An IFN-γ and TNF-α dual release fluorospot assay for diagnosing active tuberculosis.

OBJECTIVES: Currently available interferon (IFN)-γ-release assays (IGRA) cannot discriminate active tuberculosis (TB) from latent TB infection (LTBI), and so have limited clinical utility for diagnosing active TB. Since numbers of tumour necrosis factor (TNF)-α-producing T cells are highly correlated with active TB, we hypothesized that detecting IFN-γ- and/or TNF-α-producing T cells would overcome this limitation of IGRA. This study evaluated the diagnostic performances of the IFN-γ and TNF-α dual release fluorospot assay for active TB. METHODS: Adult patients with suspected TB including recent TB exposers were prospectively enrolled over a 28-month period. In addition to the conventional IGRA test (i.e. QuantiFERON-In-Tube), a fluorospot assay for detecting IFN-γ- and TNF-α-producing T cells was performed. The final diagnoses were classified by clinical category. Patients with confirmed or probable TB were regarded as active TB, and patients with not active TB were further classified as having not active TB with and without LTBI, based on the QuantiFERON-In-Tube results. RESULTS: A total of 153 patients including 45 with active TB and 108 with not active TB (38 LTBI vs. 70 not LTBI) were finally analysed. The sensitivity and specificity of the QuantiFERON-In-Tube assay for active TB were 84% (95% confidence interval (CI), 70-93) and 70% (95% CI 61-79), respectively. The IFN-γ/TNF-α dual release assay by fluorospot had substantially higher diagnostic specificity (94%) for diagnosing active TB than the IFN-γ single release assay (72%, p < 0.001), without compromising sensitivity (84% vs. 89%, p 0.79). CONCLUSIONS: The fluorospot-based IFN-γ/TNF-α dual release assay appears to be a simple and useful test for diagnosing active TB.

Cosmetic outcome of implantation of cross-linked human acellular dermal matrix after parotidectomy.

Although skin depression after parotidectomy affects the patient's satisfaction with cosmesis we know of little research about it, so we attempted to alleviate it by inserting human acellular dermal matrix (hADM) after the operation. We made a retrospective analysis of the casenotes of 63 patients who were diagnosed with parotid tumours and were operated on between January 2015 and December 2016. Factors that affect satisfaction with cosmesis, including the use of hADM, sex, age, incision, size of tumour, sample size, complications, and the name of the surgeon were recorded and evaluated on a scale from 1 (most unsatisfactory) to 10 (very satisfactory), and the satisfaction according to each factor was compared. The mean (SD) follow-up period was 13 (6) months, and 19 of the 63 patients developed complications. Satisfaction was significantly better when hADM had been inserted (p=0.0008), when the patient was female (p=0.033), or there were no complications p=0.0161). On linear regression analysis, all three factors showed a significant causal relation with satisfactory cosmesis. Insertion of hADM after operations on the parotid gland seems to be effective in improving this by preventing skin depression.

Molecular epidemiology and environmental contamination during an outbreak of parainfluenza virus 3 in a haematology ward.

BACKGROUND: Although fomites or contaminated surfaces have been considered as transmission routes, the role of environmental contamination by human parainfluenza virus type 3 (hPIV-3) in healthcare settings is not established. AIM: To describe an hPIV-3 nosocomial outbreak and the results of environmental sampling to elucidate the source of nosocomial transmission and the role of environmental contamination. METHODS: During an hPIV-3 outbreak between May and June 2016, environmental surfaces in contact with clustered patients were swabbed and respiratory specimens used from infected patients and epidemiologically unlinked controls. The epidemiologic relatedness of hPIV-3 strains was investigated by sequencing of the haemagglutinin-neuraminidase and fusion protein genes. FINDINGS: Of 19 hPIV-3-infected patients, eight were haematopoietic stem cell recipients and one was a healthcare worker. In addition, four had upper and 12 had lower respiratory tract infections. Of the 19 patients, six (32%) were community-onset infections (symptom onset within <7 days of hospitalization) and 13 (68%) were hospital-onset infections (≥7 days of hospitalization). Phylogenetic analysis identified two major clusters: five patients, and three patients plus one healthcare worker. Therefore, seven (37%) were classified as nosocomial transmissions. hPIV-3 was detected in 21 (43%) of 49 environmental swabs up to 12 days after negative respiratory polymerase chain reaction conversion. CONCLUSION: At least one-third of a peak season nosocomial hPIV-3 outbreak originated from nosocomial transmission, with multiple importations of hPIV-3 from the community, providing experimental evidence for extensive environmental hPIV-3 contamination. Direct contact with the contaminated surfaces and fomites or indirect transmission from infected healthcare workers could be responsible for nosocomial transmission.

