•Utilization of echinocandins has increased since the change in insurance coverage.•Clinical outcomes did not differ from before the policy change.•Caspofungin use was associated with decreased ...mortality in the study period.
In 2014, South Korea expanded its national health insurance coverage to include newer antifungal agents, such as echinocandins. This study aimed to investigate the effects of policy change on the prescription patterns of antifungals, medical costs and clinical outcomes of candidemia.
This retrospective cohort enrolled hospitalized patients with candidemia at three tertiary care hospitals in South Korea from January 2012 to December 2015. The utilization of antifungal agents, medical costs, length of hospital stay (LOS), and mortality before and after the health-care benefit expansion were compared, and the factors associated with all-cause 28-day mortality during the study period were analyzed.
A total of 769 candidemia cases were identified. The incidence of candidemia did not significantly vary during the study period (P = 0.253). The proportion of echinocandins, as the initial antifungal agent, and medical costs associated with candidemia significantly increased since the change in insurance coverage (P < 0.001). There was no significant difference in LOS and mortality associated with candidemia before and after the health-care benefit expansion (P = 0.696 and 0.931, respectively). Multivariate logistic regression analysis showed that initial treatment with caspofungin was associated with decreased mortality (adjusted odds ratio: 0.784; 95% confidence interval: 0.681–0.902; reference: fluconazole).
Although the utilization of newer antifungal agents and medical cost for candidemia has significantly increased since the health-care benefit expansion, there has been no change in the outcome of candidemia. However, the further increased use of newer antifungals may improve the outcome of candidemia in this country.
According to the new definition of septic shock, vasopressor therapy and hyperlactatemia are essential for diagnosis. However, there is controversy regarding the cutoff value for lactate, and ...prognostic factors in patients with septic shock and hypolactatemia. This study evaluated the prognostic significance of the cutoff value for lactate level in septic shock patients.
The retrospective observational cohort study enrolled 1043 patients aged ≥18 years who meet the revised definition of septic shock. Clinical outcomes of patients with hyperlactatemia were compared with hypolactatemia.
Of the 1022 eligible patients, 369 had an arterial lactate level ≤2 mmol/L. More patients in the high lactate group had poor prognosis than in the low lactate group. A high Sequential Organ Failure Assessment score (SOFA) score group was significant (p < 0.001) in predicting lactate levels. On the subgroup analysis of risk factors affecting mortality in the low lactate group, high Acute Physiology And Chronic Health Evaluation Ⅱ (APACHEⅡ) score (p = 0.003), high C-reactive protein (p = 0.034), and chronic heart failure (p = 0.001) were independently associated with 28-day mortality.
Arterial lactate is a very reliable diagnostic and prognostic predictor of septic shock. However, despite low arterial lactate, patients with a high APACHEⅡ score, high C-reactive protein levels, and chronic heart failure had a poorer prognosis.
A modular multichannel reaction module with microchannel-based coolant channels was considered, and a computational fluid dynamics (CFD) model was developed to describe the hydrodynamic behavior of ...the module. Reaction rates for the lumped chain length distribution of hydrocarbon products generated by the Fischer–Tropsch synthesis reaction were proposed, and the developed kinetic and CFD models were shown to satisfactorily fit the experimental data under different production rates. High heat transfer rates resulting from the use of microchannel-based cooling channel maintained the temperature peak below 10 °C, and simulation results with increased size of the catalytic bed and absence of inert materials showed that the high heat of reactions could be efficiently removed over entire catalytic beds, preventing the creation of local hot spots, which are usually observed in conventional fixed bed reactors. In addition, the efficient use of thermal energy could guarantee that methane selectivity, which needs to be maintained as low as possible, was close to approximately 10% under all conditions, while the selectivity of the desired hydrocarbons (C5+) slightly increased with increasing feed flow rates.
The incidence of Proteus mirabilis antimicrobial resistance, especially that mediated by extended-spectrum β-lactamases (ESBLs), has increased. We investigated the impact of ESBL production on the ...mortality of patients with P. mirabilis bacteremia in Korea.
Patients diagnosed with P. mirabilis bacteremia between November 2005 and December 2013 at a 2000-bed tertiary care center in South Korea were included in this study. Phenotypic and molecular analyses were performed to assess ESBL expression. Characteristics and treatment outcomes were investigated among ESBL-producing and non-ESBL-producing P. mirabilis bacteremia groups. A multivariate analysis of 28-day mortality rates was performed to evaluate the independent impact of ESBLs.
Among 62 P. mirabilis isolates from 62 patients, 14 expressed ESBLs (CTX-M, 2; TEM, 5; both, 6; other, 1), and the 28-day mortality rate of the 62 patients was 17.74%. No clinical factor was significantly associated with ESBL production. The 28-day mortality rate in the ESBL-producing group was significantly higher than that in the non-ESBL-producing group (50% vs. 8.3%, p = 0.001). A multivariate analysis showed that ESBL production (odds ratio OR, 11.53, 95% confidence interval CI, 2.11-63.05, p = 0.005) was independently associated with the 28-day mortality rate in patients with P. mirabilis bacteremia.
ESBL production is significantly associated with mortality in patients with bacteremia caused by P. mirabilis. Rapid detection of ESBL expression and prompt appropriate antimicrobial therapy are required to reduce mortality caused by P. mirabilis bacteremia.
