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Summary Objectives Clinical performance measurement in surgical antibiotic prophylaxis (SAP) was implemented as part of a national hospital evaluation program (NHEP) in Korea in 2007. This study investigated changes in SAP quality before and after the implementation of clinical performance measurement. Methods The medical records of patients who underwent three types of surgery that were included for assessment in the NHEP (NHEP surgery) – arthroplasty, gastrectomy, and hysterectomy – and two other types of non-NHEP assessment surgery – craniotomy and spine surgery (non-NHEP surgery) – at six hospitals, from August to October in 2006–2008, were retrospectively reviewed. Three clinical indicators of SAP (antibiotic selection, timing of administration of the first dose, and duration) and the development of surgical site infections (SSIs) were compared before and after implementation. Results A total of 1949 patients were enrolled: 356 arthroplasty, 273 gastrectomy, 615 hysterectomy, 168 craniotomy, and 537 spinal surgery. There were no significant changes in age, gender, wound class, or ASA score for each surgery during the study period. From 2007, SAP quality was significantly improved in NHEP surgery for the three clinical indicators. The timing of administration of the first dose was most markedly improved. SAP quality was also improved in non-NHEP surgery, but not as much as in NHEP surgery. Changes in the SSI rates for each surgery were not significant. Conclusions Hospital evaluation using clinical performance indicators can considerably improve the use of SAP. Further studies are warranted to investigate whether this hospital evaluation will decrease the development of SSIs.

This study was performed to characterize the clinical features and to identify the risk factors for resistance to extended-spectrum cephalosporins (ESCs) and for mortality in patients with Citrobacter freundii bacteremia.105 patients (agedor = 15 years) with C. freundii bacteremia in 1991-2000 were retrospectively analyzed.Nosocomial acquisition was identified in 78.1% of the patients. Hepatic, biliary and pancreatic disease was the most common underlying disease (65.7%) and the biliary tract was the most common site of infection (50.5%). The overall resistance rate to ESCs was 59.0% and was significantly associated with hepatic, biliary and pancreatic disease, recent surgery and procedure, biliary drainage catheter and previous antibiotic therapy in univariate analysis. However, only previous antibiotic therapy with ESCs (OR = 5.0, 95% CI 1.6-15.7, p = 0.006) and recent surgery or procedure (OR = 3.1, 95% CI 1.1-8.4, p = 0.03) were strong, independent risk factors in multivariate analysis. Mortality directly related to C. freundii bacteremia was 21.9% and there was no difference between cases with resistance and susceptibility to ESCs (19.4% vs 25.6%; p = 0.45). Mortality was significantly associated with rapidly fatal or ultimately fatal underlying disease, a solid tumor, septic shock and polymicrobial bacteremia in univariate analysis. Among patients who had therapeutic surgical procedures, mortality was lower (4.5%, p = 0.04). Multivariate analysis revealed rapidly or ultimately fatal disease, septic shock and polymicrobial bacteremia as independent prognostic factors.Biliary infection was the leading cause of C. freundii bacteremia. Previous antibiotic therapy, especially with ESCs, frequently predisposed for resistance to these antibiotics. However, resistance to ESCs was not associated with increased mortality.

To characterize the clinical features of bacteraemia due to tribe Proteeae, 132 cases among 130 patients from 1991 to 2000 were analysed. The organisms included the Proteus species in 63 cases (P. mirabilis in 41, P. penneri in 2 and P. vulgaris in 20), the Providencia species in 8 (P. rettgeri in 3 and P. stuartii 5) and Morganella morganii in 61. Morganella bacteraemia occurred more frequently in the hospital (70.5%). Biliary and hepatic diseases were predominant in cases with Morganella bacteraemia while cardiovascular, urological and neurological diseases were more common in cases with Proteus bacteraemia. Biliary drainage catheters had more frequently been placed in cases with Morganella bacteraemia (39.3%, p < 0.001), and urinary catheters more frequently in cases with Proteus bacteraemia (17.5%). Biliary infection was most common in cases with Morganella bacteraemia (49.2%), while urinary tract infection (UTI) was most common in cases with Proteus bacteraemia (47.6%). Mortality directly related to bacteraemia due to tribe Proteeae was 20.8% (22.6, 50.0 and 15.0% for Proteus, Providencia and Morganella bacteraemia, respectively). In conclusion, Morganella bacteraemia was most frequently associated with biliary infection, while Proteus bacteraemia was most frequently with UTI. Providencia bacteraemia was relatively uncommon and it can be associated with infections other than UTI.

To identify the clinical implications of extended-spectrum β-lactamase (ESBL) production, 162 cases of Klebsiella pneumoniae bacteraemia in 154 adults were analysed. Of these cases, 44 (27.2%) were ESBL-producing (ESBLKP). Common sources of ESBLKP bacteraemia included primary bacteraemia (34.1%) and biliary infection (29.5%). The placement of a biliary drainage catheter, nosocomial acquisition, and prior antibiotic therapy were independently associated with ESBL production in multivariate analysis. More cases of ESBLKP than non-ESBLKP received inappropriate antibiotic therapy before culture results were reported (54.5 vs. 3.4%; P =0.001). In 19 cases of ESBLKP, no significant difference in mortality was observed between patients who received appropriate empiric antibiotic therapy and those who did not (26.3 vs. 20.8%; P =0.67). The mean length of hospital stay after the onset of bacteraemia was longer in the cases of ESBLKP than in the cases of non-ESBLKP (39.6 vs. 23.9 days; P =0.008). Directly related mortality was not significantly different between the cases of ESBLKP and the cases of non-ESBLKP (23.3 vs. 20.0%; P =0.65). None of the patients with biliary infection due to ESBLKP died (0/12; P =0.03). In conclusion, ESBL production was not significantly associated with death but it had a considerable impact on patients with K. pneumoniae bacteraemia.

