Publications by authors named "Song Mi Moon"

37 Publications

Status of antimicrobial stewardship programmes in Korean hospitals including small to medium-sized hospitals and the awareness and demands of physicians: a nationwide survey in 2020.

J Glob Antimicrob Resist 2021 Jun 18;26:180-187. Epub 2021 Jun 18.

Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam 13620, Gyeonggi-do, South Korea.

Objectives: This study aimed to identify the status of antimicrobial stewardship programmes (ASPs) in small to medium-sized Korean hospitals as well as the awareness and demands about ASPs of physicians.

Methods: A questionnaire was designed based on a questionnaire from a previous nationwide survey in 2018 targeting large hospitals in Korea and modified to reflect the results of in-depth interviews with non-infectious diseases (IDs) physicians at secondary care hospitals. The survey targeted all hospitals with ≥150 beds in South Korea and was performed in May-June 2020. Only one ASP-associated physician per hospital participated in the survey.

Results: The survey response rate was 31.9% (217/680). ID specialists comprised the majority of medical personnel participating in ASPs in tertiary care hospitals. Conversely, in secondary and primary care hospitals there was no predominant medical personnel for ASPs and the median full-time equivalent was 0 for all types of medical personnel. Tertiary care hospitals, more than secondary and primary care hospitals, tended to perform ASP activities more actively. 'Workforce for ASPs', 'Establishment of healthcare fees for ASPs' and 'Development of tools for ASPs' were the most important required support for ASP improvement.

Conclusion: The level of ASP establishment was more limited in primary care hospitals than in secondary and tertiary care hospitals in Korea. To improve ASPs in Korean hospitals, a supporting workforce and the establishment of a healthcare fee for ASPs appear to be necessary.
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http://dx.doi.org/10.1016/j.jgar.2021.06.001DOI Listing
June 2021

Development of key quality indicators for appropriate antibiotic use in the Republic of Korea: results of a modified Delphi survey.

Antimicrob Resist Infect Control 2021 03 6;10(1):48. Epub 2021 Mar 6.

Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.

Background: An effective antibiotic stewardship program relies on the measurement of appropriate antibiotic use, on which there is a lack of consensus. We aimed to develop a set of key quality indicators (QIs) for nationwide point surveillance in the Republic of Korea.

Methods: A systematic literature search of PubMed, EMBASE, and Cochrane Library (publications until 20th November 2019) was conducted. Potential key QIs were retrieved from the search and then evaluated by a multidisciplinary expert panel using a RAND-modified Delphi procedure comprising two online surveys and a face-to-face meeting.

Results: The 23 potential key QIs identified from 21 studies were submitted to 25 multidisciplinary expert panels, and 17 key QIs were retained, with a high level of agreement (13 QIs for inpatients, 7 for outpatients, and 3 for surgical prophylaxis). After adding up the importance score and applicability, six key QIs [6 QIs (Q 1-6) for inpatients and 3 (Q 1, 2, and 5) for outpatients] were selected. (1) Prescribe empirical antibiotic therapy according to guideline, (2) change empirical antibiotics to pathogen-directed therapy, (3) obtain culture samples from suspected infection sites, (4) obtain two blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan. In surgical prophylaxis, the QIs to prescribe antibiotics according to the guideline and initiate antibiotic therapy 1 h before incision were selected.

Conclusions: We identified key QIs to measure the appropriateness of antibiotic therapy to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.
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http://dx.doi.org/10.1186/s13756-021-00913-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7937201PMC
March 2021

Human resources required for antimicrobial stewardship activities for hospitalized patients in Korea.

Infect Control Hosp Epidemiol 2020 12 26;41(12):1429-1435. Epub 2020 Oct 26.

Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea.

Objectives: We calculated the human resources required for an antimicrobial stewardship program (ASP) in Korean hospitals.

Design: Multicenter retrospective study.

Setting: Eight Korean hospitals ranging in size from 295 to 1,337 beds.

Methods: The time required for performing ASP activities for all hospitalized patients under antibiotic therapy was estimated and converted into hours per week. The actual time spent on patient reviews of each ASP activity was measured with a small number of cases, then the total time was estimated by applying the determined times to a larger number of cases. Full-time equivalents (FTEs) were measured according to labor laws in Korea (52 hours per week).

Results: In total, 225 cases were reviewed to measure time spent on patient reviews. The median time spent per patient review for ASP activities ranged from 10 to 16 minutes. The total time spent on the review for all hospitalized patients was estimated using the observed number of ASP activities for 1,534 patients who underwent antibiotic therapy on surveillance days. The most commonly observed ASP activity was 'review of surgical prophylactic antibiotics' (32.7%), followed by 'appropriate antibiotics recommendations for patients with suspected infection without a proven site of infection but without causative pathogens' (28.6%). The personnel requirement was calculated as 1.20 FTEs (interquartile range [IQR], 1.02-1.38) per 100 beds and 2.28 FTEs (IQR, 1.93-2.62) per 100 patients who underwent antibiotic therapy, respectively.

Conclusion: The estimated time required for human resources performing extensive ASP activities on all hospitalized patients undergoing antibiotic therapy in Korean hospitals was ~1.20 FTEs (IQR, 1.02-1.38) per 100 beds.
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http://dx.doi.org/10.1017/ice.2020.1234DOI Listing
December 2020

Recovery of Tenofovir-induced Nephrotoxicity following Switch from Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide in Human Immunodeficiency Virus-Positive Patients.

Infect Chemother 2020 Sep 16;52(3):381-388. Epub 2020 Jul 16.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.

