at

Despite the availability of a pneumococcal National Immunization Program, which provides free PPSV23 vaccination for older adults aged ≥65 years in South Korea, pneumococcal pneumonia remains one of the most common respiratory infections, with increasing antimicrobial resistance. From January to December in 2015, all pneumococcal isolates were collected from a 1,050-bed teaching hospital in South Korea. All isolates were analyzed for serotype, genotype, and antimicrobial susceptibility. Demographic, clinical and microbiological data were compared between ceftriaxone susceptible and non-susceptible cases. Among 92 microbiologically identified pneumococcal isolates, ceftriaxone non-susceptible pneumococci (CNSP) accounted for 32 cases (34.8%). Some of these cases also showed levofloxacin resistance (25%, 8/32 isolates) and all CNSP cases were multidrug resistant. Compared to patients with ceftriaxone susceptible pneumococci (CSP), long-term care facility residents (odds ratio [OR] 7.0, 95% confidence interval [CI] 0.8–62.1) and patients with chronic lung (OR 4.1, 95% CI 1.1–15.0) and renal diseases (OR 9.1, 95% CI 1.2–70.5) were more common among those with CNSP on multivariate analysis. PPSV23-unique serotypes not included in PCV13 were more common in CNSP than in CSP (34.4% versus 13.3%, p = 0.02). Regarding genotypes, ST320 (10 cases), ST166 (7 cases) and ST8279 (3 cases) were dominant in CNSP, and ST8279 was only detected in previous long-term care facility residents. Clonal expansion and spread of CNSP strains should be monitored among patients with chronic lung/renal diseases and residents of long-term care facilities.

Background Mycobacterium bovis Bacille Calmette-Guérin (BCG) osteitis, a rare complication of BCG vaccination, has not been well investigated in Korea. This study aimed to evaluate the clinical characteristics of BCG osteitis during the recent 10 years in Korea. Methods Children diagnosed with BCG osteitis at the Seoul National University Children's Hospital from January 2007 to March 2018 were included. M. bovis BCG was confirmed by multiplex polymerase chain reaction (PCR) in the affected bone. BCG immunization status and clinical information were reviewed retrospectively. Results Twenty-one patients were diagnosed with BCG osteitis and their median symptom onset from BCG vaccination was 13.8 months (range, 6.0–32.5). Sixteen children (76.2%) received Tokyo-172 vaccine by percutaneous multiple puncture method, while four (19.0%) and one (4.8%) received intradermal Tokyo-172 and Danish strain, respectively. Common presenting symptoms were swelling (76.2%), limited movement of the affected site (63.2%), and pain (61.9%) while fever was only accompanied in 19.0%. Femur (33.3%) and the tarsal bones (23.8%) were the most frequently involved sites; and demarcated osteolytic lesions (63.1%) and cortical breakages (42.1%) were observed on plain radiographs. Surgical drainage was performed in 90.5%, and 33.3% of them required repeated surgical interventions due to persistent symptoms. Antituberculosis medications were administered for a median duration of 12 months (range, 12–31). Most patients recovered without evident sequelae. Conclusion Highly suspecting BCG osteitis based on clinical manifestations is important for prompt management. A comprehensive national surveillance system is needed to understand the exact incidence of serious adverse reactions following BCG vaccination and establish safe vaccination policy in Korea., Graphical Abstract

Pneumococcal surface protein A (PspA) is an important virulence factor of pneumococci and has been investigated as a primary component of a capsular serotype-independent pneumococcal vaccine. Thus, we sought to determine the genetic diversity of PspA to explore its potential as a vaccine candidate. Among the 190 invasive pneumococcal isolates collected from Korean children between 1991 and 2016, two (1.1%) isolates were found to have no pspA by multiple polymerase chain reactions. The full length pspA genes from 185 pneumococcal isolates were sequenced. The length of pspA varied, ranging from 1,719 to 2,301 base pairs with 55.7-100% nucleotide identity. Based on the sequences of the clade-defining regions, 68.7% and 49.7% were in PspA family 2 and clade 3/family 2, respectively. PspA clade types were correlated with genotypes using multilocus sequence typing and divided into several subclades based on diversity analysis of the N-terminal α-helical regions, which showed nucleotide sequence identities of 45.7-100% and amino acid sequence identities of 23.1-100%. Putative antigenicity plots were also diverse among individual clades and subclades. The differences in antigenicity patterns were concentrated within the N-terminal 120 amino acids. In conclusion, the N-terminal α-helical domain, which is known to be the major immunogenic portion of PspA, is genetically variable and should be further evaluated for antigenic differences and cross-reactivity between various PspA types from pneumococcal isolates.

