Su Jin Jeong

RED BLOOD CELL DISTRIBUTION WIDTH IS AN INDEPENDENT PREDICTOR OF MORTALITY IN PATIENTS WITH GRAM-NEGATIVE BACTEREMIA

ABSTRACT Red blood cell distribution width (RDW) is known to be a predictor of severe morbidity and mortality in some chronic diseases such as congestive heart failure. However, to our knowledge, little is known about RDW as a predictor of mortality in patients with Gram-negative bacteremia, a major nosocomial cause of intra-abdominal infections, urinary tract infections, and primary bacteremia. Therefore, we investigated whether RDW is an independent predictor of mortality in patients with Gram-negative bacteremia. Clinical characteristics, laboratory parameters, and outcomes of 161 patients with Gram-negative bacteremia from November 2010 to March 2011 diagnosed at Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, were retrospectively analyzed. The main outcome measure was 28-day all-cause mortality. The 28-day mortality rate was significantly higher in the increased RDW group compared with the normal RDW group (P < 0.001). According to multivariate Cox proportional hazard analysis, RDW levels at the onset of bacteremia (per 1% increase, P = 0.036), the Charlson index (per 1-point increase, P < 0.001), and the Sequential Organ Failure Assessment score (per 1-point increase, P = 0.001) were independent risk factors for 28-day mortality. Moreover, the nonsurvivor group had significantly higher RDW levels 72 h after the onset of bacteremia than did the survivor group (P = 0.001). In addition, the area under the curve of RDW at the onset of bacteremia, the 72-h RDW, and the Sequential Organ Failure Assessment score for 28-day mortality were 0.764 (P = 0.001), 0.802 (P < 0.001), and 0.703 (P = 0.008), respectively. Red blood cell distribution width at the onset of bacteremia was an independent predictor of mortality in patients with Gram-negative bacteremia. Also, 72-h RDW could be a predictor for all-cause mortality in patients with Gram-negative bacteremia.

Analysis of adrenal masses by 18F-FDG positron emission tomography scanning

This study aimed to analyse the characteristics of adrenal masses visible in the computerised tomography (CT) scans which have been also evaluated by 2‐[18F]fluoro‐2‐deoxy‐D‐glucose positron emission tomography (18F‐FDG PET), and to characterise the features of 18F‐FDG PET scans associated with various adrenal endocrine tumours, especially benign functional tumours. 18F‐FDG PET scans of 105 patients with adrenal masses on the CT scan were analysed. Positive uptakes in the 18F‐FDG PET scans were seen in 60 malignant tumours (54 metastasic lesions, six primary adrenal cancers) and seven benign tumours. The positive predictive value of 18F‐FDG PET imaging to characterise an adrenal mass as a malignant tumour was 90%; the corresponding negative predictive value to rule out malignancy was also 90%. Benign adrenal tumours were smaller than that of malignant lesions (p < 0.05). The mean standardised uptake value max (SUVmax) of the metastatic lesions [8.4 ± 6.5 (μCi/g)/μCi/kg] was significantly higher than that of the benign adrenal tumours [2.4 ± 1.2 (μCi/g)/μCi/kg, p < 0.001]. Examination of only the primary adrenal lesions revealed that all adrenocortical carcinomas, two of three cases of pheochromocytomas, three of five neuroblastomas and two of four cases of primary aldosteronism showed positive 18F‐FDG uptake. In conclusion, for patients presenting adrenal masses with a high probability of malignancy, 18F‐FDG PET can be used to differentiate malignant from benign adrenal lesions. However, the 18F‐FDG PET uptake did not show an always consistent pattern for endocrine tumours, which was probably due to the variability inherent in 18F‐FDG uptake. This study suggests that 18F‐FDG PET scanning can offer supporting data to localise and characterise adrenal tumours.

Incidence and risk factors of infection in a single cohort of 110 adults with systemic lupus erythematosus

Infection is a major cause of mortality in patients with systemic lupus erythematosus (SLE). This study describes infectious complications in SLE patients and analyzes the risk factors for infection at the time of SLE diagnosis and during the course of SLE in a case-control study. Of 110 patients enrolled, 42 (38%) had at least 1 episode of infectious disease. The incidence of infectious disease was 4.4/100 patient-years (py) with a total follow-up duration of 954 y. In multivariate analysis, independent predictors of infection at the time of SLE diagnosis were an SLE disease activity index (SLEDAI) > 12 (p = 0.01), C3 levels < 90 mg/dl (p = 0.01) and positive anti-ds DNA antibodies (p < 0.01). Frequent flare-ups (p = 0.04) and follow-up duration ≥8 y (p = 0.023) were also significant risk factors for infectious diseases. It is mandatory to closely observe SLE patients with risk factors for developing infectious diseases.

