Clinical characteristics of native vertebral osteomyelitis in patients with history of acupuncture.

BACKGROUND: Considering that vertebral osteomyelitis (VO) can occur via various routes, it can be predicted that clinical characteristics may vary depending on the route of infection or risk factors of the disease. In this study, differences in clinical characteristics, causative pathogens, clinical features and prognosis were investigated in patients of native vertebral osteomyelitis with history of acupuncture. METHODS: This retrospective study was conducted at Kyung Hee University Hospital at Gangdong, Seoul. We extracted data of patients diagnosed with VO from May 2006 to February 2021 using an electronic database. Data on demography, clinical presentation, treatment, causative organisms and clinical outcomes were identified and compared according to the history of acupuncture. RESULTS: A total of 100 patients with VO were reviewed, among which 34 patients had a history of acupuncture prior to the diagnosis of VO. The frequency of Gram-positive cocci (GPC) was significantly higher in the acupuncture group than in the non-acupuncture group (p = 0.016). Abscess was observed more frequently in the acupuncture group than in the non-acupuncture group (p = 0.01). There was no difference in neurological sequelae and recurrence between the two groups. There was no difference in mortality between the two groups. (p = 0.098) CONCLUSION: This study suggests that confirming a history of acupuncture may help predict the pathogen or clinical characteristics of the disease. If the patient has a history of acupuncture, GPC can be considered as the causative organism, and the findings that abscesses and surgical treatment are more common may be helpful in evaluating patients.

The First Case of Infectious Spondylitis Caused by Gemella bergeri.

Gemella bergeri, a member of the genus Gemella, is a facultatively anaerobic, Gram-positive cocci. G. bergeri is a component of normal oral flora; however, it can become pathogenic and cause infections in patients with poor oral hygiene. A 78-year-old man was admitted to a hospital with a complaint of increasing posterior neck pain and lower back pain for 2 weeks. MRI was suggestive of infectious spondylitis at the C3-C4 level with prevertebral abscess formation, anterior epidural abscess formation. We identified Gemella bergeri in closed pus obtained during the surgery. Herein, we describe the first case of infective spondylitis caused by G. bergeri.

A case of Slackia exigua bacteremia associated with pyometra in a patient with poor dentition.

We report the first case of Slackia exigua bacteremia related to pyometra. Slackia exigua is an anaerobe that is usually found in the oral cavity and periodontal infections. After two months of treatment with antimicrobial agents, the patient recovered from infection.

Case Report of Infectious Spondylitis Caused by Kytococcus sedentarius.

BACKGROUND: Kytococcus species has not been considered a pathogen, but infections caused by this species are increasing. There are several cases of infections caused by Kytococcus sedentarius, but no case of infectious spondylitis has been reported yet. CASE PRESENTATION: A 79-year-old female patient was hospitalized because of back pain for several months. She was diagnosed with infectious spondylitis, and K. sedentarius was cultured from the pus and specimen obtained during the surgical procedure. The patient recovered completely without recurrence after 6 months of treatment with ciprofloxacin alone for 8 weeks. CONCLUSION: This is the first case report of infectious spondylitis caused by K. sedentarius.

Risk of transmission via medical employees and importance of routine infection-prevention policy in a nosocomial outbreak of Middle East respiratory syndrome (MERS): a descriptive analysis from a tertiary care hospital in South Korea.

BACKGROUND: In 2015, South Korea experienced an outbreak of Middle East respiratory syndrome (MERS), and our hospital experienced a nosocomial MERS infection. We performed a comprehensive analysis to identify the MERS transmission route and the ability of our routine infection-prevention policy to control this outbreak. METHODS: This is a case-cohort study of retrospectively analysed data from medical charts, closed-circuit television, personal interviews and a national database. We analysed data of people at risk of MERS transmission including 228 in the emergency department (ED) and 218 in general wards (GW). Data of personnel location and movement, personal protection equipment and hand hygiene was recorded. Transmission risk was determined as the extent of exposure to the index patient: 1) high risk: staying within 2 m; 2) intermediate risk: staying in the same room at same time; and 3) low risk: only staying in the same department without contact. RESULTS: The index patient was an old patient admitted to our hospital. 11 transmissions from the index patient were identified; 4 were infected in our hospital. Personnel in the ED exhibited higher rates of compliance with routine infection-prevention methods as observed objectively: 93% wore a surgical mask and 95.6% washed their hands. Only 1.8% of personnel were observed to wear a surgical mask in the GW. ED had a higher percentage of high-risk individuals compared with the GW (14.5% vs. 2.8%), but the attack rate was higher in the GW (16.7%; l/6) than in the ED (3%; 1/33). There were no transmissions in the intermediate- and low-risk groups in the ED. Otherwise 2 patients were infected in the GW among the low-risk group. MERS were transmitted to them indirectly by staff who cared for the index patient. CONCLUSIONS: Our study provide compelling evidence that routine infection-prevention policies can greatly reduce nosocomial transmission of MERS. Conventional isolation is established mainly from contact tracing of patients during a MERS outbreak. But it should be extended to all people treated by any medical employee who has contact with MERS patients. TRIAL REGISTRATION: NCT02605109 , date of registration: 11th November 2015.