Spondylodiscitis (SD) is a rare disease in children and diagnosis can be delayed because of the scarcity in incidence and lack of awareness. The purpose of this study was to evaluate and report the microbiologic epidemiology and clinical features of pediatric SD in South Korea.This was a retrospective study of children19 years old admitted for the treatment of SD between 2000 and 2014. Electronic medical records were reviewed for clinical parameters and etiologic agents.During the 15-year period, 25 patients were diagnosed with SD. The median age was 13.8 years, and 60% were male. Back pain was the most common presenting symptom (n = 17; 68%), and only 52% (n = 13) of the patients had a history of fever (≥38.0°C). In patients younger than 3 years, irritability (n = 5; 62.5%) was the most predominant symptom. Microorganisms were isolated in 22 cases, the most common being Staphylococcus aureus (40%) and Mycobacterium tuberculosis (32%). Of the 25 patients, 64% (n = 16) had blood cultures taken, 56% (n = 14) underwent percutaneous fluoroscopy-guided biopsy, and 48% (n = 12) underwent open surgical biopsy. The positive rate for microbiologic diagnosis of each method was 18.8% (n = 3) for blood culture, 71.4% (n = 10) for percutaneous biopsy and 100% (n = 12) for surgical biopsy. Overall, 52% (n = 13) needed surgical treatment along with antibiotic therapy. Patients who needed surgery had a significant delay in diagnosis compared with those that did not (median, 60 vs. 31 days; P = 0.014).S. aureus and M. tuberculosis are the predominant causes of SD in children in South Korea. Obtaining tissue culture is important to confirm the bacterial etiology of the infection and appropriately guide antibiotic therapy in a community in which the endemic organisms require treatment pathways that are widely divergent.

Background Neisseria meningitidis serogroup B is a significant cause of septicaemia and meningitis worldwide. This phase 3 randomised, controlled study assessed the immunogenicity and safety of a multicomponent meningococcal serogroup B vaccine, 4CMenB, in healthy Korean adolescents. Methods 264 adolescents (11–17 years old) were randomised to receive two doses, one month apart, of 4CMenB or control vaccines [placebo followed by one dose of a quadrivalent meningococcal ACWY glycoconjugate vaccine (MenACWY-CRM)]. Immunogenicity was evaluated by serum bactericidal assay with human complement (hSBA) against three serogroup B test strains specific for individual vaccine antigens (fHbp, NadA or PorA P1.4), and by enzyme-linked immunosorbent assay (ELISA) against the NHBA antigen. Solicited reactions and adverse events (AEs) were assessed. Results One month post-second vaccination, 98%, 97%, and 97% of subjects in the 4CMenB group achieved hSBA titres ≥4 against the fHbp, NadA and PorA test strains, respectively, while percentages in the Control group were comparable to baseline (27%, 16%, and 17%, respectively). Geometric mean ELISA concentrations (GMCs) against NHBA increased 52-fold relative to baseline in the 4CMenB group, while there was no substantial increase in GMCs in the Control group (1.05-fold). Frequencies of solicited reactions after any vaccination were higher in the 4CMenB group than in the Control group, although most reactions were of short duration and mild to moderate intensity. There were no vaccine-related serious AEs. Conclusions Two doses of 4CMenB induced robust immune responses against the vaccine antigens and were well tolerated, with no safety concerns identified, in Korean adolescents (NCT01973218).

