Changes in the characteristics of community-onset fluoroquinolone-resistant Escherichia coli isolates causing community-acquired acute pyelonephritis in South Korea.

PURPOSE: This study aimed to examine the changes in the characteristics of community-onset fluoroquinolone-resistant (FQ-R) Escherichia coli isolates causing community-acquired acute pyelonephritis (APN) in South Korea. METHODS: Blood or urine samples were prospectively collected from patients aged ≥15 years with community-acquired APN who were admitted to one of the eight Korean hospitals included in this study between September 2017 and August 2018. Phylogenetic typing, multilocus sequence typing, and molecular characterization of ß-lactamase resistance and plasmid-mediated quinolone resistance (PMQR) determinants were performed. The data were compared with those from a previous study with the same design conducted in 2010-2011. RESULTS: A total of 300 and 346 isolates were identified in 2010-2011 and 2017-2018, respectively. Among them, 76 (22.0%) and 77 (25.7%) FQ-R isolates were identified in 2010-2011 and 2017-2018, respectively. A significantly higher antimicrobial resistance against third-to fourth-generation cephalosporins, including cefotaxime (23.9% vs. 77.9%, P < 0.001), were observed among FQ-R isolates in 2017-2018 than among those in 2010-2011. A higher proportion of ST131 isolates (27.6% vs. 66.2%, P < 0.001), as well as isolates that had extended-spectrum ß-lactamase (ESBL)/plasmid-mediated AmpC ß-lactamase (PABL) (23.7% vs. 79.2%, P < 0.001), was observed in 2017-2018 than in 2010-2011. Further, more PMQR determinants (11.8% vs. 40.8%, P < 0.001) were observed in 2017-2018 than in 2010-2011. CONCLUSIONS: Among uropathogenic FQ-R E. coli isolates in South Korea, the prevalence of ST131 and the proportion of isolates containing ESBL and/or PMQR determinants have increased.

Relationship between the appropriateness of antibiotic treatment and clinical outcomes/medical costs of patients with community-acquired acute pyelonephritis: a multicenter prospective cohort study.

BACKGROUND: Inappropriate use of antibiotics not only increases antibiotic resistance as collateral damage but also increases clinical failure rates and medical costs. The purpose of this study was to determine the relationship between the appropriateness of antibiotic prescription and outcomes of community-acquired acute pyelonephritis (CA-APN). METHODS: A multicenter prospective cohort study was conducted at eight hospitals in Korea between September 2017 and August 2018. All hospitalized patients aged ≥ 19 years who were diagnosed with CA-APN on admission were recruited. The appropriateness of empirical and definitive antibiotics, as well as the appropriateness of antibiotic treatment duration and route of administration, was evaluated in accordance with the guideline and expert opinions. Clinical outcomes and medical costs were compared between patients who were administered antibiotics 'appropriately' and 'inappropriately.' RESULTS: A total of 397 and 318 patients were eligible for the analysis of the appropriateness of empirical and definitive antibiotics, respectively. Of them, 10 (2.5%) and 18 (5.7%) were administered 'inappropriately' empirical and definitive antibiotics, respectively. Of the 119 patients whose use of both empirical and definitive antibiotics was classified as 'optimal,' 57 (47.9%) received antibiotics over a longer duration than that recommended; 67 (56.3%) did not change to oral antibiotics on day 7 of hospitalization, even after stabilization of the clinical symptoms. Patients who were administered empirical antibiotics 'appropriately' had shorter hospitalization days (8 vs. 10 days, P = 0.001) and lower medical costs (2381.9 vs. 3235.9 USD, P = 0.002) than those who were administered them 'inappropriately.' Similar findings were observed for patients administered both empirical and definitive antibiotics 'appropriately' and those administered either empirical or definitive antibiotics 'inappropriately'. CONCLUSIONS: Appropriate use of antibiotics leads to better outcomes, including reduced hospitalization duration and medical costs.

Effect of discontinuation of an antimicrobial stewardship programme on the antibiotic usage pattern.

OBJECTIVES: This study aimed to analyse the effect of discontinuation of antimicrobial stewardship programme (ASP) activity on the usage pattern of antibiotics. METHODS: An interrupted time-series analysis assessing the trends in antibiotic use was conducted between September 2015 and August 2019 in an 859-bed university-affiliated hospital in Korea, where all ASP activities were discontinued in March 2018. The major activity of the ASP was a restrictive antibiotic programme. RESULTS: The use of restrictive antibiotics increased immediately after the discontinuation of the ASP by 41.06 days of therapy (DOT)/1000 patient-days in the general ward (95% confidence interval (CI) 21.04-61.08) and by 391.04 DOT/1000 patient-days in the intensive care unit (ICU) (95%CI 207.56-574.51). In addition, there were positive changes in the slope for the use of restrictive antibiotics in the general ward (7.06 DOT/1000 patient-days per month, 95%CI 4.63-9.50) and ICU (35.95 DOT/1000 patient-days per month, 95%CI 18.70-53.19). The use of broad-spectrum antibiotics in the general ward significantly decreased (-87.54 DOT/1000 patient-days, 95%CI -149.29 to -25.79). For non-broad-spectrum antibiotics, there were positive changes in the slope in the general ward (16.54 DOT/1000 patient-days per month, 95%CI 12.99-20.09) and ICU (12.85 DOT/1000 patient-days per month, 95%CI 2.32-23.38). CONCLUSIONS: After discontinuation of the ASP, antibiotic usage patterns rapidly returned to the patterns prior to the implementation of the programme.