Comparison of computed tomographic findings in pulmonary mucormycosis and invasive pulmonary aspergillosis.

Because there are no available molecular markers for pulmonary mucormycosis (PM), which has low culture sensitivity, early diagnosis and treatment rely heavily on imaging modes such as computed tomography (CT). However, there are limited data comparing CT findings for PM with those for invasive pulmonary aspergillosis (IPA). Adult patients who met the modified criteria for proven and probable PM (over an 11-year period) and IPA (over a 6-year period, owing to the availability of the galactomannan assay) according to the modified European Organization for Research and Treatment of Cancer/Mycosis Study Group definitions were retrospectively enrolled. IPA cases were selected at a 1 : 4 (PM/IPA) ratio. Thoracic CT scans were reviewed by two experienced radiologists blinded to the patients' demographics and clinical outcomes. A total of 24 patients with PM, including 20 (83%) with proven PM and four (17%) with probable PM, and 96 patients with IPA, including 12 (13%) with proven IPA and 84 (87%) with probable IPA, were eventually analysed. The reverse halo sign was more common in patients with PM (54%) than in those with IPA (6%, p < 0.001), whereas some airway-invasive features, such as clusters of centrilobular nodules, peribronchial consolidations, and bronchial wall thickening, were more common in patients with IPA (IPA 52% vs. PM 29%, p 0.04; IPA 49% vs. PM 21%, p 0.01; IPA 34% vs. PM 4%, p 0.003, respectively). The reverse halo sign was more common, and airway-invasive features were less common, in patients with PM than in those with IPA. These findings may help physicians to initiate Zygomycetes-active antifungal treatment earlier.

Diagnostic utility of diffusion tensor imaging in differentiating glioblastomas from brain metastases.

BACKGROUND AND PURPOSE: Differentiation of glioblastomas and solitary brain metastases is an important clinical problem because the treatment strategy can differ significantly. The purpose of this study was to investigate the potential added value of DTI metrics in differentiating glioblastomas from brain metastases. MATERIALS AND METHODS: One hundred twenty-eight patients with glioblastomas and 93 with brain metastases were retrospectively identified. Fractional anisotropy and mean diffusivity values were measured from the enhancing and peritumoral regions of the tumor. Two experienced neuroradiologists independently rated all cases by using conventional MR imaging and DTI. The diagnostic performances of the 2 raters and a DTI-based model were assessed individually and combined. RESULTS: The fractional anisotropy values from the enhancing region of glioblastomas were significantly higher than those of brain metastases (P < .01). There was no difference in mean diffusivity between the 2 tumor types. A classification model based on fractional anisotropy and mean diffusivity from the enhancing regions differentiated glioblastomas from brain metastases with an area under the receiver operating characteristic curve of 0.86, close to those obtained by 2 neuroradiologists using routine clinical images and DTI parameter maps (area under the curve = 0.90 and 0.85). The areas under the curve of the 2 radiologists were further improved to 0.96 and 0.93 by the addition of the DTI classification model. CONCLUSIONS: Classification models based on fractional anisotropy and mean diffusivity from the enhancing regions of the tumor can improve diagnostic performance in differentiating glioblastomas from brain metastases.

Increased incidence of herpes zoster in the setting of cytomegalovirus preemptive therapy after kidney transplantation.