라임병은 진드기를 매개로 하여 보렐리아속균 감염에 의해 발생하는 세균 질환이다. 가장 흔한 증상으로 초기에 유주성 홍반이 대부분의 환자에게서 관찰되며, 신경, 심혈관계 및 관절을 침범하는 증상이 발현할 수 있다. 저자들은 미국 코네티컷주로 여행력이 있는 13세 남자에게서 발현한 라임병을 진단하여 보고하는 바이다. 환자는 2016년 여름에 미국에서 숲 체험에 참여하던 중 발열, 두통, 양쪽 무릎 관절통을 호소하여 귀국하였으며, 내원 시 양 하지에 다수의 유주성 홍반이 관찰되었다. 심전도 검사에서 1도 방실 차단이 확인되었다. 간접면역형광항체법과 웨스턴블럿법 검사에서 라임병 특이 IgM 항체가 양성으로 확인되었다. 경구 doxycycline으로 4주간 치료하였으며, 유주성 홍반이 소실되고 심전도가 정상 소견으로 회복되었다. 라임병의 진단에 있어 호발 지역으로의 여행력을 확인하는 것이 중요하다. 라임병에 의한 심장염은 무증상 방실 전도차단으로 나타날 수 있고 고도 방실 차단으로 진행할 수 있어 주의를 요하며 적절한 항생제 치료를 통해 회복될 수 있다.

This study investigated the roles of β-lactamase and penicillin-binding protein 3 (PBP3) alterations in the development of recent antimicrobial resistance in nontypeable

To investigate the genetic background for the emergence of macrolide resistance, we characterized the genetic features of Mycoplasma pneumoniae using multilocus sequence typing. Of the 146 M. pneumoniae strains collected during the 5 consecutive outbreaks of M. pneumoniae pneumonia during 2000–2016 in South Korea, macrolide resistance increased from 0% in the first outbreak to 84.4% in the fifth. Among the 8 sequence types (STs) identified, ST3 (74.7%) was the most prevalent, followed by ST14 (15.1%). Macrolide-susceptible strains comprised 8 different STs, and all macrolide-resistant strains were ST3 (98.3%) except 1 with ST14. The proportion of macrolide-resistant strains in ST3 remained 2.2% (1/46) until the 2006–2007 outbreak and then markedly increased to 82.6% (19/23) during the 2010–2012 outbreak and 95.0% (38/40) during the 2014–2016 outbreak. The findings demonstrated that clonal expansion of ST3 M. pneumoniae was associated with the increase in macrolide resistance in South Korea.

The frequency with which the 2 B lineages have been found to cocirculate in a season has been on the rise, which has spurred the need for a quadrivalent influenza vaccine (QIV) to protect against both B lineages. The World Health Organization (WHO) recommended that QIV include both B lineages beginning in the 2013-2014 flu season. This study was conducted to evaluate the immunogenicity and safety of an egg-cultivated QIV in healthy Korean children and adolescents aged ≥ 6 months to19 years.A total of 528 subjects were randomized 4:1 to receive either a QIV (GC3110A) or a trivalent influenza vaccine. Hemagglutination inhibition antibody responses were assessed 28 days after the last dose. Safety was also evaluated.The proportion of subjects in the GC3110A group who achieved seroconversion was confirmed to exceed 40% across all age groups. The proportion of subjects aged ≥ 6 months to3 years in the GC3110A group who achieved seroprotection failed to meet the Ministry of Food and Drug Safety (MFDS) standard of 70%. Potential causes may include the small number of subjects, as well as the small dosage. However, results pertaining to the other age groups satisfied the MFDS standard. The safety profile was also comparable to that of the control.The new quadrivalent split influenza vaccine may offer broader protection to children and adolescents aged ≥ 3 years to19 years of age against both influenza B lineages than the existing trivalent influenza vaccines (Registered at the ClinicalTrials.gov NCT02541253).

BACKGROUND The cricothyroid membrane is the most commonly accessed location for invasive surgical airway. Although the laryngeal handshake method is recommended for identifying the cricothyroid membrane, there is no clinical data regarding the utility of the laryngeal handshake method in cricothyroid membrane identification. The objective of this study was to compare the accuracy of cricothyroid membrane identification between the laryngeal handshake method and simple palpation. METHODS After anaesthesia induction, the otorhinolaryngology resident and anaesthesia resident identified and marked the needle insertion point for cricothyroidotomy using simple palpation and the laryngeal handshake method, respectively. The cricothyroid membrane was confirmed with ultrasonography. Identification was determined successful if the marked point was placed within the longitudinal area of the cricothyroid membrane and within 5 mm from midline transversely. The accuracy of cricothyroid membrane identification using the laryngeal handshake method and simple palpation was compared. RESULTS A total of 123 patients were enrolled. The cricothyroid membrane was correctly identified in 87 (70.7%, 95% confidence interval 61.8-78.6%) patients using the laryngeal handshake method compared to 78 (63.4%, 95% confidence interval 54.3-71.9%) patients using simple palpation (P = .188). The time required to identify the cricothyroid membrane was longer when using the laryngeal handshake method (15 [3-48] seconds vs 10.9 [3-55] seconds, P = .003). CONCLUSION The success rate of identifying the cricothyroid membrane was similar among the anesthesiologists who performed the laryngeal handshake method and also among otorhinolaryngologists who used simple palpation.

