Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia.

INTRODUCTION: De-escalation therapy is a strategy currently used for the management of nosocomial pneumonia. In this study, we evaluated clinical outcomes and risk factors related to de-escalation therapy in patients with intensive care unit (ICU)-acquired pneumonia. METHODS: This was a retrospective observational cohort study of ICU patients who developed pneumonia more than 48 hours after admission to the ICU at Samsung Medical Center from September 2004 to December 2007. RESULTS: The 137 patients comprised 44 (32.1%) who received de-escalation therapy and 93 in the non-de-escalation group. The de-escalation group showed a lower pneumonia-related mortality rate than the non-de-escalation group by day 14 (2.3% vs. 10.8%, respectively; P = 0.08) and by day 30 (2.3% vs. 14%, respectively; P = 0.03) after the diagnosis of pneumonia. The variables independently associated with ICU-acquired pneumonia-related mortality included the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the modified Clinical Pulmonary Infection Score (CPIS) after 5 days with pneumonia. The non-de-escalation group had significantly higher APACHE II score and modified CPIS after 5 days with ICU-acquired pneumonia compared to the de-escalation group. Among all patients, 20.4% (28 of 137) had negative cultures for pathogens, and 42.9% (12 of 28) received de-escalation therapy. The latter 12 patients received de-escalation therapy and survived 30 days after the diagnosis of pneumonia. CONCLUSIONS: Patients in the de-escalation group showed a significantly lower mortality rate compared to patients in the non-de-escalation group. De-escalation therapy can be safely provided to patients with ICU-acquired pneumonia if they are clinically stable by day 5, even in those whose respiratory specimen cultures yield no specific pathogens.

Clinical outcome of catheter salvage in neutropenic cancer patients with catheter-related infection.

BACKGROUND: Catheter-related infections (CRI) cause significant morbidity and mortality in cancer patients, particularly during episodes of chemotherapy-induced neutropenia. This study was performed to evaluate clinical features and outcomes of CRI in neutropenic cancer patients. METHODS: We retrospectively analyzed clinical characteristics and outcome of febrile neutropenic cancer patients with CRI who visited the emergency department from January 1996 to June 2007. RESULTS: A total of 51 neutropenic cancer patients with CRI were identified and 53 organisms were isolated from culture specimens. The mean ± standard deviation patient age was 50 ± 15 y and the most common underlying disease was lymphoma (n = 27, 53%). Gram-positive organisms accounted for 77% of all isolated pathogens (41/53). Initial catheter salvage was attempted in 38 episodes of CRI, of which 20 were successful. In the current study the overall success rate of catheter salvage attempts was 52.6%. The failure rate of catheter salvage was significantly higher in CRI caused by Gram-negative pathogens than by Gram-positive pathogens. CONCLUSION: Although catheter salvage should be cautiously attempted for cancer patients with CRI, it might not be a treatment option for neutropenic cancer patients with CRI caused by Gram-negative bacteria.

Clinical factors predicting bacteremia in low-risk febrile neutropenia after anti-cancer chemotherapy.

PURPOSE: Bacteremia is an important clinical condition in febrile neutropenia that can cause clinical failure of antimicrobial therapy. The purpose of this study was to investigate the clinical factors predictive of bacteremia in low-risk febrile neutropenia at initial patient evaluation. METHODS: We performed a retrospective cohort study in a university hospital in Seoul, Korea, between May 1995 and May 2007. Patients who met the criteria of low-risk febrile neutropenia at the time of visit to emergency department after anti-cancer chemotherapy were included in the analysis. RESULTS: During the study period, 102 episodes of bacteremia were documented among the 993 episodes of low-risk febrile neutropenia. Single gram-negative bacteremia was most frequent. In multivariate regression analysis, initial body temperature ≥39°C, initial hypotension, presence of clinical sites of infection, presence of central venous catheter, initial absolute neutrophil count <50/mm(3), and the CRP ≥10 mg/dL were statistically significant predictors for bacteremia. A scoring system using these variables was derived and the likelihood of bacteremia was well correlated with the score points with AUC under ROC curve of 0.785. Patients with low score points had low rate of bacteremia, thus, would be candidates for outpatient-based or oral antibiotic therapy. CONCLUSIONS: We identified major clinical factors that can predict bacteremia in low-risk febrile neutropenia.

Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis.

BACKGROUND: There have been few reports on the causes and treatment outcomes for nosocomial spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. METHODS: We performed a retrospective cohort study to compare the microbiological and clinical characteristics in nosocomial versus community-acquired SBP. All patients with SBP, for whom culture was proven to be positive for SBP at Samsung Medical Center (Seoul, Republic of Korea) from 1 January 2000 through 31 June 2007, were included. Medical records and laboratory data were reviewed. Nosocomial SBP was defined as SBP diagnosed after 72 h of hospitalization. RESULTS: A total of 236 patients with SBP were enrolled (mean age +/- SD age, 56.6 +/- 10.7 years); 166 patients were women, and 70 were men. Nosocomial and community-acquired SBP occurred in 126 and 110 patients, respectively. Escherichia coli accounted for 102 (43.2%) of 236 isolates, Klebsiella species accounted for 33 isolates (14.0%), and Streptococcus species accounted for 23 isolates (9.8%). The overall 30-day mortality rate for nosocomial SBP was higher than that for community-acquired SBP (58.7% vs. 37.3%; P = .001). Nosocomial isolates of gram-negative organisms were significantly more resistant to third-generation cephalosporins (41% vs. 10.0%; P = .001) and quinolones (50.0% vs. 30.9%; P = .003), compared with community-acquired isolates. Multivariate analysis revealed that nosocomial infection, concomitant hepatocellular carcinoma, presentation with acute renal failure or shock, and resistance to third-generation cephalosporins were significant risk factors for 30-day mortality associated with SBP. CONCLUSIONS: Nosocomial SBP has a poorer outcome than community-acquired SBP. The resistance to third-generation cephalosporins for gram-negative organisms, which are more common in nosocomial cases of SBP than in community-acquired cases of SBP, adversely affects the outcome of SBP in patients with liver cirrhosis.

Clinical Presentation and Outcomes of Middle East Respiratory Syndrome in the Republic of Korea.

BACKGROUND: From May to July 2015, the Republic of Korea experienced the largest outbreak of Middle East respiratory syndrome (MERS) outside the Arabian Peninsula. A total of 186 patients, including 36 deaths, had been diagnosed with MERS-coronavirus (MERS-CoV) infection as of September 30th, 2015. MATERIALS AND METHODS: We obtained information of patients who were confirmed to have MERS-CoV infection. MERS-CoV infection was diagnosed using real-time reverse-transcriptase polymerase chain reaction assay. RESULTS: The median age of the patients was 55 years (range, 16 to 86). A total of 55.4% of the patients had one or more coexisting medical conditions. The most common symptom was fever (95.2%). At admission, leukopenia (42.6%), thrombocytopenia (46.6%), and elevation of aspartate aminotransferase (42.7%) were observed. Pneumonia was detected in 68.3% of patients at admission and developed in 80.8% during the disease course. Antiviral agents were used for 74.7% of patients. Mechanical ventilation, extracorporeal membrane oxygenation, and convalescent serum were employed for 24.5%, 7.1%, and 3.8% of patients, respectively. Older age, presence of coexisting medical conditions including diabetes or chronic lung disease, presence of dyspnea, hypotension, and leukocytosis at admission, and the use of mechanical ventilation were revealed to be independent predictors of death. CONCLUSION: The clinical features of MERS-CoV infection in the Republic of Korea were similar to those of previous outbreaks in the Middle East. However, the overall mortality rate (20.4%) was lower than that in previous reports. Enhanced surveillance and active management of patients during the outbreak may have resulted in improved outcomes.

Gastrointestinal stromal tumor solitary distant recurrence in the left brachialis muscle.