Background: Tenofovir disoproxil fumarate (TDF)-induced nephrotoxicity is related to high plasma tenofovir concentrations. Tenofovir alafenamide (TAF) is a tenofovir prodrug with 90% lower plasma tenofovir concentrations. The aim of this study was to evaluate changes in tenofovir-induced nephrotoxicity in Human Immunodeficiency Virus (HIV)-positive patients who switched from TDF to TAF.

Materials And Methods: We identified all HIV-positive patients who switched from elvitegravir/cobicistat/emtricitabine/TDF to elvitegravir/cobicistat/emtricitabine/TAF at a tertiary hospital. We assessed tubulopathy and renal dysfunction before TDF administration, at the time TAF was used following at least 3 months of TDF use, and 3 months after TAF administration. Tubulopathy was defined by the presence of at least three abnormalities in fractional excretion of phosphate, fractional excretion of uric acid, urinary β2-microglobulin, urinary N-acetyl-β-D-glucosaminidase, glucosuria or proteinuria. Renal dysfunction was defined as decreased by more than 25% in the estimated glomerular filtration rate (eGFR) relative to baseline.

Results: In 80 patients, the mean eGFR was 96.8 mL/min/1.73 m² before administration of TDF, 81.2 ( <0.001) at the time of change to TAF, 90.9 ( <0.001) after TAF administration. Renal dysfunction occurred in 19 patients (23.8%) after TDF use for a median 15 months, 11 (57.9%) of these patients recovered from renal dysfunction after TAF administration. Six patients (7.5%) had tubulopathy before TDF administration, 36 (45.0%) after TDF administration ( <0.001), 12 (15.0%) after TAF administration ( = 0.002).

Conclusion: Tenofovir-induced nephrotoxicity in HIV-positive patients receiving TDF was mostly reversible after changing to TAF. Thus, TAF-containing regimens can be administered safely to HIV-positive patients with tenofovir-induced nephrotoxicity.
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http://dx.doi.org/10.3947/ic.2020.52.3.381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533205PMC
September 2020

Clinical Score System to Differentiate Severe Fever with Thrombocytopenia Syndrome Patients from Patients with Scrub Typhus or Hemorrhagic Fever with Renal Syndrome in Korea.

J Korean Med Sci 2020 Mar 23;35(11):e77. Epub 2020 Mar 23.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.

Background: Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with high mortality in East Asia. This study aimed to develop, for primary care providers, a prediction score using initial symptoms and basic laboratory blood tests to differentiate between SFTS and other endemic zoonoses in Korea.

Methods: Patients aged ≥ 18 years diagnosed with endemic zoonoses during a 3-year period (between January 2015 and December 2017) were retrospectively enrolled from 4 tertiary university hospitals. A prediction score was built based on multivariate logistic regression analyses.

Results: Of 84 patients, 35 with SFTS and 49 with other endemic zoonoses were enrolled. In multivariate logistic regression analysis, independent predictors of SFTS included neurologic symptoms (odds ratio [OR], 12.915; 95% confidence interval [CI], 2.173-76.747), diarrhea (OR, 10.306; 95% CI, 1.588-66.895), leukopenia (< 4,000/mm³) (OR, 19.400; 95% CI, 3.290-114.408), and normal C-reactive protein (< 0.5 mg/dL) (OR, 24.739; 95% CI, 1.812-337.742). We set up a prediction score by assigning one point to each of these four predictors. A score of ≥ 2 had 82.9% sensitivity (95% CI, 71.7%-87.5%) and 95.9% specificity (95% CI, 88.0%-99.2%). The area under the curve of the clinical prediction score was 0.950 (95% CI, 0.903-0.997).

Conclusion: This study finding suggests a simple and useful scoring system to predict SFTS in patients with endemic zoonoses. We expect this strategic approach to facilitate early differentiation of SFTS from other endemic zoonoses, especially by primary care providers, and to improve the clinical outcomes.
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http://dx.doi.org/10.3346/jkms.2020.35.e77DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7086083PMC
March 2020

Antagonistic Effect of Colistin on Vancomycin Activity against Methicillin-Resistant Staphylococcus aureus in and Studies.

Antimicrob Agents Chemother 2020 03 24;64(4). Epub 2020 Mar 24.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

As concerns arise that the vancomycin MIC of methicillin-resistant (MRSA) could be increased by concurrent colistin administration, we evaluated the effect of colistin on vancomycin efficacy against MRSA via and studies. Among MRSA blood isolates collected in a tertiary-care hospital, we selected representative strains from community-associated MRSA strains (CA-MRSA; ST72-MRSA-SCC IV) and hospital-acquired MRSA strains (HA-MRSA; ST5-MRSA-SCC II). USA CA-MRSA (USA300), HA-MRSA (USA100), N315 (New York/Japan clone), and a MRSA standard strain (ATCC 43300) were used for comparison. We performed checkerboard assays to identify changes in the vancomycin MIC of MRSA following colistin exposure and evaluated the effect of a vancomycin-colistin combination using time-kill assays. We also assessed the antagonistic effect by administering vancomycin, colistin, and a combination of these two in a neutropenic murine thigh infection model. In the checkerboard assays, vancomycin MICs of all MRSA strains except N315 were increased by from 0.25 to 0.75 μg/ml following colistin exposure. However, the time-kill assays indicated antagonism only against ST5-MRSA and USA100, when the vancomycin concentration was twice the MIC. In the murine thigh infection model with ST5-MRSA and USA100, vancomycin monotherapy reduced the number of CFU/muscle >1 log compared to a combination treatment after 24 h in ST5-MRSA, indicating an antagonistic effect of colistin on vancomycin treatment. This study suggests that exposure to colistin may reduce the susceptibility to vancomycin of certain MRSA strains. Combination therapy with vancomycin and colistin for multidrug-resistant pathogens might result in treatment failure for concurrent MRSA infection.
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http://dx.doi.org/10.1128/AAC.01925-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179267PMC
March 2020

Delays in Isolating Patients Admitted to Hospital with Pulmonary Tuberculosis in Korea.