Background Invasive bacterial infections in apparently immunocompetent children were retrospectively analyzed to figure causative bacterial organisms in Korea. Methods A total of 947 cases from 25 university hospitals were identified from 2006 to 2010 as a continuance of a previous 10-year period study from 1996 to 2005. Results Escherichia coli (41.3%), Streptococcus agalactiae (27.7%), and Staphylococcus aureus (27.1%) were the most common pathogens in infants < 3 months of age. S. agalactiae was the most prevalent cause of meningitis and pneumonia and E. coli was the major cause of bacteremia without localizing signs in this group. In children 3 to 59 months of age, Streptococcus pneumoniae (54.2%), S. aureus (20.5%), and Salmonella spp. (14.4%) were the most common pathogens. S. pneumoniae was the leading cause of pneumonia (86.0%), meningitis (65.0%), and bacteremia without localizing signs (49.0%) in this group. In children ≥ 5 years of age, S. aureus (62.8%) was the predominant pathogen, followed by Salmonella species (12.4%) and S. pneumoniae (11.5%). Salmonella species (43.0%) was the most common cause of bacteremia without localizing signs in this group. The relative proportion of S. aureus increased significantly over the 15-year period (1996–2010) in children ≥ 3 months of age (P < 0.001), while that of Haemophilus influenzae decreased significantly in both < 3 months of age group (P = 0.036) and ≥ 3 months of age groups (P < 0.001). Conclusion S. agalactiae, E. coli, S. pneumoniae, and S. aureus are common etiologic agents of invasive bacterial infections in Korean children., Graphical Abstract

Mycoplasma pneumoniae is an important cause of community-acquired pneumonia in children and young adolescents. Macrolides are recommended as the first-line therapy however, macrolide resistance rates in M. pneumoniae among children have been increasing substantially. Areas covered: This review focused on clinical characteristics and treatment of macrolide-resistant M. pneumoniae pneumonia in children. Expert commentary: Antibiotic choice should be based on in vitro activity, clinical efficacy and in consideration of potential adverse events. Macrolide resistance did not contribute to the clinical severity of M. pneumoniae pneumonia, but resistance may be an aggravating factor. Antibiotics may not be required for treatment in mild cases due to the self-resolving nature of M. pneumonia infection, regardless of macrolide resistance. In contrast, antibiotic treatment of severe cases of M. pneumoniae pneumonia is complicated. The clinical benefit of tetracyclines and fluoroquinolones has been shown in terms of shortening duration of symptoms and rapid defervescence in some reports. However, due to safety concerns regarding these two alternative antibiotics, clinicians should weigh the risks and benefits when choosing treatment options. Alternative antibiotics may be considered when patients remain febrile or when chest x-rays show deterioration at least 48-72 hours after macrolide treatment.

Central line-associated bloodstream infections (CLABSIs) account for significant morbidity and mortality in patients with long-term central venous catheters (CVCs). This study was performed to identify the characteristics and risk factors of CLABSIs among children with long-term CVCs.A retrospective review of children who had a long-term CVC in Seoul National University Children's Hospital between 2011 and 2015 was performed. Data on patient demographics, the isolated pathogens and the status of CVC placement were collected. Clinical variables were compared between subjects with and without CLABSIs to determine the risk factors for CLABSIs.A total of 629 CVCs were inserted in 499 children during the 5-year period. The median age at insertion was 6.0 years (14 days-17.9 years), and hemato-oncologic disease was the most common underlying condition (n = 497, 79.0%). A total of 235 CLABSI episodes occurred in 155 children, with a rate of 0.93 per 1,000 catheter days. The most common pathogens were Klebsiella pneumoniae (n = 64, 27.2%), coagulase-negative staphylococci (n = 40, 17.0%) and Staphylococcus aureus (n = 28, 12.0%). In the univariate analysis, the gender, underlying disease, catheter characteristics and insertion technique did not increase the risk for CLABSI. In both the univariate and logistic regression analyses, patients with prior BSIs (odds ratio 1.66; 95% confidence interval: 1.090-2.531; P = 0.018) were more likely to have a CLABSI.CLABSI prevention is of particular concern for children with a prior BSI. Furthermore, the antimicrobial resistance of major pathogens should be monitored to enable the empiric selection of appropriate antibiotics in patients with long-term CVCs.