Hospital-acquired fever in oriental medical hospitals.

BACKGROUND: Traditional Oriental medicine is used in many Asian countries and involves herbal medicines, acupuncture, moxibustion, and cupping. We investigated the incidence and causes of hospital-acquired fever (HAF) and the characteristics of febrile inpatients in Oriental medical hospitals (OMHs). METHODS: Patients hospitalized in two OMHs of a university medical institute in Seoul, Korea, were retrospectively reviewed from 2006 to 2013. Adult patients with HAF were enrolled. RESULTS: There were 560 cases of HAF (5.0%). Infection, non-infection, and unknown cause were noted in 331 cases (59.1%), 109 cases (19.5%), and 120 cases (21.4%) of HAF, respectively. Respiratory tract infection was the most common cause (51.2%) of infectious fever, followed by urinary tract infection. Drug fever due to herbal medicine was the most common cause of non-infectious fever (53.1%), followed by procedure-related fever caused by oriental medical procedures. The infection group had higher white blood cell count (WBC) (10,400/mm3 vs. 7000/mm3, p < 0.001) and more frequent history of antibiotic therapy (29.6% vs. 15.1%, p < 0.001). Multivariate analysis showed that older age (odds ratio (OR) 1.67, 95% confidence interval (C.I.) 1.08-2.56, p = 0.020), history of antibiotic therapy (OR 3.17, C.I. 1.85-5.41, p < 0.001), and WBC > 10,000/mm3 (OR 2.22, C.I. 1.85-3.32, p < 0.001) were associated with infection. CONCLUSIONS: Compared to previous studies on HAF in Western medicine, the incidence of HAF in OMHs was not high. However, Oriental medical treatment does play some role in HAF. Fever in patients with history of antibiotic therapy, or high WBC was more likely of infectious origin.

Infectivity of an Asymptomatic Patient With Middle East Respiratory Syndrome Coronavirus Infection.

During the MERS outbreak in Korea, one case of asymptomatic or mild MERS-CoV infection was noted. Eighty-two persons were exposed to the case without protection. They were isolated and RT-PCR and serology for MERS were performed. There was no transmission through an asymptomatic MERS case in this study.

Predictive risk factors for Listeria monocytogenes meningitis compared to pneumococcal meningitis: a multicenter case-control study.

PURPOSE: Various immunocompromised conditions increase the risk of meningitis caused by Listeria monocytogenes. However, the relative importance of these risk factors has not been well established. We determined the risk factors that predict meningitis due to L. monocytogenes compared to that caused by Streptococcus pneumoniae. METHODS: A nationwide multicenter case-control study was conducted in Korea. Cases of meningitis caused by L. monocytogenes between 1998 and 2013 were included. Patients with pneumococcal meningitis were included as controls. Multivariate logistic regression analysis was used to predict the risk factors of Listeria meningitis. RESULTS: A total of 36 cases and 113 controls were enrolled. The most significant predictive risk factor of Listeria meningitis was a prior history of receiving immunosuppressive therapy (odds ratio 8.12, 95 % CI 2.47-26.69). Chronic liver disease was the second most important predictive risk factor (OR 5.03, 95 % CI 1.56-16.22). Delaying appropriate antibiotic therapy by more than 6 h (hazard ratio 2.78) and fatal underlying disease (hazard ratio 2.88) were associated with increased mortality. CONCLUSIONS: Patients with a prior history of receiving immunosuppressive therapy within 1 month and chronic liver disease have 8.1-fold and 5-fold increased risk of meningitis by L. monocytogenes compared to S. pneumoniae, respectively.

Otomastoiditis caused by Candida auris: Case report and literature review.