J Korean Med Sci 2019 Nov 11;34(43):e270. Epub 2019 Nov 11.

Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.

Background: Delays in isolating patients admitted to hospital with active pulmonary tuberculosis (PTB) can contribute to nosocomial transmission; however, in Korea, patients with clinically diagnosed PTB are not routinely isolated while awaiting microbiological confirmation of the diagnosis. We aimed to assess the extent of delays in isolating patients admitted with PTB and to identify the factors associated with delayed isolation.

Methods: We retrospectively reviewed the electronic medical records of patients aged ≥ 18 years with active PTB, between January 2008 and December 2017, from two Korean hospitals.

Results: Among 1,062 patients, 612 (57.6%) were not isolated on admission day. The median time from admission to isolation was 1 day (interquartile range: 0-2 days). The independent risk factor most strongly associated with delayed isolation was admission to departments other than pulmonology or infectious diseases departments (adjusted odds ratio [aOR], 5.302; 95% confidence interval [CI], 3.177-8.847; < 0.001). Factors associated with isolation on admission day were a past history of tuberculosis (TB) (aOR, 0.669; 95% CI, 0.494-0.906; = 0.009), night sweats (aOR, 0.530; 95% CI, 0.330-0.851; = 0.009), and apical infiltrates on chest radiographs (aOR, 0.452; 95% CI, 0.276-0.740; = 0.002).

Conclusion: Concerning patients subsequently diagnosed with active PTB, > 50% were not isolated on admission day. We suggest that the patients with clinically suspected PTB including the elderly who have a past history of TB, night sweats, or apical infiltration on chest radiographs, be presumptively isolated on admission, without waiting for microbiological confirmation of the diagnosis.
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http://dx.doi.org/10.3346/jkms.2019.34.e270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6838606PMC
November 2019

Immunogenicity of Influenza Vaccination in Patients with Cancer Receiving Immune Checkpoint Inhibitors.

Clin Infect Dis 2020 07;71(2):422-425

Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.

Among prospectively enrolled adult patients with cancer receiving immune checkpoint inhibitors (ICIs; n = 46) or cytotoxic agents (n = 90), seroprotection and seroconversion rates after seasonal quadrivalent influenza vaccinations were higher with ICI than with cytotoxic chemotherapy. These results support annual influenza vaccinations for cancer patients receiving ICIs. Clinical Trials Registration clinicaltrials.gov (NCT03590808).
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http://dx.doi.org/10.1093/cid/ciz1092DOI Listing
July 2020

Ongoing outbreak of human adenovirus-associated acute respiratory illness in the Republic of Korea military, 2013 to 2018.

Korean J Intern Med 2021 01 5;36(1):205-213. Epub 2019 Sep 5.

Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background/aims: Human adenovirus type 55 (HAdV-55), an emerging epidemic strain, has caused several large outbreaks in the Korean military since 2014, and HAdV-associated acute respiratory illness (HAdV-ARI) has been continuously reported thereafter.

Methods: To evaluate the epidemiologic characteristics of HAdV-ARI in the Korean military, we analyzed respiratory virus polymerase chain reaction (RV-PCR) results, pneumonia surveillance results, and severe HAdV cases from all 14 Korean military hospitals from January 2013 to May 2018 and compared these data with nationwide RV surveillance data for the civilian population.

Results: A total of 14,630 RV-PCRs was performed at military hospitals. HAdV (45.4%) was the most frequently detected RV, followed by human rhinovirus (12.3%) and influenza virus (6.3%). The percentage of the military positive for HAdV was significantly greater than the percentage of civilians positive for HAdV throughout the study period, with a large outbreak occurring during the winter to spring of 2014 to 2015. The outbreak continued until the end of the study, and non-seasonal detections increased over time. The reported number of pneumonia patients also increased during the outbreak. Case fatality rate was 0.075% overall but 15.6% in patients with respiratory failure. The proportion of severe patients did not change significantly during the study period.

Conclusion: A large HAdV outbreak is currently ongoing in the Korean military, with a trend away from seasonality, and HAdV-55 is likely the predominant strain. Persistent efforts to control the outbreak, HAdV type-specific surveillance, and vaccine development are required.
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http://dx.doi.org/10.3904/kjim.2019.092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7820655PMC
January 2021

Therapeutic outcome of spinal implant infections caused by Staphylococcus aureus: A retrospective observational study.

Medicine (Baltimore) 2018 Oct;97(40):e12629

Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul.

Spinal implant infection is a rare but significant complication of spinal fusion surgery, and the most common pathogen is Staphylococcus aureus. It is difficult to treat due to this pathogen's biofilm-forming ability and antibiotic resistance. We evaluated the therapeutic outcome of treatments for S aureus spinal implant infections. We retrospectively reviewed all patients with S aureus spinal implant infections at 11 tertiary-care hospitals over a 9-year period. Parameters predictive of treatment failure and recurrence were analyzed by Cox regression. Of the 102 patients with infections, 76 (75%) were caused by methicillin-resistant S aureus (MRSA) and 51 (50%) were late-onset infections. In all, 83 (81%) patients were managed by debridement, antibiotics, and implant retention (DAIR) and 19 (19%) had their implants removed. The median duration of all antibiotic therapies was 52 days. During a median follow-up period of 32 months, treatment failure occurred in 37 (36%) cases. The median time to treatment failure was 113 days, being <1 year in 30 (81%) patients. DAIR (adjusted hazard ratio [aHR], 6.27; P = .01) and MRSA infection (aHR, 4.07; P = .009) were independently associated with treatment failure. Rifampin-based combination treatments exhibited independent protective effects on recurrence (aHR, 0.23; P = .02). In conclusion, among patients with S aureus spinal implant infections, MRSA and DAIR were independent risk factors for treatment failure, and these risk factors were present in the majority of patients. In this difficult-to-treat population, the overall treatment failure rate was 36%; rifampin may improve the outcomes of patients with S aureus spinal implant infections.
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http://dx.doi.org/10.1097/MD.0000000000012629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200525PMC
October 2018

Evaluation of Methicillin-Resistance Rates among Community-associated Infections in Korean Military Personnel.