Voriconazole is an antifungal drug used to treat fungal infections. This was a retrospective study of 61 children with hemato-oncologic diseases or solid organ transplantation who were administered voriconazole for invasive fungal infections. Of the 61 patients, 31 (50.8%) were in the therapeutic drug monitoring (TDM) group, and 30 (49.2%) were in the non-TDM group. At 12 weeks, treatment failure rate in the non-TDM group was higher than the TDM group (78.6% versus 40.0%, p = 0.038). Drug discontinuation due to adverse events was less frequent in the TDM group than the non-TDM group (26.0% versus 92.3%, p = 0.001). Children required higher dosages to maintain drug levels within the targeted therapeutic range: an average of 8.3 mg/kg/dose in patients

Background In this study, we aimed to identify demographic and clinical variables that correlate with perceived information provision among cancer patients and determine the association of information provision with decisional conflict (DC). Patients and methods We enrolled a total of 625 patients with cancer from two Korean hospitals in 2012. We used the European Organization for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire (QLQ-INFO26) to assess patients' perception of the information received from their doctors and the Decisional Conflict Scale (DCS) to assess DC. To identify predictive sociodemographic and clinical variables for adequate information provision, backward selective logistic regression analyses were conducted. In addition, adjusted multivariate logistic regression analyses were carried out to identify clinically meaningful differences of perceived level of information subscales associated with high DC. Results More than half of patients with cancer showed insufficient satisfaction with medical information about disease (56%), treatment (73%), other services (83%), and global score (80%). In multiple logistic regression analyses, lower income and education, female, unmarried status, type of cancer with good prognosis, and early stage of treatment process were associated with patients' perception of inadequate information provision. In addition, Information about the medical tests with high DCS values clarity [adjusted odds ratio (aOR), 0.54; 95% confidence interval (CI) 0.30–0.97] and support (aOR, 0.53; 95% CI 0.33–0.85) showed negative significance. For inadequate information perception about treatments and other services, all 5 DCS scales (uncertainty, informed, values clarity, support, and effective decision) were negatively related. Global score of inadequate information provision also showed negative association with high DCS effective decision (aOR, 0.43; 95% CI 0.26–0.71) and DCS uncertainty (aOR, 0.46; 95% CI 0.27–0.77). Conclusion This study found that inadequate levels of perceived information correlated with several demographic and clinical characteristics. In addition, sufficient perceived information levels may be related to low levels of DC.

Summary Background Group B Streptococcus (GBS) strains are classified by the polysaccharide capsule, which is an important virulence factor and stimulator of antibody-associated immunity. As GBS infections in neonates may be life-threatening, GBS screening and intrapartum antibiotic prophylaxis have been implemented for prevention. In Korea, there are few reports on the GBS serotype distribution and antibiotic resistance patterns because GBS screening and intrapartum prophylaxis are not done routinely. Methods The serotype distribution and antibiotic resistance of GBS in infants in Korea with invasive bacterial infections were examined for the 19-year period 1995–2013. Isolates obtained previously from hospitals located in three different regions were analyzed for capsular serotype by PCR and sequencing and for antimicrobial susceptibility. Results Among 56 isolates serotyped, the most common serotypes were III (44.6%) and V (28.6%), followed by Ia (14.3%), Ib (10.7%), and VI (1.8%). No penicillin-resistant strains were detected, however 51.8% of the strains had resistance to erythromycin and 55.4% showed clindamycin resistance. Resistance was highest (93.8%) to both erythromycin and clindamycin for serotype V; all 15 isolates resistant to erythromycin were cMLS B phenotype and had a high level of resistance to both erythromycin and clindamycin with MIC levels >256μg/ml, and all but one were positive for erm B. Conclusion In this study in Korea, serotype V was identified in a relatively large proportion of GBS isolates and this serotype showed a high level of resistance to erythromycin and clindamycin in a statistically significant majority. Continuous monitoring of changes in clinical disease and molecular characteristics is important for the treatment and prevention of invasive GBS disease in infants.