BACKGROUND: Herpes zoster (HZ) is a common infectious disease after kidney transplantation (KT). The incidence of HZ may increase during cytomegalovirus (CMV) preemptive therapy. We therefore evaluated the incidence, risk factors, and clinical outcomes of HZ after KT, according to the type of CMV prophylaxis used. METHODS: We retrospectively established a cohort of KT recipients who underwent transplantation from June 2008 to May 2010. Patients were categorized into 3 groups according to CMV prophylaxis regimen: Group A (preemptive therapy), Group B (universal prophylaxis <3 months), and Group C (universal prophylaxis >3 months). The incidence rate of HZ was compared in each group, and risk factors for HZ were identified. RESULTS: The incidence rate of HZ was 46.6 (95% confidence interval [CI] 31.4-66.5) per 1000 person-years. The incidence rate was higher in Group A than in Group C (80.0 vs. 13.0 per 1000 person-years; P = 0.001). Median onset time of HZ after KT was shorter in Group A than in Group B (0.9 vs. 9.9 months; P < 0.001) and Group C (0.9 vs. 14.8 months; P = 0.008). Post-herpetic neuralgia occurred in 7 patients (23%). No visceral involvement or death was related to HZ. By multivariate analysis, only female gender (corrected relative risk 1.59; 95% CI 1.09-2.00) was independently associated with HZ development. CONCLUSIONS: In the setting of CMV preemptive therapy, a differentiated varicella zoster virus-specific prophylaxis might be necessary for patients with HZ risk factors.

agr Dysfunction and persistent methicillin-resistant Staphylococcus aureus bacteremia in patients with removed eradicable foci.

PURPOSE: Persistent Staphylococcus aureus bacteremia (SAB) has been observed in patients with eradicated foci, but there are few studies of the risk factors and clinical outcomes of persistent bacteremia. This study determined the risk factors for persistent methicillin-resistant S. aureus (MRSA) bacteremia in patients without retained eradicable foci, including genotypic characteristics. METHODS: All adult SAB patients were investigated between 2008 and 2010. Persistent bacteremia was defined as bacteremia lasting >7 days after treatment and patients were monitored prospectively. The study included patients without retained eradicable foci, e.g., removed prosthetic devices and intravenous catheters removed after diagnosis, and those without metastatic infections. RESULTS: Persistent bacteremia occurred in 36 % (31/87) SAB patients with eradicated foci. There were no significant differences in successful defervescence (2.0 vs. 2.0 days, P = 0.55) and total length of hospital stay after bacteremia in the persistent bacteremia group and resolved bacteremia group (P = 0.32). The difference in MRSA bacteremia-related 30-day mortality with persistent bacteremia and resolved bacteremia was not significant (P = 0.12). However, agr dysfunction was higher in persistent bacteremia patients (94 %) than those with resolved bacteremia (75 %, P = 0.03). Multivariate analysis using a logistic regression model found that only agr dysfunction [odds ratio (OR) 4.83, 95 % confidence interval (CI) 1.02-22.89, P = 0.04] was an independent risk factor for persistent bacteremia. CONCLUSIONS: This study suggests that persistent bacteremia with eradicated foci might not adversely affect the outcome for MRSA bacteremia patients. agr dysfunction in S. aureus was significantly associated with persistent bacteremia.

Comparison of the QuantiFERON-TB Gold In-Tube test with the tuberculin skin test for detecting latent tuberculosis infection prior to hematopoietic stem cell transplantation.