J Korean Med Sci 2018 Sep 21;33(39):e250. Epub 2018 Aug 21.

Division of Infectious Diseases, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea.

To evaluate methicillin-resistance (MR) rates among community-associated (CA) infections in the Korean military, we screened electronic medical records of 223 patients with infection in a military referral hospital from 2012 to 2017. During the study period, MR rates did not change annually, and were not different between officers and conscripted personnel. Among conscripted personnel, MR rates in CA infections did not increase with longer duration of military service, both in trend analysis and multivariate analysis. In conclusion, MR rates among CA infections did not increase during military service in Korea.
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http://dx.doi.org/10.3346/jkms.2018.33.e250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6146148PMC
September 2018

Protective Effectiveness of Inactivated Hantavirus Vaccine Against Hemorrhagic Fever With Renal Syndrome.

J Infect Dis 2018 04;217(9):1417-1420

Division of Infectious Diseases, Department of Medicine, Armed Forces Capital Hospital, Seongnam.

As there is no effective treatment against hemorrhagic fever with renal syndrome (HFRS), the development of effective vaccine is important. An inactivated hantavirus vaccine (IHV) has been used in Korea, but there has been controversy regarding its effectiveness. We conducted a case-control study to evaluate the vaccine effectiveness (VE) of IHV against HFRS in the Korean military. Unadjusted and adjusted VEs of IHV were 59.1% and 58.9%, respectively. VE was higher in divisions with high incidence of HFRS (unadjusted VE, 71.4%; adjusted VE, 78.7%). Our study demonstrated the moderate effectiveness of IHV in high-risk populations residing in endemic area.
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http://dx.doi.org/10.1093/infdis/jiy037DOI Listing
April 2018

Incidence and risk factors of postoperative pneumonia following cancer surgery in adult patients with selected solid cancer: results of "Cancer POP" study.

Cancer Med 2018 01 22;7(1):261-269. Epub 2017 Dec 22.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

The aim of this study was to investigate the incidence and risk factors of postoperative pneumonia (POP) within 1 year after cancer surgery in patients with the five most common cancers (gastric, colorectal, lung, breast cancer, and hepatocellular carcinoma [HCC]) in South Korea. This was a multicenter and retrospective cohort study performed at five nationwide cancer centers. The number of cancer patients in each center was allocated by the proportion of cancer surgery. Adult patients were randomly selected according to the allocated number, among those who underwent cancer surgery from January to December 2014 within 6 months after diagnosis of cancer. One-year cumulative incidence of POP was estimated using Kaplan-Meier analysis. An univariable Cox's proportional hazard regression analysis was performed to identify risk factors for POP development. As a multivariable analysis, confounders were adjusted using multiple Cox's PH regression model. Among the total 2000 patients, the numbers of patients with gastric cancer, colorectal cancer, lung cancer, breast cancer, and HCC were 497 (25%), 525 (26%), 277 (14%), 552 (28%), and 149 (7%), respectively. Overall, the 1-year cumulative incidence of POP was 2.0% (95% CI, 1.4-2.6). The 1-year cumulative incidences in each cancer were as follows: lung 8.0%, gastric 1.8%, colorectal 1.0%, HCC 0.7%, and breast 0.4%. In multivariable analysis, older age, higher Charlson comorbidity index (CCI) score, ulcer disease, history of pneumonia, and smoking were related with POP development. In conclusions, the 1-year cumulative incidence of POP in the five most common cancers was 2%. Older age, higher CCI scores, smoker, ulcer disease, and previous pneumonia history increased the risk of POP development in cancer patients.
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http://dx.doi.org/10.1002/cam4.1259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5773948PMC
January 2018

Epidemiology and Clinical Characteristics of Zika Virus Infections Imported into Korea from March to October 2016.

J Korean Med Sci 2017 Sep;32(9):1440-1444

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.

Zika is a re-emerging, mosquito-borne viral infection, which has been recently shown to cause microcephaly and Guillain-Barré syndrome. Since 2015 the number of infected patients has increased significantly in South America. The purpose of this study was to identify the epidemiologic and clinical characteristics of patients with Zika virus (ZIKV) infections in Korea. Patients who had visited areas of risk and tested positive in the ZIKV reverse transcriptase polymerase chain reaction (RT-PCR) in blood, urine, or saliva specimens were included. The first Korean case of ZIKV infection was reported in March 2016, and 14 cases had been reported by October 2016. The median age of the patients was 34 years (19-64 years). Ten patients had been exposed in Southeast Asia and 4 in Latin America. Rash was the most common symptom (92.9%; 13/14), followed by myalgia (50.0%; 7/14), and arthralgia (28.6%, 4/14). There were no neurologic abnormalities and none of the patients was pregnant. Results of biochemical tests were normal. Positivity rates of RT-PCR for ZIKV in serum, urine, and saliva were 53.8%, 100.0%, and 83.3%, respectively in the first week of symptoms. In conclusion, 14 patients with ZIKV infections were reported in Korea by October 2016 and all of them had mild clinical symptoms.
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http://dx.doi.org/10.3346/jkms.2017.32.9.1440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546962PMC
September 2017

Olecranon Osteomyelitis due to Actinomyces meyeri: Report of a Culture-Proven Case.

