Jong Hoo Lee

Clinical characteristics of nursing home-acquired pneumonia in elderly patients admitted to a Korean teaching hospital

Background/Aims: Nursing home-acquired pneumonia (NHAP) is included under healthcare-associated pneumonia. However, the optimal treatment strategy for NHAP has been controversial in several studies. We evaluated the clinical features of NHAP compared to community-acquired pneumonia (CAP) in elderly patients admitted with pneumonia. Methods: This was a retrospective study in elderly patients aged ≥ 65 years with NHAP or CAP who were hospitalized at Jeju National University Hospital between January 2012 and April 2013. Results: A total of 209 patients were enrolled, and 58 (27.7%) had NHAP. The patients with NHAP were older, had more frequent central nervous system disorders, and showed worse clinical parameters. Potential drug-resistant pathogens were more frequently detected in the NHAP group (22.4% vs. 9.9%, p = 0.018), and the incidences of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were 8.6% and 10.3%, respectively. In-hospital mortality occurred in 13 patients (22.4%) with NHAP and 17 patients (11.2%) with CAP (p = 0.039). In multivariate analyses, only higher pneumonia severity index (PSI) score was associated with increased mortality (p < 0.001), and the PSI score was higher in the NHAP group than that in the CAP group. Conclusions: Elderly patients admitted with NHAP showed more severe pneumonia at onset, higher rates of potentially drug-resistant pathogens, and worse clinical outcomes than those with CAP. However, higher in-hospital mortality in those with NHAP seemed to be related to the PSI score reflecting host factors and severity of pneumonia rather than the type of pneumonia or the presence of drug-resistant pathogens.

Healthcare-Associated Pneumonia among Hospitalized Patients: Is It Different from Community Acquired Pneumonia?

Background The increasing number of outpatients with multidrug-resistant (MDR) pathogens has led to a new category of pneumonia, termed healthcare-associated pneumonia (HCAP). We determined the differences in etiology and outcomes between patients with HCAP and those with community-acquired pneumonia (CAP) to clarify the risk factors for HCAP mortality. Methods A retrospective study comparing patients with HCAP and CAP at Jeju National University Hospital. The primary outcome was 30-day mortality. Results A total of 483 patients (208 patients HCAP, 275 patients with CAP) were evaluated. Patients with HCAP were older than those with CAP (median, 74 years; interquartile range [IQR], 65-81 vs. median, 69 years; IQR, 52-78; p<0.0001). Streptococcus pneumoniae was the major pathogen in both groups, and MDR pathogens were isolated more frequently from patients with HCAP than with CAP (18.8% vs. 4.9%, p<0.0001). Initial pneumonia severity was greater in patients with HCAP than with CAP. The total 30-day mortality rate was 9.9% and was higher in patients with HCAP based on univariate analysis (16.3% vs. 5.1%; odds ratio (OR), 3.64; 95% confidence interval (CI), 1.90-6.99; p<0.0001). After adjusting for age, sex, comorbidities, and initial severity, the association between HCAP and 30-day mortality became non-significant (OR, 1.98; 95% CI, 0.94-4.18; p=0.167). Conclusion HCAP was a common cause of hospital admissions and was associated with a high mortality rate. This increased mortality was related primarily to age and initial clinical vital signs, rather than combination antibiotic therapy or type of pneumonia.

Usefulness of sputum induction with hypertonic saline in a real clinical practice for bacteriological yields of active pulmonary tuberculosis.

Background Mycobacterial identification in active pulmonary tuberculosis (APTB) is confirmative, even though successful rates using self-expectorated sputum are limited. Sputum specimens collected by hypertonic saline nebulization showed higher bacteriologic diagnostic sensitivities over those of self-expectoration, mostly studied in smear-negative or sputum-scarce patients. The efficacy of induced sputum was rarely assessed in real clinical settings. Methods A prospective randomized case-control study was performed in one hospital. The subjects highly suspicious of APTB were asked to provide 3 pairs of sputum specimens in 3 consecutive days. The first pairs of the specimens were obtained either by self-expectoration (ES) from the next day of the visit or sputum induction with 7% saline nebulization in clinic (SI), and the other specimens were collected in the same way. The samples were tested in microscopy, culture, and polymerase chain reaction (PCR). The outcomes of the bacteriological diagnosis were compared. Results Seventy six patients were assigned to either ES (38 subjects, median age of 51, 65.8% male) or SI (38 subjects, median age of 55, 52.6% male). APTB was clinically confirmed in 51 patients (70.8%), 27 in ES and 24 in SI. Among the APTB, more adequate specimens were collected from SI (41/65, 63.1%) than ES (34/80, 42.5%) (p=0.01). Bacteriological confirmation was achieved in 14 (58.3%) patients in SI, and 13 (48.1%) in ES (p=0.46). In the same-day bacteriological diagnosis with microscopy and PCR, there were positive results for 9 patients (37.5%) in SI and 7 patients (25.9%) in ES (p=0.37). Conclusion Sputum induction improves sputum specimen adequacy. It may be useful for the same-day bacteriological diagnosis with microscopic examination and PCR.

pncA Mutations in the Specimens from Extrapulmonary Tuberculosis.