Fungal otomastoiditis is a rare disease, but can be fatal for immunocompromised patients. Recently, there have been increasing cases of otologic infection caused by Candida auris. Candida auris can be easily misdiagnosed for other species and treatment is difficult due to multidrug resistance. Clinician should be aware of this rare pathogen, and it should be treated with appropriate antifungal agent with surgical debridement.

Impact of reduced vancomycin MIC on clinical outcomes of methicillin-resistant Staphylococcus aureus bacteremia.

Vancomycin has been a key antibiotic agent for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. However, little is known about the relationship between vancomycin MIC values at the higher end of the susceptibility range and clinical outcomes. The aim of this study was to determine the impact of MRSA bacteremia on clinical outcomes in patients with a vancomycin MIC near the upper limit of the susceptible range. Patients with MRSA bacteremia were divided into a high-vancomycin-MIC group (2 µg/ml) and a low-vancomycin-MIC group (≤1.0 µg/ml). We examined the relationship between MIC, genotype, primary source of bacteremia, and mortality. Ninety-four patients with MRSA bacteremia, including 31 with a high vancomycin MIC and 63 with a low MIC were analyzed. There was no significant difference between the presence of agr dysfunction and SCCmec type between the two groups. A higher vancomycin MIC was not found to be associated with mortality. In contrast, high-risk bloodstream infection sources (hazard ratio [HR], 4.63; 95% confidence interval [CI] = 1.24 to 17.33) and bacterial eradication after treatment (HR, 0.06; 95% CI = 0.02 to 0.17), irrespective of vancomycin MIC, were predictors of all-cause 30-day mortality. Our study suggests that a high-risk source of bacteremia is likely to be associated with unfavorable clinical outcomes, but a high vancomycin MIC in a susceptible range, as well as genotype characteristics, are not associated with mortality.

The role of infectious disease consultations in the management of patients with fever in a long-term care facility.

BACKGROUND: Infectious disease (ID) clinicians can provide essential services for febrile patients in tertiary hospitals. The aim of this study was to evaluate the role of ID consultations (IDC) in managing hospitalized patients with infections in an oriental medical hospital (OMH), which serves as a long-term care facility. To our knowledge, this is the first study on the role of IDCs in managing patients in an OMH. METHODS: This retrospective study was conducted in an OMH in Seoul, Korea, from June 2006 to June 2013. RESULTS: Among the 465 cases of hospital-acquired fever, 141 (30.3%) were referred for ID. The most common cause of fever was infection in both groups. The peak body temperature of the patient was higher in IDC group (38.8±0.6°C vs. 38.6±0.5°C, p<0.001). Crude mortality at 30 days (14.6% vs. 7.8%, p = 0.043) and infection-attributable mortality (15.3% vs. 6.7%, p = 0.039) were higher in the No-IDC group. Multivariable analysis showed that infection as the focus of fever (adjusted Odd ratio [aOR] 3.49, 95% confidence interval (CI) 1.64-7.44), underlying cancer (aOR 10.32, 95% CI 4.34-24.51,), and multiorgan dysfunction syndrome (aOR 15.68, 95% CI 2.06-119.08) were associated with increased 30-day mortality. Multivariate analysis showed that in patients with infectious fever, appropriate antibiotic therapy (aOR 0.19, 95% CI 0.05-0.76) was the only factor associated with decreased infection-attributable mortality while underlying cancer (aOR 7.80, 95% CI 2.555-23.807) and severe sepsis or septic shock at the onset of fever (aOR 10.15, 95% CI 1.00-102.85) were associated with increased infection-attributable mortality. CONCLUSION: Infection was the most common cause of fever in patients hospitalized for OMH. Infection as the focus of fever, underlying cancer, and MODS was associated with increased 30-day mortality in patients with nosocomial fever. Appropriate antibiotic therapy was associated with decreased infection-attributable mortality in patients with infectious fever.

Bloodstream infections in adult patients with cancer: clinical features and pathogenic significance of Staphylococcus aureus bacteremia.