A total of 244 patients including 100 (41%) autologous hematopoietic stem cell transplant (HCT) recipients and 144 (59%) allogeneic HCT recipients were enrolled over a 28-month period. During the study period, no prophylaxis for latent tuberculosis (TB) infection was administrated. Of these, 201 (82%) had Bacillus Calmette-Guérin (BCG) scars or prior histories of BCG vaccination. The tuberculin skin test (TST) and the QuantiFERON-TB Gold In-Tube (QFT-GIT) test were performed simultaneously in all 244 patients. TST indurations were ≥ 5 mm in 39 of these patients (15%), and in 25 (10%) indurations were ≥ 10 mm. In addition, 40 (16%) had positive QFT-GIT outcomes, and 34 (14%) indeterminate outcomes. If the 34 patients with indeterminate QFT-GIT results were excluded from the overall agreement analysis, the agreement between the TST results (induration size ≥ 5 mm) and the QFT-GIT results in the 210 patients with clear QFT results was poor (κ = 0.08, 95% confidence interval [CI] -0.06 to 0.24), as it was for the patients with indurations ≥ 10 mm (κ = 0.15, 95% CI -0.004 to 0.31). During follow up, 2 patients developed TB after HCT. The incidence of TB in the patients with positive QFT-GIT outcomes was 2.80 per 100 person-years (95% CI 0.07-15.81), whereas among those with positive TST (≥ 5 mm) results, it was 0 per 100 person-years (95% CI 0-8.00). However, this finding should be cautiously interpreted because of the relatively short follow up and the fact that the sample size of the study cohort did not have adequate power. In conclusion, our data show that, although the frequencies of positive outcomes in the 2 TB screening tests were similar, the overall agreement between the TST and the QFT-GIT test was poor, regardless of BCG vaccination history.

Diagnostic yield of the cytomegalovirus (CMV) antigenemia assay and clinical features in solid organ transplant recipients and hematopoietic stem cell transplant recipients with CMV pneumonia.

Data are limited on the value of non-invasive diagnostic methods, such as the cytomegalovirus (CMV) antigenemia assay, and the clinical features of CMV pneumonia in patients who have undergone solid organ transplant (SOT) compared with those who have had hematopoietic stem cell transplant (HSCT). All adult patients with suspected CMV pneumonia, who had received SOT or HSCT in a tertiary hospital during a 5-year period, were retrospectively enrolled. CMV pneumonia was defined as clinical and radiographic evidence of pneumonia in association with the isolation of CMV in viral cultures of bronchoalveolar lavage or lung tissue specimens, or with the identification of CMV in lung tissue. In total, 36 patients with CMV pneumonia were identified. Of these, 29 (80%) had received SOT and 7 (20%) had received HSCT. The incidence of CMV pneumonia in the patients with SOT (3.0 per 1000 person-years [95% confidence interval {CI} 0.6-8.7]) was lower than in those with HSCT (17.0 per 1000 person-years [95% CI 9.9-27.2], P = 0.003) and CMV-related mortality showed a tendency to have lower mortality in patients with SOT (10% [3/29]) than with HSCT (43% [3/7], P = 0.07). The overall sensitivity of the CMV assay (≥ 1/200,000 leukocytes) in patients with CMV pneumonia was 69% (95% CI 52-84%). The CMV antigenemia test is of limited value in diagnosing CMV pneumonia, given the high cost of false-negative diagnoses of CMV pneumonia.

Awareness of blindness and other smoking-related diseases and its impact on motivation for smoking cessation in eye patients.

PURPOSE: Cigarette smoking is a major cause of morbidity and mortality. The association between smoking and eye diseases is less widely recognised relative to other better-known smoking-related conditions. This study aims to assess the awareness and fear of known smoking-related diseases among current smokers attending an ophthalmology outpatient clinic and to evaluate their relative impact on the likelihood of smoking cessation. PATIENTS AND METHODS: A cross-sectional survey using a structured interview of randomly selected current smokers attending an eye clinic was conducted. The knowledge of six smoking-related diseases (lung cancer, heart attack, stroke, blindness, other cancers, and other lung diseases) was assessed. The fear of smoking-related conditions and the relative impact of each smoking-related condition on the smoker's motivation to quit smoking were evaluated. RESULTS: Out of 200 current smokers aged from 14 to 83 years, only 42.5% (85 patients) were aware that smoking causes blindness. Smokers' perception of harm caused by smoking was 6.53±3.21 (mean±SD) on a visual analogue scale of 0 to 10. Patients placed blindness as the second most important motivating factor to quit smoking immediately, within 1 year and 5 years, after lung cancer. CONCLUSION: The awareness of the risk of blindness from smoking was lowest compared with five other smoking-related diseases among eye patients who smoke. However, blindness remains a key motivational factor in smoking cessation and hence should be emphasised as an important negative health consequence of smoking in public health education and anti-smoking campaigns.