Vancomycin-resistant enterococci bacteremia: Risk factors for mortality and influence of antimicrobial therapy on clinical outcome

OBJECTIVES This study evaluated the effects of antimicrobial treatment against vancomycin-resistant enterococci (VRE) and delayed administration of anti-VRE therapy on mortality, and determined independent risk factors for delayed all-cause mortality of VRE bacteremia patients. METHODS Over 10 years, 153 patients with clinically significant monomicrobial VRE bacteremia were identified among a total of 2834 patients in a VRE cohort. The main outcomes were immediate (7-day) and delayed (28-day, 60-day) all-cause mortality. RESULTS The 7-day (P<0.001) and 28-day (P=0.041) mortalities were lower in the group receiving anti-VRE therapy, but the 60-day mortality (P=0.113) was unaffected. The mortalities of patients receiving anti-VRE therapy later than 72h after the onset of bacteremia were no different from that of patients receiving treatment within 72h. Both a higher APACHE II score (hazard ratio [HR], 1.10; P<0.001 and HR, 1.12; P<0.001, respectively) and the presence of septic shock at the onset of bacteremia (HR, 1.91; P=0.047 and HR, 1.78; P=0.034, respectively) were independent risk factors for 28-day and 60-day mortality. CONCLUSION These findings suggest that in spite of antibiotic therapy against VRE, patients with VRE bacteremia eventually have a higher risk of death because of severe illness at the onset of bacteremia.

Measurement of plasma sTREM-1 in patients with severe sepsis receiving early goal-directed therapy and evaluation of its usefulness.

ABSTRACT The plasma level of soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) has been shown to be helpful in identifying critically ill patients with infection. However, it remains unknown whether it can be used to predict prognosis in patients with severe sepsis. This study investigated whether various inflammatory mediators, including sTREM-1, could be used as reliable markers to predict the prognosis of patients receiving early goal-directed therapy (EGDT). We prospectively enrolled patients 18 years or older with severe sepsis from April 2009 to May 2010 at a 2,000-bed university hospital. Patients were eligible if the initial resuscitation according to EGDT protocol was immediately performed at the emergency department. Plasma sTREM-1, C-reactive protein, and procalcitonin concentrations were measured on days 0, 3, 7, and 14. Soluble TREM-1 concentrations were significantly higher at admission and pre-EGDT in nonsurvivors (n = 16) than in survivors (n = 47) (514.1 pg/mL [interquartile range, 412.7–1,749.5 pg/mL] vs. 182.4 pg/mL [interquartile range, 54.3–327.0 pg/mL]; P = 0.001). Procalcitonin and C-reactive protein levels did not significantly differ, whereas central venous oxygen saturation and lactate levels at admission were significantly different between the two groups. The only sTREM-1 level remained significantly higher in nonsurvivors until death. On multivariate regression analysis, log(sTREM-1) (P = 0.028), central venous oxygen saturation (P = 0.022), and Simplified Acute Physiology Score II (P = 0.048) values at admission were independently significant. These results suggest that plasma sTREM-1 level at admission could be used as a marker to identify patients with a poor prognosis despite complete initial resuscitation in severe sepsis.

Incidence and risk factors for carbapenem-and multidrug-resistant Acinetobacter baumannii bacteremia in hematopoietic stem cell transplantation recipients

Abstract Background: Bacteremia with multidrug-resistant (MDR) Acinetobacter baumannii with carbapenem resistance is an important healthcare-associated infection that increases morbidity and mortality in immunocompromised patients. The aim of this study was to assess the annual incidence and clinical characteristics of such bacteremia and to identify the risk factors for infection in hematopoietic stem cell transplantation (HSCT) recipients. Methods: A retrospective cohort and case–control study was conducted in 483 HSCT recipients between January 2005 and December 2011 at a single tertiary center. Thirty-eight control HSCT patients without evidence of post-transplant infection were matched with 19 patients with bacteremia due to MDR A. baumannii in a 2:1 ratio. Results: The total incidence of carbapenem-resistant–MDR A. baumannii bacteremia was 0.52 cases/10,000 patient-days. In most cases (17 of 19, 89.5%), bacteremia developed after engraftment. Pneumonia was the origin of bacteremia in all patients. Eighteen (94.7%) patients with bacteremia and 3 (8.3%) without bacteremia died. In multivariate regression analyses, the duration between admission and HSCT (odds ratio (OR) 2.19 per 1-day increase, p = 0.030) and a history of care in an intensive care unit after HSCT (OR 32.2, p = 0.021) were independent risk factors for the development of carbapenem-resistant–MDR A. baumannii bacteremia. Conclusions: We report that carbapenem-resistant–MDR A. baumannii bacteremia in HSCT recipients is a fatal infectious complication and mainly develops after engraftment.

