Effects of gentamicin monotherapy for the initial treatment of community-onset complicated non-obstructive acute pyelonephritis due to Enterobacteriaceae in elderly and non-elderly women.

Aminoglycosides may serve as fluoroquinolone-sparing or cephalosporin-sparing agents if the clinical effectiveness of aminoglycoside monotherapy is demonstrated. The purposes of this study were to investigate the clinical efficacy of gentamicin as an initial empirical antimicrobial agent and to evaluate the effects of gentamicin resistance on clinical outcomes in women with complicated non-obstructive acute pyelonephritis (APN). Medical records of 1066 women with a diagnosis of APN were reviewed retrospectively. We enrolled 275 women with community-onset complicated non-obstructive APN due to Enterobacteriaceae who received gentamicin as their initial antibiotic. Of these 275 patients, 43 had gentamicin-resistant (GM-R) Enterobacteriaceae APN, and 232 had gentamicin-susceptible (GM-S) Enterobacteriaceae APN. The early clinical success rates were 67.4% (29/43) versus 89.7% (208/232) at 72 h in the GM-R versus the GM-S groups (p 0.001). The overall clinical cure rate was 100% (43/43) and 98.7% (229/232) in the GM-R and GM-S groups, respectively. The duration of hospital stay was significantly longer in the elderly, although there were no significant differences in the rates of early clinical success, final clinical cure, mortality, and time to fever clearance between the elderly and non-elderly groups. Resistance of Enterobacteriaceae to gentamicin, haematuria and serum C-reactive protein level≥20 mg/dL were independently associated with early clinical failure. Gentamicin can be an effective initial antibiotic option for empirical therapy in women with community-onset complicated APN who do not need urological interventional procedures. The use of gentamicin may contribute to a reduction of fluoroquinolone or broad-spectrum cephalosporin use in the treatment of complicated APN.

Clinical characteristics predicting early clinical failure after 72 h of antibiotic treatment in women with community-onset acute pyelonephritis: a prospective multicentre study.

In patients with community-onset acute pyelonephritis (CO-APN), assessing the risk factors for poor clinical response after 72 h of antibiotic treatment (early clinical failure) is important. The objectives of this study were to define those risk factors, and to assess whether early clinical failure influences mortality and treatment outcomes. We prospectively collected the clinical and microbiological data of women with CO-APN in South Korea from March 2010 to February 2012. The numbers of cases in the early clinical success and early clinical failure groups were 840 (79.1%) and 222 (20.9%), respectively. Final clinical failure and mortality were higher in the early clinical failure group than in the early clinical success group (14.9% vs 2.3%, p <0.001; 6.8% vs 0.1%, p 0.001, respectively). In a multiple logistic regression model, the risk factors for early clinical failure among the total 1062 patients were diabetes mellitus (OR 1.5; 95% CI 1.1-2.1), chronic liver diseases (OR 3.3; 95% CI 1.6-6.7), malignancy (OR 2.2; 95% CI 1.1-4.4), Pitt score ≥2 (OR 2.5; 95% CI 1.6-3.8), presence of azotaemia (OR 1.8; 95% CI 1.2-2.7), white blood cell count ≥20 000/mm(3) (OR 2.5; 95% CI 1.6-4.0), serum C-reactive protein level ≥20 mg/dL (OR 1.7; 95% CI 1.2-2.4), and history of antibiotic usage within the previous year (OR 1.5; 95% CI 1.1-2.2). Analysing the subgroup of 743 patients with CO-APN due to Enterobacteriaceae, fluoroquinolone resistance of the uropathogen was another factor associated with early clinical failure (OR 1.7; 95% CI 1.1-2.5). Simple variables of underlying diseases, previous antibiotic usage and initial laboratory test outcomes can be used to decide on the direction of treatment in CO-APN.

Clinical characteristics of community-acquired acute pyelonephritis caused by ESBL-producing pathogens in South Korea.

OBJECTIVES: The aim of this study was to determine the risk factors and clinical characteristics of community-acquired acute pyelonephritis (CA-APN) caused by extended-spectrum ß-lactamase (ESBL)-producing organisms. METHODS: From March 2010 to February 2011, patients with CA-APN were recruited in 11 hospitals in South Korea. Clinical and microbiological data were collected prospectively, and the ESBLs and multilocus sequence types of the ESBL-producing Escherichia coli were characterized. Comparison between CA-APN caused by ESBL-producing Enterobacteriaceae and those by non-ESBL-producing organisms was performed. RESULTS: A total of 566 patients were recruited. Enterobacteriaceae were detected in 526 patients. Forty-six isolates (46/526, 8.7 %) were positive for ESBLs. Clinical and microbiological failure did not differ between the two groups, despite there being fewer patients with ESBL-positive isolates provided with appropriate antibiotics initially (19.6 vs. 93.8 %, p < 0.001). However, the duration of hospitalization was longer in the ESBL group (10.5 vs. 7.0 days, p = 0.012). In a logistic regression model, Charlson score ≥1 point [odds ratio (OR) 3.4, 95 % confidence interval (CI) 1.6-7.0, p = 0.001], antibiotics usage during the previous year (OR 3.1, 95 % CI 1.4-7.2, p = 0.008), and urinary catheterization during the previous month (OR 4.4, 95 % CI 1.1-17.6, p = 0.035) were associated with the risks of CA-APN by ESBL producers. CTX-M-15 (48 %) and CTX-M-14 (38 %) were the most common ESBLs. ST131 was the most common clone (7/24, 29.1 %), which was more frequently resistant to cefepime, fosfomycin, and temocillin. CONCLUSIONS: The risk factors for CA-APN by ESBL producers were Charlson score ≥1 point, antibiotics usage during the previous year, and urinary catheterization during the previous month.