Comparison of higher dose and lower dose ganciclovir for cytomegalovirus prophylaxis in seropositive heart transplant recipients.

BACKGROUND: We performed a retrospective historical cohort study to compare the efficacy of higher dose (HD, 10 mg/kg/day for 2 weeks, followed by 5 mg/kg/day intravenously for 2 weeks) and lower dose (LD, 5 mg/kg/day for 4 weeks) ganciclovir (GCV) for cytomegalovirus (CMV) prophylaxis in seropositive heart transplant recipients. METHODS: All consecutive patients undergoing heart transplantation (HT) between June 1999 and January 2008 at our institution were enrolled. All recipients were seropositive for CMV before HT. Before October 2005, 72 patients received the HD regimen and after October 2005, 36 patients received the LD regimen. We followed up all patients for 1 year. RESULTS: In the HD group 43 of 72 patients (60%) developed CMV infections vs. 21 of 36 patients (58%) in the LD group (P=0.89). CMV diseases occurred in 4 patients of the HD group (6%) and 4 patients of the LD group (11%) (P=0.44). The incidence of acute rejection was not significantly different between the 2 groups (14% vs. 6%; P=0.33). Among patients who completed 4-week courses of prophylaxis, 32 of 58 patients (55%) in the HD group developed CMV infections vs. 18 of 30 patients (60%) in the LD group (P=0.66). CMV diseases occurred in 3 patients of the HD group (5%) and 4 of the LD group (13%) (P=0.22). Acute rejection incidence did not differ significantly between the 2 groups (17% vs. 7%; P=0.21). CONCLUSIONS: LD GCV for CMV prophylaxis may not be inferior to the HD regimen in seropositive HT recipients.

Anti-CD3 recombinant diphtheria immunotoxin therapy of cutaneous T cell lymphoma.

The recombinant CD3 immunotoxin, A-dmDT(390)-bisFv(UCHT1), composed of the catalytic and translocation domains of diphtheria toxin fused to two single chain Fv fragments of an anti-CD3epsilon monoclonal antibody was administered to five patients with cutaneous T cell lymphoma (CTCL) by eight 15 min intravenous infusions over four days. Side effects were fever, chills, nausea, hypoalbuminemia, transaminasemia and reactivation of EBV and CMV. Half-life of drug was 40 min. Anti-immunotoxin antibodies developed in all patients after two weeks. Two patients had partial remissions lasting 1 and 6+ months. The agent is undergoing further dose escalation and shows promising results in this disease.

Conscious sedation during ophthalmic surgery under local anesthesia.

Sedation during ophthalmic local anesthesia helps to ensure comfort and cooperation during eye surgery. Sedation requirements of ophthalmic patients have changed with the popularization of newer surgical and anesthetic techniques. Many sedative agents are available to anesthesiologists including benzodiazepines, intravenous anesthetic induction agents, narcotic analgesics and a-adrenoreceptor agonists. However, there is no single ideal sedative agent, regime or protocol that can completely cater to the wide spectrum of ophthalmic procedures performed in a heterogeneous patient population. Moreover, the clinical practice of sedation during ophthalmic surgery under local anesthesia is varied and not without risk of complications and adverse events. Hence, balanced sedative techniques should only be used after careful consideration of patient profile, the type of eye surgery, and patient and surgeon preferences. Good knowledge of the pharmacology of sedative agents is fundamental to their useful clinical application.

The N-methyl-D-aspartate receptor type 2A is frequently methylated in human colorectal carcinoma and suppresses cell growth.

