IN the presence of septic shock, every hour in delaying the administration of effective antibiotics is associated with a measurable increase in mortality. This is especially true for neutropenic patients with septic shock.1 As there is a higher incidence of involving multi-drug resistant pathogens for neutropenic patients, the decision on antibiotics regime remains a challenge for physicians.2 Immunosuppression and previous antibacterial use are factors that promote the spread of multi-drug resistant pathogens, and the possibility of co-existing multi-drug resistant pathogens should be suspected when treating patients with these risk factors who developed refractory shock. Here we present a case with neutropenic fever and refractory shock whose blood culture yielded multi-drug resistant Acinetobacter baumannii and carbapenem- resistant Klebsiella pneumoniae.
Acinetobacter Infections ; blood ; drug therapy ; microbiology ; Acinetobacter baumannii ; drug effects ; isolation & purification ; Adult ; Bacteremia ; blood ; drug therapy ; microbiology ; Carbapenems ; administration & dosage ; pharmacology ; therapeutic use ; Drug Resistance, Multiple, Bacterial ; Fatal Outcome ; Humans ; Klebsiella Infections ; blood ; drug therapy ; microbiology ; Klebsiella pneumoniae ; drug effects ; isolation & purification ; Male ; Shock, Septic ; blood ; drug therapy ; microbiology

Megalocytic interstitial nephritis is a rare form of kidney disease caused by chronic inflammation. We report a case of megalocytic interstitial nephritis occurring in a 45-yrold woman who presented with oliguric acute kidney injury and acute pyelonephritis accompanied by Escherichia coli bacteremia. Her renal function was not recovered despite adequate duration of susceptible antibiotic treatment, accompanied by negative conversion of bacteremia and bacteriuria. Kidney biopsy revealed an infiltration of numerous histiocytes without Michaelis-Gutmann bodies. The patient's renal function was markedly improved after short-term treatment with high-dose steroid.
Acute Disease ; Acute Kidney Injury/complications/*drug therapy/pathology ; Anti-Bacterial Agents/therapeutic use ; Azithromycin/therapeutic use ; Bacteremia/*drug therapy/microbiology/pathology ; Cefotaxime/therapeutic use ; Creatinine/blood ; Escherichia coli ; Escherichia coli Infections/*drug therapy/microbiology/pathology ; Female ; Humans ; Kidney/pathology ; Methylprednisolone/therapeutic use ; Middle Aged ; Nephritis, Interstitial/*drug therapy/immunology/pathology ; Pyelonephritis/complications/*drug therapy/pathology ; Renal Dialysis ; Shock, Septic/drug therapy/microbiology

This study aimed to compare the clinical presentations of Aeromonas hydrophila, A. veronii biovar sobria and A. caviae monomicrobial bacteremia by a retrospective method at three hospitals in Taiwan during an 8-yr period. There were 87 patients with A. hydrophila bacteremia, 45 with A. veronii biovar sobria bacteremia and 22 with A. caviae bacteremia. Compared with A. hydrophila and A. veronii biovar sobria bacteremia, A. caviae bacteremia was more healthcare-associated (45 vs 30 and 16%; P = 0.031). The patients with A. caviae bacteremias were less likely to have liver cirrhosis (27 vs 62 and 64%; P = 0.007) and severe complications such as shock (9 vs 40 and 47%; P = 0.009) and thrombocytopenia (45 vs 67 and 87%; P = 0.002). The APACHE II score was the most important risk factor of Aeromonas bacteremia-associated mortalities. The APACHE II scores of A. caviae bacteremias were lower than A. hydrophila bacteremia and A. veronii biovar sobria bacteremia (7 vs 14 and 16 points; P = 0.002). In conclusion, the clinical presentation of A. caviae bacteremia was much different from A. hydrophila and A. veronii biovar sobria bacteremia. The severity and mortality of A. caviae bacteremia were lower than A. hydrophila or A. veronii biovar sobria bacteremia.
APACHE ; Adult ; Aeromonas caviae/drug effects/*pathogenicity ; Aeromonas hydrophila/drug effects/*pathogenicity ; Aged ; Aged, 80 and over ; Bacteremia/complications/drug therapy/*microbiology/mortality ; Cross Infection/microbiology ; Female ; Gram-Negative Bacterial Infections/complications/drug therapy/*microbiology/mortality ; Humans ; Liver Cirrhosis/microbiology ; Male ; Middle Aged ; Retrospective Studies ; Shock, Septic/microbiology ; Taiwan ; Thrombocytopenia/complications ; Young Adult