Anti-vascular endothelial growth factor antibody attenuates inflammation and decreases mortality in an experimental model of severe sepsis

IntroductionSevere sepsis is associated with an unacceptably high rate of mortality. Recent studies revealed elevated levels of vascular endothelial growth factor (VEGF), a potent angiogenic and vascular permeability factor, in patients with sepsis. There was also an association between VEGF levels and sepsis severity. Here we investigate the effects of an anti-VEGF antibody (Bevacizumab, Bev) in an experimental model of sepsis.MethodsHuman umbilical vein endothelial cells (HUVECs), murine cecal ligation and puncture (CLP), and endotoxemia models of sepsis were used. HUVECs were treated with lipopolysaccharide (LPS) and/or Bev, harvested and cytokine mRNA levels determined using a semi-quantitative reverse transcription-polymerase chain reaction assay. The levels of inflammatory cytokine were also determined in HUVECs supernatants. In addition, the effects of Bev on mortality in the CLP and endotoxemia models of sepsis were evaluated.ResultsTreatment with Bev and LPS significantly decreased the expression and the level of inflammatory cytokines in HUVECs relative to LPS alone. In CLP and endotoxemia models, survival benefits were evident in mice given 0.1 mg/kg of Bev relative to the CLP or LPS alone (P <0.001 and P = 0.028, respectively), and in 6 h post-treated mice relative to the CLP alone for the effect of different time of Bev (P = 0.033). In addition, Bev treatment inhibited LPS-induced vascular leak in the lung, spleen and kidney in the murine endotoxemia model (P <0.05).ConclusionsAnti-VEGF antibody may be a promising therapeutic agent due to its beneficial effects on the survival of sepsis by decreasing inflammatory responses and endothelial permeability.

Risk factors for the acquisition of carbapenem-resistant Escherichia coli at a tertiary care center in South Korea: A matched case-control study

BACKGROUND Carbapenem resistance among gram-negative bacilli is an emerging threat worldwide. The objective of this study was to identify risk factors for the acquisition of carbapenem-resistant Escherichia coli (CRE). METHODS We conducted a matched case-control study comprising 57 cases of acquisition of CRE and 114 controls (1:2 matched) selected from patients with a culture of carbapenem-susceptible E coli between January 2006 and December 2010 at a 2000-bed tertiary care center in South Korea. RESULTS On univariate analysis, previous use of carbapenem (P < .01), fluoroquinolone (P < .01), and glycopeptide (P < .01), as well as length of hospital stay (P < .05), were significantly associated with CRE acquisition. On multivariate analysis, previous use of carbapenem (odds ratio [OR], 4.56; 95% confidence interval [CI] 1.44-14.46; P = .01) and previous use of fluoroquinolone (OR, 2.81; 95% CI, 1.14-6.99; P = .03) were independent risk factors. CONCLUSIONS At this institute, the antibiotic selective pressure of carbapenems and fluoroquinolones was shown to be an important risk factor for the acquisition of CRE.

Clinical Review of Endogenous Endophthalmitis in Korea: A 14-Year Review of Culture Positive Cases of Two Large Hospitals.

Purpose To identify the clinical features and outcomes of endogenous endophthalmitis in Korea. Materials and Methods We reviewed 18 patients with endogenous endophthalmitis at 2 Korean hospitals, treated over a 14 year period between January 1993 and December 2006. Results The comorbidities observed in these cases were diabetes mellitus and liver cirrhosis. The most common pathogens, which were found in 7 patients each (38.9%), were Klebsiella pneumonia and Pseudomonas aeruginosa. All patients were treated with systemic antibiotics and fortified topical antibiotics. A surgical approach including vitrectomy was performed in 9 cases (50.0%). The prognosis was generally poor, and visual acuity improved slightly in 6 patients (33.3%). Conclusion In this study, diabetes mellitus and Klebsiella pneumonia showed a close relationship with endogenous endophthalmitis, respectively. Endogenous endophthalmitis is a serious risk to sight and careful attention to establishing the diagnosis and management may decrease the ocular morbidity.

Disseminated Mycobacterium kansasii infection associated with skin lesions: a case report and comprehensive review of the literature.

Mycobacteruim kansasii occasionally causes disseminated infection with poor outcome in immunocompromised patients. We report the first case of disseminated M. kansasii infection associated with multiple skin lesions in a 48-yr-old male with myelodysplastic syndrome. The patient continuously had taken glucocorticoid during 21 months and had multiple skin lesions developed before 9 months without complete resolution until admission. Skin and mediastinoscopic paratracheal lymph node (LN) biopsies showed necrotizing granuloma with many acid-fast bacilli. M. kansasii was cultured from skin, sputum, and paratracheal LNs. The patient had been treated successfully with isoniazid, rifampin, ethmabutol, and clarithromycin, but died due to small bowel obstruction. Our case emphasizes that chronic skin lesions can lead to severe, disseminated M. kansasii infection in an immunocompromised patient. All available cases of disseminated M. kansasii infection in non HIV-infected patients reported since 1953 are comprehensively reviewed.