Infect Chemother 2016 Sep 2;48(3):234-238. Epub 2016 Sep 2.

Division of Infectious Diseases, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.

Actinomyces meyeri is a Gram positive, strict anaerobic bacterium, which was first described by Meyer in 1911. Primary actinomycotic osteomyelitis is rare and primarily affects the cervicofacial region, including mandible. We present an unusual case of osteomyelitis of a long bone combined with myoabscess due to A. meyeri. A 70-year-old man was admitted for pain and pus discharge of the right elbow. Twenty-five days before admission, he had hit his elbow against a table. MRI of the elbow showed a partial tear of the distal triceps tendon and myositis. He underwent open debridement and partial bone resection for the osteomyelitis of the olecranon. Biopsy showed no sulfur granules, but acute and chronic osteomyelitis. The excised tissue grew A. meyeri and Peptoniphilus asaccharolyticus. Intravenous ceftriaxone was administered and switched to oral amoxicillin. Infection of the extremities of actinomycosis often poses diagnostic difficulties, but it should not be neglected even when the characteristic pathologic findings are not present.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5048008PMC
http://dx.doi.org/10.3947/ic.2016.48.3.234DOI Listing
September 2016

Erratum: Nocardia Brain Abscess in an Immunocompetent Patient.

Infect Chemother 2015 Dec 30;47(4):304. Epub 2015 Dec 30.

Department of Internal Medicine, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea.

[This corrects the article on p. 45 in vol. 46, PMID: 24693470.].
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http://dx.doi.org/10.3947/ic.2015.47.4.304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716284PMC
December 2015

Erratum: A Case of Acute Pyogenic Sacroiliitis and Bacteremia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus.

Infect Chemother 2015 Dec 30;47(4):303. Epub 2015 Dec 30.

Division of Infectious Disease, Gachon University Gil Medical Center, Incheon, Korea.

[This corrects the article on p. 441 in vol. 45, PMID: 24475359.].
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http://dx.doi.org/10.3947/ic.2015.47.4.303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716283PMC
December 2015

CAPD peritonitis caused by co-infection with Cellulosimicrobium cellulans (Oerskovia xanthineolytica) and Enterobacter cloacae: a case report and literature review.

Intern Med 2015 15;54(6):627-30. Epub 2015 Jan 15.

Department of Internal Medicine, Kyung Hee University School of Medicine, Korea.

A 50-year-old woman with end-stage renal disease on continuous ambulatory peritoneal dialysis was admitted with abdominal pain, fever and cloudy peritoneal fluid. The diagnosis was peritonitis, and the causative bacteria were Cellulosimicrobium cellulans and Enterobacter cloacae. She was subsequently treated with the administration of intraperitoneal antibiotics and removal of the infected indwelling catheter. We herein report a case of Cellulosimicrobium cellulans and Enterobacter cloacae co-infection in a patient with peritonitis and review the relevant literature.
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http://dx.doi.org/10.2169/internalmedicine.54.3261DOI Listing
September 2015

Therapeutic outcomes of hematogenous vertebral osteomyelitis with instrumented surgery.

Clin Infect Dis 2015 May 6;60(9):1330-8. Epub 2015 Feb 6.

Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju.

Background: Patients with hematogenous vertebral osteomyelitis (HVO) occasionally require instrumentation for spinal stabilization. However, placing instrumentation in the setting of spinal infection raises concerns about recurrent infection due to bacteria adhering to the foreign material. In this study, we evaluated the therapeutic outcomes of patients with HVO who underwent instrumented surgery.

Methods: We conducted a retrospective chart review of adult patients with microbiologically diagnosed HVO who underwent surgical intervention in 5 tertiary care hospitals over an 8-year period.

Results: A total of 153 patients with HVO underwent surgical management for their infections. Of these 153 patients, 94 (61.4%) underwent surgical debridement alone (noninstrumented surgery) and 59 (38.6%) underwent surgical debridement and instrumentation (instrumented surgery). The median durations of antibiotic therapy were 66 and 80 days for the noninstrumentation and instrumentation groups, respectively (P = .22). Clinical outcomes were similar between the groups, including rates of infection-related death (2.1% vs 0%; P = .52), primary failure (1.1% vs 5.1%; P = .30), and recurrence (4.8% vs 6.8%; P = .72). Among the instrumentation group, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 22.2% (4-6 weeks), 9.1% (6-8 weeks), and 2.6% (≥ 8 weeks; P = .04). Duration of pre-instrumentation antibiotic therapy and single-stage operation (vs 2-stage operation) were not risk factors for recurrence.

Conclusions: Spinal instrumentation in patients with HVO may be safe with pathogen-directed prolonged antibiotic therapy and should not be abandoned or delayed solely because of the risk of recurrence.
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http://dx.doi.org/10.1093/cid/civ066DOI Listing
May 2015

Comparison of clinical manifestations, outcomes and cerebrospinal fluid findings between herpes simplex type 1 and type 2 central nervous system infections in adults.

J Med Virol 2014 Oct 5;86(10):1766-71. Epub 2014 Jul 5.

Department of Infectious Diseases, Gachon University Gil Hospital, Incheon, Republic of Korea.