Vibrio cholerae non-O1 have caused several well-studied food-borne outbreaks of gastroenteritis and also have been responsible for sporadic cases of otitis media, wound infection, and bacteremia. Few cases of liver abscess caused by Vibrio cholerae non-O1 have been reported. A 73-year-old man with underlying diabetes mellitus was admitted with nausea, vomiting, dyspepsia and febrile sensation. We identified Vibrio cholerae non-O1 in his blood cultures and multiple hepatic microabscess on abdominal computed tomography. He was treated with systemic antibiotics and fluid therapy, but died due to septic shock on sixth day. We report here, a case of liver abscess with bacteremia due to Vibrio cholerae non-O1 in a patient with diabetes mellitus.
Aged ; Anti-Bacterial Agents/therapeutic use ; Bacteremia/drug therapy/*microbiology ; Ceftriaxone/therapeutic use ; Humans ; Liver Abscess/*diagnosis/drug therapy/microbiology ; Male ; Metronidazole/therapeutic use ; Shock, Septic/diagnosis ; Tomography, X-Ray Computed ; Vibrio Infections/drug therapy/*microbiology ; Vibrio cholerae non-O1/*isolation & purification

Clostridium difficile (C. difficile) is a common causative agent of pseudomembranous colitis (PMC). C. difficile-associated diarrhea (CDAD) ranges from mild diarrhea to life threatening PMC. Recently, a highly virulent strain of C. difficile polymerase chain reaction ribotype 027 was found in North America, Europe, and Japan. A 52-yr-old woman with anti-tuberculosis medication and neurogenic bladder due to traffic accident experienced five episodes of C. difficile PMC after taking antibiotics for pneumonia along with septic shock and acute renal failure. She was readmitted to the intensive care unit and treated with oral vancomycin with refractory of oral metronidazole, inotropics and probiotics for over 60 days. C. difficile isolated both at the first and the last admission was identified as C. difficile ribotype 027 by ribotyping, toxinotyping, and tcdC gene sequencing, which turned out the same pathogen as the epidemic hypervirulent B1/NAP1 strain. This is the first case of C. difficile PCR ribotype 027 in Korea. After discharge, she was maintained on probiotics and rifaximin for 3 weeks. She had no relapse for 6 months.
Accidents, Traffic ; Antitubercular Agents/therapeutic use ; Base Sequence ; Clostridium difficile/*classification/genetics/isolation & purification ; Enterocolitis, Pseudomembranous/*diagnosis/drug therapy/*microbiology ; Female ; Humans ; Kidney Failure, Acute/diagnosis ; Korea ; Middle Aged ; Molecular Sequence Data ; Polymerase Chain Reaction ; Ribotyping ; Shock, Septic/diagnosis

We report a case of acute fatal exacerbation of chronic hepatitis B in a 50-year-old man with multiple myeloma being treated with thalidomide. The patient had a medical history of chronic hepatitis B and was diagnosed with stage IIIA multiple myeloma. He suffered two episodes of transient transaminitis of unknown origin after successive autologous stem cell transplantations. Spontaneous resolutions of the transaminitis were observed without special management. At that time, PCR of hepatitis B virus (HBV) were all-negative. After 5-months' administration of thalidomide for the second relapse of the multiple myeloma, he suddenly experienced dizziness and jaundice. The level of HBV DNA was 1, 641 pg/mL and the serologic tests for other viruses were negative. Despite conventional supportive care, he expired due to septic shock caused by Klebsiella pneumonia. Based on the stable disease status of the multiple myeloma and exclusion of other hepatotoxic agents, it was assumed that the exacerbation of the hepatitis B virus during the thalidomide therapy preceded the bacterial sepsis. With the increased use of thalidomide in cancer treatment, cautious monitoring of the viral burden should be performed in patients with chronic hepatitis B.
Angiogenesis Inhibitors/administration & dosage/*adverse effects ; Hepatitis B, Chronic/*etiology ; Humans ; Klebsiella Infections/complications ; Male ; Middle Aged ; Multiple Myeloma/*drug therapy ; Shock, Septic/microbiology ; Thalidomide/administration & dosage/*adverse effects

OBJECTIVETo observe the effects of different doses of hydrocortisone (HC) on acute lung injury (ALI) and inflammatory response in rats at early stage of septic shock induced by Escherichia coli and to investigate the possible mechanisms for such differences.