Background Pyrazinamide (PZA) is an effective antitubercular drug that becomes toxic to Mycobacterium tuberculosis when converted to pyrazinoic acid by pyrazinamidase (PZase), encoded by mycobacterial pncA. A strong association was noted between the loss of PZase activity and PZA resistance. The causative organisms in extrapulmonary tuberculosis are rarely cultured and isolated. To detect pncA mutations in specimens from extrapulmonary tuberculosis as confirmative diagnosis of mycobacterial infection and alternative susceptibility test to PZA. Methods Specimens were collected from clinically proven extrapulmonary tuberculosis. pncA was sequenced and compared with wild-type pncA. Results pncA from 30 specimens from 23 donors were successfully amplified (56.6% in specimens, 59% in donors). Six mutations in pncA were detected (20.0% in amplified specimens, 26.1% in specimen donors) at nucleotide positions of 169, 248 and 419. The mutation at position 169 results in substitution of aspartic acid for histidine, a possible allelic variation of M. bovis that have intrinsic PZA resistance. The mutation at position 248 changes proline into arginine and that at position 419, arginine into histidine. Conclusion DNA-based diagnosis using pncA may be simultaneously useful for the early diagnosis of mycobacterial infection and the rapid susceptibility to PZA in extrapulmonary tuberculosis. A potential implication of pncA allelic variation at 169 might be suggested as a rapid diagnostic test for M. bovis infection or Bacille Calmette-Guérin (BCG) reactivation.

Predictive Factors of Methicillin-Resistant Staphylococcus aureus Infection in Elderly Patients with Community-Onset Pneumonia

Background Methicillin-resistant Staphylococcus aureus (MRSA) infection is a severe and life-threatening disease in patients with community-onset (CO) pneumonia. However, the current guidelines lack specificity for a screening test for MRSA infection. Methods This study was retrospectively conducted in elderly patients aged ≥65 years, who had contracted CO-pneumonia during hospitalization at the Jeju National University Hospital, between January 2012 and December 2014. We analyzed the risk factors of MRSA in these patients and developed a scoring system to predict MRSA infection. Results A total of 762 patients were enrolled in this study, including 19 (2.4%) with MRSA infection. Healthcare-associated pneumonia (HCAP) showed more frequent MRSA infection compared to community-acquired pneumonia (4.4% vs. 1.5%, respectively; p=0.016). In a multivariate logistic regression analysis, admissions during the influenza season (odds ratio [OR], 2.896; 95% confidence interval [CI], 1.022–8.202; p=0.045), chronic kidney disease (OR, 3.555; 95% CI, 1.157–10.926; p=0.027), and intensive care unit admission (OR, 3.385; 95% CI, 1.035–11.075; p=0.044) were identified as predictive factors for MRSA infection. However, the presence of HCAP was not significantly associated with MRSA infection (OR, 1.991; 95% CI, 0.720–5.505; p=0.185). The scoring system consisted of three variables based on the multivariate analysis, and showed moderately accurate diagnostic prediction (area under curve, 0.790; 95% CI, 0.680–0.899; p<0.001). Conclusion MRSA infection would be considered in elderly CO-pneumonia patients, with three risk factors identified herein. When managing elderly patients with pneumonia, clinicians might keep in mind that these risk factors are associated with MRSA infection, which may help in selecting appropriate antibiotics.

A Case of Posterior Mediastinal Plasmacytoma Confounded by Community-Acquired Pneumonia

Plasmacytomas are extramedullary accumulations of plasma cells originating from soft tissue. Mediastinal plasmacytoma is a rare presentation. A 67-year-old man recovered after antibiotic treatment for community-acquired pneumonia. However, on convalescent chest radiography after 3 months, mass like lesion at the right lower lung field was newly detected. Follow-up chest computed tomography (CT) revealed an increase in the extent of the right posterior mediastinal mass that we had considered to be pneumonic consolidations on previous CT scans. Through percutaneous needle biopsy, we diagnosed IgG kappa type extramedullary plasmacytoma of the posterior mediastinum.

A Case of Pulmonary Mycobacterium kansasii Disease Complicated with Tension Pneumothorax.

Pneumothorax is an extremely rare complication of non-tuberculous mycobacterial infection. A 52-year-old man presenting with difficulty breathing and chest pain was admitted to our hospital. A right-sided pneumothorax was observed on chest radiography and chest computed tomography showed multiple cavitating and non-cavitating nodules with consolidation in the upper to middle lung zones bilaterally. Serial sputum cultures were positive for Mycobacterium kansasii, and he was diagnosed with pulmonary M. kansasii disease complicated by tension pneumothorax. After initiation of treatment including decortications and pleurodesis, the patient made a full recovery. We herein describe this patients course in detail and review the current relevant literature.

Health outcomes, education, healthcare delivery and quality – 3053. Is it necessary to re-evaluate the airway hyperresponsiveness while in the treatment of mild asthma?

Results Among 54 patients, 22 (40.7%) were AHR-negative. The considerable factors for the maintenance of AHR is male sex, presence of dyspnea at initial presentation and high dose inhaled corticosteroid plus long acting beta agonist at initial presentation (respectively, p < 0.05). Age, symptoms other than dyspnea, blood tests, results of the spirometry, diagnostic methods at presentation and time intervals from diagnosis to follow-up tests showed no difference between AHR-negativity and AHR-positivity. Multivariable analyses failed to show a statistical significance in the two groups. Conclusions In mild asthmatics, about 40% might show no AHR, the clinical remission of the disease. Changing AHR status in mild asthma while undergoing medical treatment is not predictable, so that cessation of regular controller medication might be advocated, and then a reassessment of AHR should be mandatory.