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gastrointestinal tract that are most commonly found in the stomach. Although GISTs can spread to the liver and peritoneum, metastasis to the skeletal muscle is very rare and only four cases have previously been reported. These cases involved concurrent skeletal metastases of primary GISTs or liver metastases. Here, we report the first case of a distant recurrence in the brachialis muscle after complete remission of an extra-luminal gastric GIST following a wedge resection of the stomach, omental excision, and adjuvant imatinib therapy for one year. Ten months after therapy completion, the patient presented with swelling and tenderness in the left arm. Magnetic resonance imaging revealed a large mass in the brachialis muscle, which showed positivity for c-kit and CD34 upon pathologic examination. This is the first reported case of a solitary distant recurrence of a GIST in the muscle after complete remission had been achieved.

Anti-anaerobic coverage is not necessary for Klebsiella pneumoniae liver abscess: a propensity score-matched cohort study.

Although most Klebsiella pneumoniae liver abscesses have been reported to be monomicrobial, clinical outcomes have not been compared between antimicrobial therapy with and without anti-anaerobic coverage. A propensity score-matched cohort study was conducted using the 731 cases of K. pneumoniae liver abscess. Clinical outcomes were compared between a group discontinuing anti-anaerobic agents after K. pneumoniae identification and a group continuing. A total of 170 cases were matched at a 1:1 ratio using their propensity to discontinue anti-anaerobic agents. The McNemar's test showed no difference in mortality rates (1.8% for discontinuation versus 2.3% for continuation; P = 1.00) or relapse (1.8% versus 2.9%; P = 0.73) between groups. Early discontinuation of anti-anaerobic agents had no association with treatment failure by means of the generalized estimating equation model (odds ratio 0.48; P = 0.14) and the Kaplan-Meier method (P = 0.85) in matched groups. Early discontinuation of anti-anaerobic agents does not affect the clinical outcomes of patients with K. pneumoniae liver abscess.

Nasal deformity due to tuberculous chondritis.

Tuberculosis (TB) is a common disease worldwide. However, nasal TB is quite rare, and the diagnosis of nasal TB requires a high index of suspicion. The most common symptoms of this unusual presentation are nasal obstruction and nasal discharge. We present a case of nasal TB with involvement of the hard palate presenting with a chronically progressive nasal deformity and ulceration of the hard palate. A biopsy confirmed the diagnosis, and medication for TB was started and the lesions resolved. When a patient presents with chronic ulcerative lesions that do not respond to antibiotic treatment, TB should be included in the differential diagnosis. Biopsy of the lesion can aid in the confirmation of the diagnosis.

Clinical experience of tigecycline treatment in infections caused by extensively drug-resistant Acinetobacter spp.

BACKGROUND: Tigecycline has broad spectrum antimicrobial activity and is approved for complicated intra-abdominal infections, complicated skin and soft tissue infections, and community-acquired pneumonia. There are few data on clinical experience of tigecycline in hospital-acquired pneumonia (HAP) and Acinetobacter spp. infection. METHODS: A retrospective study was performed at eight hospitals in Korea from May 2009 to January 2010. Adult patients treated with tigecycline regardless of their source of infection or pathogens were enrolled. RESULTS: Tigecycline was administered in 108 patients. Pneumonia was the most common infection (43.5%), followed by skin and soft tissue infections (20.4%). Acinetobacter baumannii was isolated from 83 patients (76.9%) accounting for 50.3% of isolated pathogens, showing a resistance rate of 67.5% to carbapenems. Superinfection was identified in 32 patients (29.6%). Pseudomonas aeruginosa was most common microorganism causing superinfection (46.9%). Overall 30-day mortality rate was 52.9%. Thirty-day mortality rate of HAP and Acinetobacter spp. infection was 60.5% and 59.4%, respectively. CONCLUSION: Tigecycline can be considered as an alternative therapy in patients with HAP or infections caused by Acinetobacter spp., especially extensively drug-resistant A. baumannii.