Carbapenem-resistant Acinetobacter baumannii: diversity of resistant mechanisms and risk factors for infection.

Carbapenem-resistant Acinetobacter baumannii (CRAB) are an increasing infectious threat in hospitals. We investigated the clinical epidemiology of CRAB infections vs. colonization in patients, and examined the mechanisms of resistance associated with elevated minimum inhibitory concentrations (MICs) for carbapenems. From January to June 2009, 75 CRAB strains were collected. CRAB infection was significantly associated with malignancy and a high APACHE II score. The most dominant resistance mechanism was ISAba1 preceding OXA-51, producing strains with overexpression of efflux pump. Strains carrying blaOXA-23-like enzymes had higher carbapenem MICs than those carrying blaOXA-51-like enzymes; however, the presence of multiple mechanisms did not result in increased resistance to carbapenems. There was no difference in the resistance mechanisms in strains from infected and colonized patients. The majority of strains were genetically diverse by DNA macrorestriction although there was evidence of clonal spread of four clusters of strains in patients.

Acute cytomegalovirus pneumonia and hepatitis presenting during acute HIV retroviral syndrome.

Cytomegalovirus (CMV) disease is a frequent opportunistic infection that usually occurs in the late stages of HIV infection as a result of reactivation of a latent infection. We report a case of a 23-year-old man with acute retroviral syndrome complicated by coexisting CMV pneumonia and CMV hepatitis, which were documented by histopathological examination. His CMV pneumonia and hepatitis were assumed to be primary CMV diseases owing to the absence of CMV IgG antibody. To the best of our knowledge, this is the first case of simultaneous CMV pneumonia and hepatitis occurring as primary CMV diseases during primary HIV infection. This case indicates that invasive CMV diseases such as pneumonia and hepatitis should be considered even in patients with primary HIV infection.

Risk factor analysis of invasive liver abscess caused by the K1 serotype Klebsiella pneumoniae.

The increasing prevalence of Klebsiella pneumoniae liver abscess in Asian countries is attributable to virulent strains of the K1 serotype. We investigated the risk factors for the K1 serotype K. pneumoniae liver abscess. A case-control study was performed using the database of a nationwide study of liver abscess in Korea. Multivariate logistic regression analysis was performed for 78 cases of the K1 serotype K. pneumoniae liver abscess and 81 controls with non-Klebsiella. Diabetes mellitus was the significant risk factor (OR 2.13; 95% CI 1.026 approximately 4.428; P = 0.042) for the K1 serotype K. pneumoniae liver abscess. Biliary disorders had a strong negative association (OR 0.18; 95% CI 0.078 approximately 0.410; P < 0.001). This study suggests that diabetes mellitus is a more significant risk factor for the K1 serotype K. pneumoniae liver abscess than for the non-Klebsiella liver abscess.

Infectious complications in living-donor liver transplant recipients: a 9-year single-center experience.

BACKGROUND: Infectious complications following living-donor liver transplantation (LDLT) remain a major cause of morbidity and mortality. We analyzed the frequency and type of infectious complications according to the post-transplantation period, and their risk factors with regard to morbidity and mortality. METHODS: We retrospectively analyzed 208 subjects who had undergone LDLT during a 9-year period. RESULTS: The rate of infection was 1.69 per patient during the study period. The predominant infections were intra-abdominal infections (37.6%), primary bacteremia (17.4%), and pneumonia (14.5%). Within the first post-transplant month, 140 (39.9%) infections were detected, and catheter-related coagulase-negative staphylococci (44) were the most common infectious agents. During the 2-6-month post-transplant period, 109 infectious episodes occurred (31.1%), and Enterococcus sp. (n=16) related to biliary infection was the most frequent isolate. After the sixth month, 96 infectious episodes (29%) occurred, and biliary tract-related Escherichia coli (n=19) was the major causative organism. The overall mortality was 24.5% (51/208); 1-year survival rate was 88% (196/208). Post-transplant infection-related mortality was 52.9% (27/51). Biliary tract complications, such as biliary stenosis or leakage, significantly increased the mortality (P=0.01); however, reoperation (retransplantation or resurgery for biliary tract obstruction/leakage or to control bleeding) significantly reduced the mortality (P=0.01). CONCLUSIONS: Our data showed that early catheter removal would mainly aid in reducing infectious complications in the 1-month post-transplantation period. Aggressive management, including reoperation, would lower the mortality in the LDLT recipients.