In previous reports on the viral causes of central nervous system (CNS) infections, it has been generally recognized that HSV-1 is a major cause of encephalitis, while HSV-2 is the predominant cause of aseptic meningitis in adults. To examine this matter, the clinical characteristics in the two types of HSV CNS infections were investigated. In a retrospective cohort study which included all adult patients (≥16 years) between January 1999 and December 2013 in a 2,700-bed tertiary care hospital, all the patients in whom PCR of the CSF for HSV was positive were identified. Ninety-five patients with positive CSF PCR results for HSV were included, 21 with HSV-1 and 74 with HSV-2. Many patients with HSV-1 had encephalitis (13/21, 61.9%), whereas most patients with HSV-2 had meningitis (62/74, 83.8%). However, HSV-1 and HSV-2 accounted for similar proportion of patients with HSV encephalitis (13/25, 52.0% vs. 12/25, 48.0%). Neurological sequelae were more frequent among patients with HSV-1 (9/21, 42.9% vs. 6/74, 8.1%; P = 0.001). The present study suggests that HSV-2 is not only a major cause of aseptic meningitis, but also it may cause serious manifestation as HSV-1 encephalitis in adults.
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http://dx.doi.org/10.1002/jmv.23999DOI Listing
October 2014

Nocardia brain abscess in an immunocompetent patient.

Infect Chemother 2014 Mar 21;46(1):45-9. Epub 2014 Mar 21.

Department of Internal Medicine, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea.

Nocardia cerebral abscess is rare, constituting approximately 1-2% of all cerebral abscesses. Mortality for a cerebral abscess of Nocardia is three times higher than that of other bacterial cerebral abscesses, therefore, early diagnosis and therapy is important. Nocardia cerebral abscess is generally occur among immunocompromised patients, and critical infection in immunocompetent patients is extremely rare. We report on a case of a brain abscess by Nocardia farcinica in an immunocompetent patient who received treatment with surgery and antibiotics. This is the second case of a brain abscess caused by N. farcinica in an immunocompetent patient in Korea.
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http://dx.doi.org/10.3947/ic.2014.46.1.45DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970313PMC
March 2014

A Case of Acute Pyogenic Sacroiliitis and Bacteremia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus.

Infect Chemother 2013 Dec 27;45(4):441-5. Epub 2013 Dec 27.

Division of Infectious Disease, Gachon University Gil Medical Center, Incheon, Korea.

Pyogenic sacroiliitis is a rare osteoarticular infection, occurring most frequently in children and young adults. Diagnosis of the disease is challenging because of a general lack of awareness of the disease and its nonspecific signs and symptoms. Staphylococcus aureus is the most common causative bacteria in pyogenic sacroiliitis. Methicillin-resistant S. aureus (MRSA) has typically been considered a hospital-associated pathogen; however, community-acquired (CA)-MRSA infections are becoming increasingly common in Korea. We report the first domestic case of acute pyogenic sacroiliitis with abscess and bacteremia caused by CA-MRSA. The pathogen carried the type IV-A staphylococcal cassette chromosome mec (SCCmec) without the Panton-Valentine leukocidin (PVL) gene, and was identified as sequence type (ST) 72 by multilocus sequence typing.
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http://dx.doi.org/10.3947/ic.2013.45.4.441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902811PMC
December 2013

Living donor and recipient screening for latent tuberculosis infection by tuberculin skin test and interferon-gamma releasing assay in a country with an intermediate burden of tuberculosis.

J Infect Chemother 2013 Oct 7;19(5):1009-13. Epub 2013 Aug 7.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Republic of Korea.

There are few data on donor screening for latent tuberculosis infection (LTBI) using the tuberculin skin test (TST) and interferon-gamma releasing assay (IGRA). In South Korea, most renal allografts involve living donors (average, 80%). Hence, we have an opportunity to evaluate donor and recipient screening for LTBI by TST and IGRA. All donors and recipients admitted for kidney transplantation during a 20-month period were evaluated prospectively by using TST and Mycobacterium tuberculosis-specific enzyme-linked immunosorbent spot (ELISPOT) assay. The study population consisted of 205 living donor-recipient pairs (≥16 years) including 15 (7%) who yielded indeterminate donor or recipient ELISPOT results. Of the 205 donors, 63 (31%) gave a positive TST ≥5 mm, 33 (16%) a positive TST ≥10 mm, and 96 (47%) a positive ELISPOT. Of the 205 recipients, 9 (5%) gave a positive TST ≥5 mm, 3 (2%) a positive TST ≥10 mm, and 79 (39%) had a positive ELISPOT. Of the 205 donor-recipient pairs, only 59 (29%) gave negative donor and recipient ELISPOT results and 139 (68%) negative donor and recipient TSTs (<5 mm) (P < 0.001). One third of donor-recipient pairs tends to be positive in the TST, and two thirds of the donor-recipient pairs tends to be positive in the ELISPOT. Given the high positive rate of LTBI obtained by screening donors, further studies on the clinical value of solid organ transplant donors with positive TST or ELISPOT and health economics analysis in countries with intermediate burden of TB are needed for policy decisions on isoniazid (INH) prophylaxis.
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http://dx.doi.org/10.1007/s10156-013-0578-9DOI Listing
October 2013

Comparison of characteristics of bacterial bloodstream infection between adult patients with allogeneic and autologous hematopoietic stem cell transplantation.

Biol Blood Marrow Transplant 2013 Jun 6;19(6):994-9. Epub 2013 Apr 6.

Division of Hematology and Medical Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Republic of Korea.