Comparison of the clinical characteristics of community-acquired acute pyelonephritis between male and female patients.

BACKGROUND: Community-acquired acute pyelonephritis (CA-APN) is relatively rare in men. This study aimed to compare the clinical characteristics of CA-APN between male and female patients. METHODS: We prospectively collected the clinical and microbiological data of hospitalized CA-APN patients aged ≥19 years in South Korea from March 2010 to February 2011 in 11 hospitals and from September 2017 to August 2018 in 8 hospitals. Only the first episodes of APN of each patient during the study period were included. RESULTS: From 2010 to 2011, 573 patients from 11 hospitals were recruited, and from 2017 to 2018, 340 patients were recruited from 8 hospitals. Among them, 5.9% (54/913) were male. Male patients were older (66.0 ± 15.2 vs. 55.3 ± 19.0 years, P < 0.001), had a higher Charlson comorbidity index (1.3 ± 1.5 vs. 0.7 ± 1.2, P = 0.027), and had a higher proportion of structural problems in the urinary tract (40.7% vs. 6.1%, P < 0.001) than female patients. Moreover, the total duration of antibiotic treatment was longer (21.8 ± 17.8 d vs. 17.3 ± 9.4 d, P = 0.001) and the proportion of carbapenem usage was higher (24.1% vs. 9.5%, P = 0.001) in men than in women. Male patients were hospitalized for longer durations than female patients (median, 10 d vs. 7 d, P < 0.001). CONCLUSIONS: Male CA-APN patients were older and had more comorbidities than female CA-APN patients. In addition, male patients received antibiotic treatment for a longer duration than female patients.

Changes in Clinical Characteristics of Community-Acquired Acute Pyelonephritis and Antimicrobial Resistance of Uropathogenic Escherichia coli in South Korea in the Past Decade.

This study examined changes in the clinical characteristics of community-acquired acute pyelonephritis (CA-APN) in South Korea between the period 2010-2011 and 2017-2018. We recruited all CA-APN patients aged ≥19 years who visited eight hospitals in South Korea from September 2017 to August 2018, prospectively. Data collected were compared with those from the previous study in 2010-2012, with the same design and participation from 11 hospitals. A total of 617 patients were enrolled and compared to 818 patients' data collected in 2010-2011. Escherichia coli was the most common causative pathogen of CA-APN in both periods (87.3% vs. 86.5%, p = 0.680). E. coli isolates showed significantly higher antimicrobial resistance against fluoroquinolone (32.0% vs. 21.6%, p < 0.001), cefotaxime (33.6% vs. 8.3%, p < 0.001), and trimethoprim/sulfamethoxazole (37.5% vs. 29.2%, p = 0.013) in 2017-2018 than in 2010-2011. Total duration of antibiotic treatment increased from 16.55 ± 9.68 days in 2010-2011 to 19.12 ± 9.90 days in 2017-2018 (p < 0.001); the duration of carbapenem usage increased from 0.59 ± 2.87 days in 2010-2011 to 1.79 ± 4.89 days in 2010-2011 (p < 0.001). The median hospitalization was higher for patients in 2017-2018 than in 2010-2011 (9 vs. 7 days, p < 0.001). In conclusion, antimicrobial resistance of E. coli to almost all antibiotic classes, especially third generation cephalosporin, increased significantly in CA-APN in South Korea. Consequently, total duration of antibiotic treatment, including carbapenem usage, increased.

Independent risk factors for contralateral patent processus vaginalis undetected by pre-operative ultrasonography in boys with unilateral inguinal hernia.

PURPOSE: Many trials have been done to make sure probability of metachronous contralateral side hernia (MCH) and contralateral patent processus vaginalis (CPPV). But the necessity of contralateral side exploration is still on debate. The aim is to investigate the risk factors for the consideration of contralateral examination on operation. MATERIALS AND METHODS: The study was designed as retrospectively. Patients with unilateral inguinal hernia from January 2010 to May 2015 were enrolled. Pre-operative ultrasonography was done in all patients. Patients with obvious contralateral side hernia on pre-operative US were excluded. The presence of CPPV was evaluated by transinguinal laparoscopy during the operation. RESULTS: In univariate analysis, hernial sac size only shows difference (P value: 0.001). The others, location of the hernia, age at surgery, gestational age (preterm), low birth weight and parent's age, did not show statistically significant differences. Multivariate analysis also demonstrates CPPV is more common in patients with large hernial sac (Odds ratio: 2.727, 95% confidence interval 1.495-4.974, P value: 0.001). CONCLUSION: We propose that surgeons should consider contralateral evaluation during operation in case with large ipsilateral hernial sac, although CPPV was not detected by pre-operative US.