METHODSALI model of early septic shock was induced in rats by two injections of Escherichia coli at 5 hours interval, with the first intraperitoneal injection of 6.50 x 10(10) cfu/kg and followed by an external jugular vein injection of 2.00 x 10(11) cfu/kg. Forty Wistar rats were randomly divided into the following five groups: normal control, ALI without HC treatment, high-dose HC (150 mg/kg), medium-dose HC (20 mg/kg) and low-dose HC (6 mg/kg). Two hours after the treatment, the specimens were collected for histopathological examination and the biological indexes of lung injury were measured. The expressions of intercellular adhesion molecule-1 (ICAM-1) and glucocorticoid receptor (GR) in lung tissues were also investigated by immunohistochemical assays.

RESULTSThe biological indexes of lung injury [wet/dry weight ratio (g/g), total protein concentration in bronchoalveolar lavage fluid (mg/L) and lung permeability index (10(-3))] in ALI group (4.76 +/- 0.10, 278.96 +/- 60.45, 4.73 +/- 0.60) were significantly increased as compared to those in normal control group (4.10 +/- 0.07, 67.46 +/- 13.27, 1.12 +/- 0.15) (P < 0.05). The grades of ALI pathologic changes in ALI group (11.13 +/- 1.13) was significantly higher than that in the normal control group (0.50 +/- 0.53, P < 0.05). The ratio of expression area of ICAM-1 in ALI group (0.149 +/- 0.037) was significantly increased as compared to that in the normal control group (0.051 +/- 0.018) (P < 0.05). The ratio of expression area of GR all group (0.043 +/- 0.037) was significantly decreased as compared to that in the normal Control group (0.124 +/- 9.040) (P < 0.05) After administration of HC, all the lung injury indexes, pathological grades and the ratios of expression area of ICAM-1 and GR were significantly improved, with the most remarkable effects observed in the low-dose HC group. The expressions of ICAM-1 and GR showed a significantly negative linear correlation (r = 0.55, P < 0.0001).

CONCLUSIONThese results indicated that the low-dose HC treatment had the most remarkable effects of improving the biological indexes of lung injury, inflammatory mediators and pathological changes. These HC dose dependent therapeutic effects might be associated with the level of GR expression.

Acute Lung Injury ; drug therapy ; metabolism ; microbiology ; Animals ; Disease Models, Animal ; Dose-Response Relationship, Drug ; Escherichia coli ; Escherichia coli Infections ; complications ; Glucocorticoids ; therapeutic use ; Hydrocortisone ; therapeutic use ; Intercellular Adhesion Molecule-1 ; biosynthesis ; Lung ; metabolism ; Rats ; Rats, Wistar ; Receptors, Glucocorticoid ; biosynthesis ; Shock, Septic ; drug therapy ; metabolism ; microbiology

Sphingobacterium spiritivorum has been rarely isolated from clinical specimens of immunocompromised patients, and there have been no case reports of S. spiritivorum infection in Korea to our knowledge. We report a case of S. spiritivorum bacteremia in a 68-yr-old woman, who was diagnosed with acute myeloid leukemia and subsequently received chemotherapy. One day after chemotherapy ended, her body temperature increased to 38.3degrees C. A gram-negative bacillus was isolated in aerobic blood cultures and identified as S. spiritivorum by an automated biochemical system. A 16S rRNA sequencing analysis confirmed that the isolate was S. spiritivorum. The patient received antibiotic therapy for 11 days but died of septic shock. This is the first reported case of human S. spiritivorum infection in Korea. Although human infection is rare, S. spiritivorum can be a fatal opportunistic pathogen in immunocompromised patients.
Aged ; Anti-Bacterial Agents/therapeutic use ; Bacteremia/*complications/drug therapy/*microbiology ; Bone Marrow Cells/pathology ; Fatal Outcome ; Female ; Humans ; Immunocompromised Host ; Leukemia, Myeloid, Acute/*complications ; Phylogeny ; RNA, Ribosomal, 16S/genetics ; Sequence Analysis, DNA ; Shock, Septic/etiology/microbiology ; Sphingobacterium/classification/genetics/isolation & purification/*physiology