OBJECTIVES: The aim of this study was to more precisely delineate the characteristics and outcomes of bloodstream infections in adult cancer patients. METHODS: Using a database for nationwide surveillance of bacteremia, we analyzed data related to bacteremia in adult patients with cancer in order to evaluate clinical features and outcomes and to define predictive factors for mortality. RESULTS: Of 1,246 patients, 896 (71.9%) had solid tumors, 328 (26.3%) had hematologic malignancies, and 22 (1.8%) had both. The following conditions were more common in the neutropenic group than in the non-neutropenic group: nosocomial acquisition, hematologic malignancy, corticosteroid use, immunosuppressant use, primary bacteremia, and pneumonia (all P < 0.05). The infections were caused by Gram-negative bacilli in 55.6% and by Gram-positive cocci in 32.7%. Gram-negative pathogens were more frequently isolated from neutropenic patients than from non-neutropenic patients (61.9% vs. 53.5%, P = 0.010), with a significant predominance of Escherichia coli and Klebsiella pneumoniae. Among 1,001 patients whose outcomes could be evaluated, the overall 30-day mortality rate was 24.1%, and multivariate analysis showed that Staphylococcus aureus bacteremia was a significant factor associated with mortality (odds ratio (OR), 1.80; 95% confidence interval (CI), 1.03-3.15), along with nosocomial acquisition, pneumonia, severe sepsis or septic shock, and higher Pitt bacteremia score (all P values <0.05). CONCLUSION: This study represents the comprehensive assessment of bloodstream infections in neutropenic versus non-neutropenic cancer patients. Given the pathogenic significance of S. aureus bacteremia in adult patients with cancer, additional strategies for the management of S. aureus bacteremia in cancer patients are needed to improve outcomes.

Unusual primary peritonitis due to Streptococcus pyogenes in a young healthy woman.

We describe the first case of primary peritonitis in Korea of a healthy person due to Streptococcus pyogenes. In the absence of comorbid conditions, such as liver cirrhosis, immunosuppression, or nephrotic syndrome, primary peritonitis is uncommon in a young healthy woman. Abdomen computed tomography revealed ascites in the lower abdomen and peritoneal enhancement suggesting peritonitis. In diagnostic laparoscopy, purulent ascites was found in the pelvic cavity but both ovaries and fallopian tubes were intact. There were no intra-abdominal abnormalities such as bowel perforation, appendicitis, or necrosis. The reports of blood culture, ascites culture, and cervical swab culture confirmed S. pyogenes. After use of antibiotics, the patient was cured and discharged without sequelae.

Spread of methicillin-resistant Staphylococcus aureus between the community and the hospitals in Asian countries: an ANSORP study.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in hospitals in many Asian countries. Recent emergence of community-associated (CA) MRSA worldwide has added another serious concern to the epidemiology of S. aureus infections. To understand the changing epidemiology of S. aureus infections in Asian countries, we performed a prospective, multinational surveillance study with molecular typing analysis. METHODS: We evaluated the prevalence of methicillin resistance in S. aureus isolates in CA and healthcare-associated (HA) infections, and performed molecular characterization and antimicrobial susceptibility tests of MRSA isolates. RESULTS: MRSA accounted for 25.5% of CA S. aureus infections and 67.4% of HA infections. Predominant clones of CA-MRSA isolates were ST59-MRSA-SCCmec type IV-spa type t437, ST30-MRSA-SCCmec type IV-spa type t019 and ST72-MRSA-SCCmec type IV-spa type t324. Previously established nosocomial MRSA strains including sequence type (ST) 239 and ST5 clones were found among CA-MRSA isolates from patients without any risk factors for HA-MRSA infection. CA-MRSA clones such as ST59, ST30 and ST72 were also isolated from patients with HA infections. CONCLUSIONS: Our findings confirmed that MRSA infections in the community have been increasing in Asian countries. Data also suggest that various MRSA clones have spread between the community and hospitals as well as between countries.

Fatal necrotizing fasciitis due to Streptococcus pneumoniae: a case report.

Necrotizing fasciitis is known to be a highly lethal infection of deep-seated subcutaneous tissue and superficial fascia. Reports of necrotizing fasciitis due to Streptococcus pneumoniae are exceedingly rare. We report a case of necrotizing fasciitis in a 62-yr-old man with liver cirrhosis and diabetes mellitus. He presented with painful swelling of left leg and right hand. On the day of admission, compartment syndrome was aggravated and the patient underwent surgical exploration. Intra-operative findings revealed necrotizing fasciitis and cultures of two blood samples and wound aspirates showed S. pneumoniae. The patient died despite debridement and proper antimicrobial treatment. To the best of our knowledge, this is the first case of fatal necrotizing fasciitis with meningitis reported in Korea. We also review and discuss the literature on pneumococcal necrotizing fasciitis.

Catheter-related candidemia caused by Candida haemulonii in a patient in long-term hospital care.