Although autologous and allogeneic hematopoietic stem cell transplantation (HSCT) are fundamentally different procedures, a tailored approach to bacterial bloodstream infection (BSI) according to the type of HSCT has not yet been suggested. We evaluated the characteristics of BSI after HSCT, with a focus on comparison of BSIs between recipients of autologous HSCT (auto-HSCT) and allogeneic HSCT (allo-HSCT). Among 134 patients (59 received allo-HSCT and 75 received auto-HSCT) who underwent HSCT, BSIs were reported earlier in patients who underwent auto-HSCT, compared with those who underwent allo-HSCT (mean 12.1 ± 3.4 days versus 32.8 ± 27.1 days, P = .006). Among patients receiving allo-HSCT, postneutrophil-engraftment bacterial BSI showed an association with grade ≥ 2 acute graft-versus-host disease (GVHD). In patients who underwent auto-HSCT, results of multivariate analysis showed that not receiving prophylactic antibiotics (P = .004) and having elevated serum C-reactive protein (P = .034) were risk factors of BSI. Elevated CRP (P = .01) and acute GVHD ≥ grade 2 (P = .002) were independent risk factors in patients who underwent allo-HSCT. Those differences originated mainly from the impact of acute GVHD-related postengraftment BSIs of patients who underwent allo-HSCT. To establish the best defense strategy against BSI, the distinctive natures of bacterial BSI after HSCT between auto-HSCT and allo-HSCT should be considered.
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http://dx.doi.org/10.1016/j.bbmt.2013.03.019DOI Listing
June 2013

Treatment duration for uncomplicated Staphylococcus aureus bacteremia to prevent relapse: analysis of a prospective observational cohort study.

Antimicrob Agents Chemother 2013 Mar 17;57(3):1150-6. Epub 2012 Dec 17.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Practice guidelines recommend at least 14 days of antibiotic therapy for uncomplicated Staphylococcus aureus bacteremia (SAB). However, these recommendations have not been formally evaluated in clinical studies. To evaluate the duration of therapy for uncomplicated SAB, we analyzed data from our prospective cohort of patients with SAB. A prospective observational cohort study was performed in patients with SAB at a tertiary-care hospital in Korea between August 2008 and September 2010. All adult patients with SAB were prospectively enrolled and observed over a 12-week period. Uncomplicated SAB was defined as follows: negative results of follow-up blood cultures at 2 to 4 days, defervescence within 72 h of therapy, no evidence of metastatic infection, and catheter-related bloodstream infection or primary bacteremia without evidence of endocarditis on echocardiography. Of 483 patients with SAB, 111 met the study criteria for uncomplicated SAB. Fifty-three (47.7%) had methicillin-resistant SAB. When short-course therapy (<14 days) and intermediate-course therapy (≥14 days) were compared, the treatment failure rates (10/38 [26.3%] versus 16/73 [21.9%]) and crude mortality (7/38 [18.4%] versus 16/73 [21.9%]) did not differ significantly between the two groups. However, short-course therapy was significantly associated with relapse (3/38 [7.9%] versus 0/73; P = 0.036). In multivariate analysis, primary bacteremia was associated with a trend toward increased treatment failure (P = 0.06). Therefore, in the treatment of uncomplicated SAB, it seems reasonable to consider at least 14 days of antibiotic therapy to prevent relapse, as practice guidelines recommend. Because of its poor prognosis, primary bacteremia, even with a low risk of complication, should not be treated with short-course therapy.
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http://dx.doi.org/10.1128/AAC.01021-12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591920PMC
March 2013

Impact of adequate empirical combination therapy on mortality from bacteremic Pseudomonas aeruginosa pneumonia.

BMC Infect Dis 2012 Nov 16;12:308. Epub 2012 Nov 16.

Departments of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul, Republic of Korea.

Background: Pseudomonas aeruginosa has gained an increasing amount of attention in the treatment of patients with pneumonia. However, the benefit of empirical combination therapy for pneumonia remains unclear. We evaluated the effects of adequate empirical combination therapy and multidrug-resistance in bacteremic Pseudomonas pneumonia on the mortality.

Methods: A retrospective cohort study was performed at the 2,700-bed tertiary care university hospital. We reviewed the medical records of patients with bacteremic pneumonia between January 1997 and February 2011. Patients who received either inappropriate or appropriate empirical therapy were compared by using marginal structural model. Furthermore, we investigated the direct impact of combination therapy on clinical outcomes in patients with monomicrobial bacteremic pneumonia.

Results: Among 100 consecutive patients with bacteremic Pseudomonas pneumonia, 65 patients were classified in the adequate empirical therapy group, 32 of whom received monotherapy and 33 combination therapy. In the marginal structural model, only inadequate therapy was significantly associated with 28-day mortality (p = 0.02), and multidrug-resistance was not a significant risk factor.To examine further the direct impact of combination therapy, we performed a subgroup analysis of the 65 patients who received adequate therapy. Multivariate logistic regression analysis identified absence of septic shock at the time of bacteremia (OR, 0.07; 95% CI, 0.01-0.49; p = 0.008), and adequate combination therapy (OR, 0.05; 95% CI, 0.01-0.34; p = 0.002) as variables independently associated with decreased all-cause 28-day mortality.

Conclusions: Our study suggests that adequate empirical combination therapy can decrease mortality in patients with bacteremic Pseudomonas pneumonia.
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http://dx.doi.org/10.1186/1471-2334-12-308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3519646PMC
November 2012

Persistent catheter-related Staphylococcus aureus bacteremia after catheter removal and initiation of antimicrobial therapy.

PLoS One 2012 24;7(10):e46389. Epub 2012 Oct 24.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Objectives: Catheter-related Staphylococcus aureus bacteremia (CRSAB) occasionally persists despite catheter removal and initiation of appropriate antimicrobial therapy. The aim of this study was to determine the incidence, risk factors, and outcomes of persistent CRSAB after catheter removal and initiation of antimicrobial therapy.