This study investigated predictors associated with 14-day mortality, and focused especially on the impact of appropriate antimicrobial treatment among patients with carbapenem-resistant Acinetobacter baumannii (CRAB) bacteremia. This retrospective study was performed at a tertiary care hospital in Korea from June 2007 to June 2010. Antibiotic therapy was considered appropriate if the antibiotics were administered via an appropriate route within 24 hr after the result of blood culture, had in vitro sensitivity to isolated strains, and of an adequate dosage according to the current guidelines. Ninety-five patients with A. baumannii bacteremia were included; of these, 53 (55.8%) were infected with CRAB. The overall infection-related 14-day mortality was higher in patients receiving inappropriate antimicrobial therapy than in patients receiving appropriate therapy (59.5% [22/37] vs 13.8% [8/58], P < 0.05). Multivariate analysis showed that septic shock (OR 10.5, 95% CI, 1.93-57.4; P = 0.006), carbapenem-resistance (OR 7.29, 95% CI 1.57-33.8; P = 0.01), pneumonia as a source of bacteremia (OR 5.29, 95% CI 1.07-26.1; P = 0.04), and inappropriate antimicrobial therapy (OR 8.05, 95% CI 1.65-39.2; P = 0.009) were independent risk factors for 14-day mortality. Early definite antimicrobial therapy had an influence on favorable outcomes in patients with A. baumannii bacteremia.
APACHE ; Acinetobacter Infections/drug therapy/microbiology/*mortality ; Acinetobacter baumannii/drug effects/*isolation & purification ; Adult ; Age Factors ; Aged ; Anti-Bacterial Agents/*therapeutic use ; Carbapenems/pharmacology ; Diabetes Complications ; Drug Resistance, Bacterial ; Female ; Humans ; Male ; Middle Aged ; Odds Ratio ; Pneumonia/etiology ; Prognosis ; Retrospective Studies ; Risk Factors ; Shock, Septic/etiology ; Survival Rate

BACKGROUND/AIMS: Incidence of pyogenic liver abscess (PLA) has been increasing worldwide, especially in the elderly population. Therefore, the aim of this study is to elucidate the clinical features and outcomes of PLA in elderly patients. METHODS: A total of 602 patients diagnosed with PLA from January 2003 to January 2013 were analyzed retrospectively. The patients were divided according to two age groups; > or =65 years (n=296) and <65 years (n=306). RESULTS: The mean age was 73.59+/-5.98 (range, 65-93) years in the elderly group. Significantly higher incidence of females (52.4% vs. 29.1%, p<0.001), hepatobiliary disease (41.2% vs. 24.8%, p<0.001), hepatobiliary procedure (29.4% vs. 13.7%, p<0.001), underlying malignancy (18.2% vs. 4.6%, p<0.001), culture positivity of resistant organism (20.6% vs. 14.4%, p=0.047), occurrence of complication (19.6% vs. 12.8%, p=0.026), and higher white blood cell (13.44+/-6.56 vs. 12.26+/-5.89, p=0.021), but lower rates of right lobe abscess (67.2% vs. 80.4%, p<0.001), fever (68.6% vs. 79.3%, p=0.003), and lower CRP (16.79+/-9.67 vs. 18.80+/-9.86, p=0.012) was observed in elderly PLA patients, compared to younger patients. Regarding complications, elderly patients had higher incidence of septic shock (8.1% vs. 2.3%, p=0.001) and cardiovascular disease (2% vs. 0%, p=0.014). CONCLUSIONS: More atypical presentations and complications tend to occur in elderly PLA patients compared with younger patients. Clinicians should be aware of these age-related differences in PLA and devise management strategies accordingly.
Adolescent ; Adult ; Age Factors ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents/therapeutic use ; Cardiovascular Diseases/epidemiology/etiology ; Child ; Drug Resistance, Bacterial ; Escherichia coli/isolation & purification ; Female ; Humans ; Incidence ; Klebsiella pneumoniae/isolation & purification ; Leukocyte Count ; Liver Abscess, Pyogenic/*drug therapy/epidemiology/microbiology/*pathology ; Male ; Middle Aged ; Prognosis ; Republic of Korea/epidemiology ; Retrospective Studies ; Sex Factors ; Shock, Septic/epidemiology/etiology ; Young Adult