N-methyl-D-aspartate receptors (NMDARs) are the predominant excitatory neurotransmitter receptors in the mammalian brain. We found that among the three NMDARs examined (NMDAR1, NMDAR2A, NMDAR2B), only NMDAR2A was silenced in colorectal carcinoma (CRC) cell lines at basal line and reactivated by the demethylating agent, 5-aza-2'-deoxycytidine. NMDAR2A was expressed in normal colon epithelium, while expression was hardly detectable in colon cancer tissues. Promoter methylation of NMDAR2A was confirmed by bisulfite sequencing and combined bisulfite restriction analysis in the CRC cell lines and primary tumors. Quantitative methylation-specific PCR demonstrated NMDAR2A promoter hypermethylation in 82 of 100 primary human CRC, 15 of 100 normal corresponding epithelial tissues and 1 of 11 (9%) normal colon mucosa samples obtained from patients without cancer. Moreover, forced expression of full-length NMDAR2A in CRC cell lines induced apoptosis and almost abolished the ability of the cells to form colonies in culture, while NMDAR2A knockdown increased cell growth. Thus, NMDAR2A is commonly hypermethylated in primary human CRC and possesses tumor-suppressive activity.

Arterial spin-labeling and MR spectroscopy in the differentiation of gliomas.

BACKGROUND AND PURPOSE: Noninvasive grading of gliomas remains a challenge despite its important role in the prognosis and management of patients with intracranial neoplasms. In this study, we evaluated the ability of cerebral blood flow (CBF)-guided voxel-by-voxel analysis of multivoxel proton MR spectroscopic imaging ((1)H-MRSI) to differentiate low-grade from high-grade gliomas. MATERIALS AND METHODS: A total of 35 patients with primary gliomas (22 high grade and 13 low grade) underwent continuous arterial spin-labeling perfusion-weighted imaging (PWI) and (1)H-MRSI. Different regions of the gliomas were categorized as "hypoperfused," "isoperfused," and "hyperperfused" on the basis of the average CBF obtained from contralateral healthy white matter. (1)H-MRSI indices were computed from these regions and compared between low- and high-grade gliomas. Using a similar approach, we applied a subgroup analysis to differentiate low- from high-grade oligodendrogliomas because they show different physiologic and genetic characteristics. RESULTS: Cho(glioma (G)/white matter (WM)), Glx(G/WM), and Lip+Lac(G)/Cr(WM) were significantly higher in the "hyperperfused" regions of high-grade gliomas compared with low-grade gliomas. Cho(G/WM) and Lip+Lac(G)/Cr(WM) were also significantly higher in the "hyperperfused" regions of high-grade oligodendrogliomas. However, metabolite ratios from the "hypoperfused" or "isoperfused" regions did not exhibit any significant differences between high-grade and low-grade gliomas. CONCLUSION: The results suggest that (1)H-MRSI indices from the "hyperperfused" regions of gliomas, on the basis of PWI, may be helpful in distinguishing high-grade from low-grade gliomas including oligodendrogliomas.

Resistance to extended-spectrum cephalosporins and mortality in patients with Citrobacter freundii bacteremia.

BACKGROUND: This study was performed to characterize the clinical features and to identify the risk factors for resistance to extended-spectrum cephalosporins (ESCs) and for mortality in patients with Citrobacter freundii bacteremia. PATIENTS AND METHODS: 105 patients (aged > or = 15 years) with C. freundii bacteremia in 1991-2000 were retrospectively analyzed. RESULTS: Nosocomial acquisition was identified in 78.1% of the patients. Hepatic, biliary and pancreatic disease was the most common underlying disease (65.7%) and the biliary tract was the most common site of infection (50.5%). The overall resistance rate to ESCs was 59.0% and was significantly associated with hepatic, biliary and pancreatic disease, recent surgery and procedure, biliary drainage catheter and previous antibiotic therapy in univariate analysis. However, only previous antibiotic therapy with ESCs (OR = 5.0, 95% CI 1.6-15.7, p = 0.006) and recent surgery or procedure (OR = 3.1, 95% CI 1.1-8.4, p = 0.03) were strong, independent risk factors in multivariate analysis. Mortality directly related to C. freundii bacteremia was 21.9% and there was no difference between cases with resistance and susceptibility to ESCs (19.4% vs 25.6%; p = 0.45). Mortality was significantly associated with rapidly fatal or ultimately fatal underlying disease, a solid tumor, septic shock and polymicrobial bacteremia in univariate analysis. Among patients who had therapeutic surgical procedures, mortality was lower (4.5%, p = 0.04). Multivariate analysis revealed rapidly or ultimately fatal disease, septic shock and polymicrobial bacteremia as independent prognostic factors. CONCLUSION: Biliary infection was the leading cause of C. freundii bacteremia. Previous antibiotic therapy, especially with ESCs, frequently predisposed for resistance to these antibiotics. However, resistance to ESCs was not associated with increased mortality.