Methods: Consecutive patients with CRSAB were prospectively included from over a 41-month period. We compared the clinical features, 40 bacterial virulence genes, and outcomes between patients with persistent CRSAB (i.e., bacteremia for >3 days after catheter removal and initiation of appropriate antimicrobial therapy) and non-persistent CRSAB.

Results: Among the 220 episodes of CRSAB, the catheter was kept in place in 17 (6%) and removed in 203 (94%) cases. In 43 (21%) of the 203 episodes, bacteremia persisted for >3 days after catheter removal and initiation of antimicrobial therapy. Methicillin resistance (Odds ratio [OR], 9.01; 95% confidence interval [CI], 3.05-26.61; P<0.001), non-catheter prosthetic devices (OR, 5.37; 95% CI, 1.62-17.80; P=0.006), and renal failure (OR, 3.23; 95% CI, 1.48-7.08; P=0.003) were independently associated with persistent CRSAB. Patients with persistent CRSAB were more like to experience complication than were those with non-persistent CRSAB (72% vs. 15%; P<0.001). Among all episodes due to methicillin-resistant S. aureus, persistent CRSAB isolates were associated with accessory gene regulator (agr) group II (P= .04), but presence of other bacterial virulence genes, distribution of vancomycin minimum inhibitory concentration distribution, and frequency of vancomycin heteroresistance did not differ between the groups.

Conclusions: In patients with CRSAB, bacteremia persisted in 21% of cases despite catheter removal and initiation of antimicrobial therapy. Methicillin resistance, renal failure, and non-catheter prosthetic devices were independent risk factors for persistent CRSAB, which was associated with a higher rate of complications.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0046389PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480347PMC
April 2013

Efficacy of linezolid-based salvage therapy compared with glycopeptide-based therapy in patients with persistent methicillin-resistant Staphylococcus aureus bacteremia.

J Infect 2012 Dec 14;65(6):505-12. Epub 2012 Aug 14.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Objective: We evaluated the efficacy of linezolid-based salvage therapy compared with glycopeptide-based therapy in patients with persistent (≥7 days) methicillin-resistant Staphylococcus aureus bacteremia (MRSA-B).

Methods: All patients with MRSA-B during 2-year period at a tertiary-care hospital were prospectively enrolled. Linezolid-based salvage therapy was classified if patients switched glycopeptides to linezolid with/without carbapenem due to persistent MRSA-B. Covariate adjustment using the propensity score and inverse probability of treatment weighting (IPTW) using the propensity score were performed to control for bias in treatment assignment.

Results: Of 377 patients with MRSA-B, 90 with persistent MRSA-B were included. Of these, 38 (42%) were classified as linezolid-based salvage group and the remaining 52 (58%) as glycopeptide-based therapy group. The duration of persistent bacteremia (median 16 days vs. 10 days; P = 0.008) was longer in linezolid-based salvage group than in the comparator. However, the 30-day mortality (11% vs. 25%; P = 0.08) had a trend toward being lower in linezolid-based salvage group than those in the comparator. Logistic regression models with covariate adjustment and IPTW using propensity scores also revealed that linezolid-based salvage showed a trend toward having better outcome than the comparator, although this did not reach any statistically significance (OR 0.31; 95% CI 0.03-2.95 and OR 0.19; 95% CI 0.01-3.39, respectively).

Conclusions: While having worse prognostic factors compared with glycopeptide-based therapy, linezolid-based salvage therapy revealed a trend toward better outcomes than the comparator. Our data suggest that linezolid-based salvage therapy would be considered in patients with persistent MRSA-B despite the use of glycopeptides therapy.
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http://dx.doi.org/10.1016/j.jinf.2012.08.007DOI Listing
December 2012

Viral infection in patients with severe pneumonia requiring intensive care unit admission.

Am J Respir Crit Care Med 2012 Aug 14;186(4):325-32. Epub 2012 Jun 14.

Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Rationale: The role of viruses in pneumonia in adults and the impact of viral infection on mortality have not been elucidated. Previous studies have significant limitations in that they relied predominantly on upper respiratory specimens.

Objectives: To investigate the role of viral infection in adult patients with pneumonia requiring intensive care unit (ICU) admission.

Methods: A retrospective analysis of a prospective cohort was conducted in a 28-bed medical ICU. Patients with severe community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) were included in the study.

Measurements And Main Results: A total of 198 patients (64 with CAP, 134 with HCAP) were included for analysis. Of these, 115 patients (58.1%) underwent bronchoscopic bronchoalveolar lavage (BAL), 104 of whom were tested for respiratory viruses by BAL fluid reverse-transcription polymerase chain reaction (RT-PCR). Nasopharyngeal specimen RT-PCR was performed in 159 patients (84.1%). Seventy-one patients (35.9%) had a bacterial infection, and 72 patients (36.4%) had a viral infection. Rhinovirus was the most common identified virus (23.6%), followed by parainfluenza virus (20.8%), human metapneumovirus (18.1%), influenza virus (16.7%), and respiratory syncytial virus (13.9%). Respiratory syncytial virus was significantly more common in the CAP group (CAP, 10.9%; HCAP, 2.2%; P = 0.01). The mortalities of patients with bacterial infections, viral infections, and bacterial-viral coinfections were not significantly different (25.5, 26.5, and 33.3%, respectively; P = 0.82).

Conclusions: Viruses are frequently found in the airway of patients with pneumonia requiring ICU admission and may cause severe forms of pneumonia. Patients with viral infection and bacterial infection had comparable mortality rates.
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http://dx.doi.org/10.1164/rccm.201112-2240OCDOI Listing
August 2012
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