This study investigated the molecular mechanisms of carbapenem resistance in clinical isolates of Klebsiella pneumoniae from Korea and the clinical outcomes of resistant K. pneumoniae infection. ...Sixteen K. pneumoniae isolates showing resistance to carbapenems collected from a tertiary-care hospital were examined for the mechanisms of carbapenem resistance. PCR and sequencing experiments detected the bla(DHA-1) AmpC β-lactamase gene in all 16 clinical isolates, whilst the bla genes of extended-spectrum β-lactamases were detected in 12 of 16 isolates. SDS-PAGE experiments indicated that all the isolates lacked the 35 kDa and/or 36 kDa outer-membrane proteins (OMPs). Sequence analysis of the corresponding OMP genes revealed various alterations. PFGE analysis demonstrated that there were no major clonal relationships among the K. pneumoniae isolates. However, multilocus sequence typing experiments showed that all isolates shared the same sequence type (ST), ST11, except for one isolate of ST48. The crude mortality rate of infected patients was 81.8 %. Carbapenem resistance was mainly due to a combination of DHA-1 AmpC β-lactamase coupled with the loss of OmpK35 and/or OmpK36 and was associated with poor clinical outcome.
Liver stiffness measurement (LSM) using transient elastography (Fibroscan®) can identify individuals with potential underlying liver disease. We evaluated the prevalence of abnormal LSM values as ...assessed using LSM and its predictors in HIV-infected asymptomatic patients receiving combined antiretroviral treatment (cART) without HBV/HCV coinfection.
We prospectively recruited 93 patients who had consistently been undergoing cART for more than 12 months at Severance Hospital in Seoul, Republic of Korea, from June to December 2010. LSM values >5.3 kPa were defined as abnormal.
Thirty-nine (41.9%) had abnormal LSM values. On multivariate correlation analysis, the cumulative duration of boosted and unboosted protease inhibitors (PIs) were the independent factors which showed a negative and positive correlation to LSM values, respectively (β = -0.234, P = 0.023 and β = 0.430, P<0.001). In multivariate logistic regression analysis, the cumulative exposure duration of boosted-PIs and γ-glutamyltranspeptidase levels were selected as the independent predictors which showed a negative and positive correlation with abnormal LSM values, respectively (odds ratio OR, 0.941; 95% confidence interval CI, 0.889-0.997; P = 0.039 and OR, 1.032; 95% CI, 1.004-1.060; P = 0.023).
The high percentage of HIV-infected asymptomatic patients receiving cART without HBV/HCV coinfection had abnormal LSM values. The cumulative exposure duration of boosted-PIs and γ-GT level were independent predictors which showed a negative and positive correlation with abnormal LSM values, respectively.
A hospital outbreak of
e carbapenemase (KPC)-producing
(KPN) linked with an index case of community-acquired infection occurred in an urban tertiary care hospital in Seoul, South Korea. Therefore, we ...performed an outbreak investigation and whole genome sequencing (WGS) analysis to trace the outbreak and investigate the molecular characteristics of the isolates.
From October 2014 to January 2015, we identified a cluster of three patients in the neurosurgery ward with sputum cultures positive for carbapenem-resistant KPN. An epidemiological investigation, including pulsed-field gel electrophoresis analysis was performed to trace the origins of this outbreak. The index patient's infection was community acquired. Active surveillance cultures using perirectal swabbing from exposed patients, identified one additional patient with KPC-producing KPN colonization. WGS analyses using PacBio RSII instruments were performed for four linked isolates. WGS revealed a genetic linkage of the four isolates belonging to the same sequence type (ST307). All KPN isolates harbored conjugative resistance plasmids, which has
carbapenemase genes contained within the Tn
"a" isoform and other resistance genes. However, WGS showed only three isolates among four KPC-producing KPN were originated from a common origin.
This report demonstrates the challenge that KPC-2-producing KPN with the conjugative resistance plasmid may spread not only in hospitals but also in community, and WGS can help to accurately characterize the outbreak.
Hypervirulent Clostridium difficile strains, most notably BI/NAP1/027, have been increasingly emerging in Western countries as local epidemics. We performed a prospective multicentre observational ...study from December 2011 to May 2012 to identify recent incidences of toxigenic culture-confirmed hospital-onset C. difficile infections (CDI) and their associated clinical characteristics in South Korea. Patients suspected of having been suffering from CDI more than 48 h after admission and aged ≥20 years were prospectively enrolled and provided loose stool specimens. Toxigenic C. difficile culture (anaerobic culture+toxin A/B/binary gene PCR) and PCR ribotyping were performed in one central laboratory. We enrolled 98 toxigenic culture-confirmed CDI-infected patients and 250 toxigenic culture-negative participants from three hospitals. The incidence of toxigenic culture-confirmed hospital-onset CDI cases was 2.7 per 10,000 patient-days. The percentage of severe CDI cases was relatively low at only 3.1%. UK ribotype 018 was the predominant type (48.1%). There were no hypervirulent BI/NAP1/027 isolates identified. The independent risk factors for toxigenic culture-confirmed hospital-onset CDI were invasive procedure (odds ratio (OR) 7.3, P=0.003) and past CDI history within 3 months (OR 28.5, P=0.003). In conclusion, the incidence and severity of CDI in our study were not higher than reported in Western countries.
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