Concurrent nocardia related brain abscess and semi-invasive pulmonary aspergillosis in an immunocompetent patient.

We describe here the first case of a concurrent brain abscess caused by Norcardia spp. and semi-invasive pulmonary aspergillosis in an immunocompetent patient. After one year of appropriate antimicrobial therapy and surgical drainage of the brain abscess, the nocardia brain abscess and pulmonary aspergillosis have resolved.

Usefulness of C-reactive protein for evaluating clinical outcomes in cirrhotic patients with bacteremia.

BACKGROUND/AIMS: The purpose of this study was to evaluate the value of initial C-reactive protein (CRP) as a predictor of clinical outcome and to investigate whether follow-up CRP measurement is useful for the prediction of the clinical outcome of bloodstream infections in patients with liver cirrhosis (LC), whose CRP production in response to infection may be attenuated. METHODS: A retrospective, observational study including 202 LC patients with Escherichia coli or Klebsiella pneumoniae bacteremia was conducted to assess the usefulness of serial CRP measurements in predicting clinical outcome in LC patients. The CRP ratio was defined as the ratio of the follow-up CRP level to the initial CRP level. RESULTS: The overall 30-day mortality rate of the study population was 23.8% (48/202). In the multivariate analysis, advanced age (≥ 70 years), healthcare-associated or nosocomial infections, model for end-stage liver disease (MELD) score of ≥ 30, and initial body temperature of < 37℃ were significant factors associated with mortality (all p < 0.05). No association between initial CRP level and mortality was found. In a further analysis including 87 evaluable cases who had repeated CRP measurements at day 4 and/or 5, a CRP ratio of ≥ 0.7 was found to be a significant factor associated with mortality (odds ratio, 19.12; 95% confidence interval, 1.32 to 276.86; p = 0.043) after adjusting for other confounding variables. CONCLUSIONS: Initial CRP level did not predict mortality of sepsis in LC patients. However, serial CRP measurements during the first week of antimicrobial therapy may be useful as a prognostic factor for mortality in LC patients.

Impact of inappropriate antimicrobial therapy on outcome in patients with hospital-acquired pneumonia caused by Acinetobacter baumannii.

OBJECTIVES: The purpose of this study was to evaluate the impact of inappropriate antimicrobial therapy on the outcome of patients with hospital-acquired pneumonia (HAP) caused by Acinetobacter baumannii. METHODS: All cases of HAP caused by A. baumannii from January 2000 to March 2006 at the Samsung Medical Center (Seoul, Korea) were analyzed retrospectively. RESULTS: A total of 116 patients with clinically significant Acinetobacter HAP were enrolled. Among the A. baumannii isolates, 60.3% showed multi-drug resistance (MDR), 16.4% were found to have imipenem resistance, and 15.5% had pan-drug resistance (PDR). The mean APACHE II score of the patients was 22.3 +/- 7.9. The overall in-hospital and pneumonia-related mortality rates were 47.4% and 37.9%, respectively. The univariate analysis showed that the factors associated with pneumonia-related mortality were: MDR, PDR, high APACHE II score, inappropriate empirical antimicrobial therapy, and inappropriate definitive antimicrobial treatment (All p < 0.05). Among these, a high APACHE II score and inappropriate definitive antimicrobial therapy were found to be independent factors associated with a high mortality, after adjustment for other variables. CONCLUSIONS: The appropriate definitive antimicrobial therapy should be provided in patients with HAP caused by A. baumannii.

A case of granular cell tumor of the trachea.

A 20-year-old man presented to our outpatient clinic with hemoptysis, cough, and pleuritic chest pain. His chest radiograph and pulmonary function tests (PFT) were normal. A bronchoscopy showed a small yellowish patch with a regular surface. A direct bronchoscopic biopsy was performed. The pathologic findings showed a benign granular cell tumor. The respiratory symptoms resolved after biopsying the tumor. On follow up, there were no signs of recurrence of the granular cell tumor after a period of 24 months.