Candida haemulonii, one of the non-albicans Candida species, is an emerging yeast pathogen that is known to be resistant to amphotericin B and other antifungal agents such as azoles. These anti-fungal agents have often been associated with clinical treatment failure, so no treatment regimen has been clearly established for invasive C. haemulonii infections. We investigated a catheter-related infection of C. haemulonii candidemia in an adult patient in long-term hospital care. In the early stages, the candidemia remained persistent despite treatment with fluconazole. However, after changing the antifungal agent to caspofungin, the candidemia was resolved. Fluconazole and amphotericin B are not reliable empirical antifungal agents for invasive C. haemulonii infections, as shown in previous case reports. An echinocandin such as caspofungin may be an appropriate empirical choice of antifungal agent for an invasive C. haemulonii infection.

Nonclonal emergence of colistin-resistant Klebsiella pneumoniae isolates from blood samples in South Korea.

In vitro activities of colistin and other drugs were tested against 221 Klebsiella pneumoniae isolates that were collected between 2006 and 2007 in nine tertiary care South Korean hospitals from patients with bacteremia. The clonality of colistin-resistant K. pneumoniae (CRKP) isolates was assessed by multilocus sequence typing (MLST). We found that 15 isolates (6.8%) were resistant to colistin. MLST showed that CRKP isolates were nonclonal, with colistin resistance in K. pneumoniae occurring independently and not by clonal spreading.

Bloodstream infections and clinical significance of healthcare-associated bacteremia: a multicenter surveillance study in Korean hospitals.

Recent changes in healthcare systems have changed the epidemiologic paradigms in many infectious fields including bloodstream infection (BSI). We compared clinical characteristics of community-acquired (CA), hospital-acquired (HA), and healthcare-associated (HCA) BSI. We performed a prospective nationwide multicenter surveillance study from 9 university hospitals in Korea. Total 1,605 blood isolates were collected from 2006 to 2007, and 1,144 isolates were considered true pathogens. HA-BSI accounted for 48.8%, CA-BSI for 33.2%, and HCA-BSI for 18.0%. HA-BSI and HCA-BSI were more likely to have severe comorbidities. Escherichia coli was the most common isolate in CA-BSI (47.1%) and HCA-BSI (27.2%). In contrast, Staphylococcus aureus (15.2%), coagulase-negative Staphylococcus (15.1%) were the common isolates in HA-BSI. The rate of appropriate empiric antimicrobial therapy was the highest in CA-BSI (89.0%) followed by HCA-BSI (76.4%), and HA-BSI (75.0%). The 30-day mortality rate was the highest in HA-BSI (23.0%) followed by HCA-BSI (18.4%), and CA-BSI (10.2%). High Pitt score and inappropriate empirical antibiotic therapy were the independent risk factors for mortality by multivariate analysis. In conclusion, the present data suggest that clinical features, outcome, and microbiologic features of causative pathogens vary by origin of BSI. Especially, HCA-BSI shows unique clinical characteristics, which should be considered a distinct category for more appropriate antibiotic treatment.

Membranous obstructive Candida tracheitis as a complication of endotracheal intubation and tracheostomy.

This report describes a rare case of acute life-threatening stridor that was due to membranous obstructive Candida tracheitis, and this condition occurred after long-term endotracheal intubation and tracheostomy. An obstructive membrane was found 2 cm above the carina by bronchofiberscopy. The removal of the membrane resulted in the complete relief of the airway obstruction.

The cefazolin inoculum effect in methicillin-susceptible Staphylococcus aureus blood isolates: their association with dysfunctional accessory gene regulator (agr).

We evaluated the clinical significance of the cefazolin inoculum effect (CIE) in methicillin-susceptible Staphylococcus aureus (MSSA) isolates. In total, 146 isolates were recovered from patients with MSSA bacteremia at 9 hospitals in Korea. The CIE was observed in 16 MSSA isolates, and while type A was the only detected ß-lactamase in MSSA isolates exhibiting the CIE, no strains expressing type B, C, or D ß-lactamases exhibited this effect. The CIE was only observed in agr group III and I isolates and was significantly more common in isolates with agr dysfunction than in those with functional agr (P<0.001). Even among isolates producing type A ß-lactamase, the CIE was also prevalent in isolates with dysfunctional agr than in isolates with functional agr (P=0.025). This study demonstrates an association between the CIE of MSSA isolates and agr dysfunction, in addition to those between the CIE and type A ß-lactamase.