Retrospective analysis of clinical and microbiological aspects of Klebsiella oxytoca bacteremia over a 10-year period.

From 1991 to 2000, 125 sporadic cases of Klebsiella oxytoca bacteremia were analyzed retrospectively to review clinical features and to identify the risk factors associated with resistance to extended-spectrum cephalosporins and fatal outcome. Bacteremia was acquired nosocomially in 52% of the patients. Almost all patients (97%) had an underlying disease, with biliary and pancreatic disease occurring most frequently (55%). The biliary tract was the most common site of infection (44%). Resistance to extended-spectrum cephalosporins was identified in 22 of the 125 (18%) Klebsiella oxytoca blood isolates and resistance to ciprofloxacin in 9 (7%). Only previous antibiotic therapy was strongly associated with resistance to extended-spectrum cephalosporins in patients with Klebsiella oxytoca bacteremia ( P=0.009). The mortality rate was 24% and was higher in patients infected with isolates resistant to extended-spectrum cephalosporins (41% vs. 20%; P=0.04). In multivariate analysis, fatal outcome was independently associated with septic shock, deteriorated mental status, polymicrobial bacteremia, and solid tumor. Surgical therapy had a protective effect (OR, 0.06; 95% CI, 0.005-0.7; P=0.03). In conclusion, Klebsiella oxytoca bacteremia was most commonly associated with biliary tract infection. Previous antibiotic therapy was strongly associated with resistance to extended-spectrum cephalosporins in patients with Klebsiella oxytoca bacteremia.

Risk factors for penicillin resistance and mortality in Korean adults with Streptococcus pneumoniae bacteremia.

A retrospective analysis was performed to measure the incidence of pneumococcal bacteremia and to identify risk factors for penicillin resistance and prognostic factors for outcome in adults. A total of 151 cases of pneumococcal bacteremia were identified from 149 adults during the period 1996-2000. The overall rate of penicillin resistance was 49%, ranging from 54.2% in 1996 to 48.5% in 2000 (P=0.93). Rates of resistance to ceftriaxone, clindamycin, erythromycin, and trimethoprim-sulfamethoxazole were 21.6%, 51%, 62%, and 44.7%, respectively. Multidrug resistance was documented in 47.7% of the cases. Penicillin resistance was significantly associated with solid tumor, biliary drainage catheter, and previous beta-lactam therapy in the univariate analysis. However, the associations were not as significant as independent risk factors in the multivariate analysis. Mortality was 23.8% and did not change significantly during the study period (P=0.06). Mortality rates in cases caused by penicillin-susceptible Streptococcus pneumoniae and penicillin-resistant Streptococcus pneumoniae were 23% and 24.7%, respectively (P=0.81). Mortality was not significantly influenced by penicillin resistance, even high-level resistance (24.4% vs. 20%; P=0.64). Multivariate analysis revealed that antineoplastic chemotherapy, respiratory failure, and acute renal failure were independent prognostic factors for mortality. In conclusion, the rate of penicillin resistance among pneumococcal blood isolates was high in the late 1990s, but penicillin resistance, and even high-level penicillin resistance, was not significantly associated with increased mortality in adults with pneumococcal bacteremia.