This retrospective study was conducted to determine the risk factors for resistance to extended-spectrum cephalosporins (ESCs) and to examine the influence of previous use of an aminoglycoside with an ESC on resistance to ESCs in patients with Enterobacter bacteremia from January 1991 through December 2000. A total of 423 episodes of Enterobacter bacteremia among 414 patients were documented during the 10-year study period. Three hundred thirty-two (78%) isolates were Enterobacter cloacae, 72 (17%) Enterobacter aerogenes, and 19 (4%) other Enterobacter species. Causative isolates exhibited resistance to ESCs in 225 episodes and susceptibility in 198 episodes. Nosocomial acquisition was an independent risk factor for resistance to ESCs (odds ratio [OR], 3.4; 95% confidence interval [95%CI], 1.7-6.8). The median number of antibiotics used was significantly greater in cases caused by resistant isolates than in cases caused by susceptible isolates (OR, 1.8; 95%CI, 1.2-2.6). Resistance to ESCs was associated with previous use of any ESC (OR, 5.0; 95%CI, 2.5-10.2). The proportion of resistant episodes in patients treated previously with an aminoglycoside plus an ESC was not different from that in patients treated with an ESC alone. In conclusion, previous use of ESCs was associated with resistance to ESCs in patients with Enterobacter bacteremia; moreover, previous use of an aminoglycoside with an ESC did not significantly decrease the risk of resistance to ESCs.

With the increased use of indwelling central venous catheters, increasing numbers of cases of Rhodotorula fungemia have been observed in patients with neoplasia and neutropenia. In most patients with catheter-related Rhodotorula fungemia, the condition has been treated with broadspectrum antibiotics. We report two cases of central venous catheter-related Rhodotorula rubra fungemia that occurred in patients with acute myeloblastic leukemia. Both patients were in a state of neutropenia. One patient was treated with amphotericin B and his central venous catheter was removed, but he died of Klebsiella pneumoniae bacteremia. The other patient was treated with amphotericin B and discharged, with a central venous catheter, after recovery from neutropenia. Although the management of catheter-related Rhodotorula fungemia infections remains controversial, resolution of the underlying disease is more important than catheter removal for recovery from Rhodotorula rubra fungemia.

624 대한의사협회지 사례: 44세 어머니와 15세 아들이 10일 전부터 4박 5일 동안 필리핀 보라카이로 여름 휴가를 다녀왔다. 3일 전 아 들이 먼저 그 다음날부터는 어머니에게 발열과 두통이 생겼 으며 눈이 아프고 뻑뻑해졌다고 병원에 왔다. 당시 요통이나 관절통은 없었다. 어머니의 체온은 36.7°C였고 얼굴과 양쪽 팔과 다리에 홍반 반점이 나 있었다. 담당의사는 뎅기열일 가능성이 높다고 판단하였다. 병의 경과에 대한 설명을 들은 환자들이 검사(결과가 나중에 나오기 때문에)나 입원을 원하 지 않아 의사는 진료를 종결하였다. 뎅기열은 제4군 법정감염병으로 우리나라에서 가장 흔히 보고되는 해외유입 전염병이다. 뎅기열은 학술문헌에 1995년 처음 보고되었다[1]. 현재까지 국내 발생으로 보고된 사례 는 없고 모두 해외에서 유입되었다. 유입 추정 국가는 90% 이상 동남아시아와 남아시아였다[2]. 질병관리본부 자료 에 따르면 지난 10년 동안 뎅기열 보고건수는 10배 이상 증가하였는데 2013년에는 256건이 보고되었다(Figure 1) [3]. 임상에서 흔히 혈청검사를 의뢰하는 출혈열신증후군이 2013년 563건 보고된 것과 비교하면 뎅기열 보고건수가 어 느 정도 규모인지 짐작할 수 있다. 한편, 한국관광공사 통계 로는 2013년 내국인 출국자가 1,484만 명이었다[4]. 이 중 약 90%가 아시아를 여행하였으며 그 가운데 적어도 400만 명이 동남아시아를 여행한 것으로 추산된다. 성인 여행자에 서 뎅기바이러스 감염은 무증상 감염과 증상 감염이 1:0.8 에서 1:3.3의 비율로 보고되었다. 이런 비율까지 감안한다 면 우리나라에서 실제 뎅기바이러스 감염자는 보고된 수치 보다 훨씬 더 많을 것으로 추정된다. 뎅기바이러스는 열대-아열대 지역에서 전세계적으로 발 견되는데 25억 명 이상(전세계 인구의 40%)이 노출되어 있 으며 100개가 넘는 나라에서 풍토병으로 전파되고 있다. 세계보건기구에 따르면, 전세계적으로 5천만에서 1억 건 의 뎅기감염이 매년 발생하고 이로 인해 50만 건의 입원과 22,000건의 사망이 발생한다[5]. 뎅기감염은 드물게 중증이 나 치명적인 질환으로 진행(악화)하기도 하는데, 중증질환 (뎅기출혈열, 뎅기쇼크증후군)이 발생하는 경우는 뎅기바이 러스 감염의 1% 정도다. 여행자들에게 중증감염이 발생하 는 것은 드물겠으나 해외체류자나 여행자가 많아지면 숫자 는 증가할 것이다. 뎅기바이러스에 감염된 이집트숲모기(Aedes aegypti)나 흰줄숲모기(A. albopictus)에 전파되는 급성 발열성 질환으 로 모기에 물린 지 3-14일(대개 5-9일)만에 증상이 시작된 다. 뎅기바이러스는 무증상 감염으로부터 뎅기열, 뎅기출혈 한국에서 뎅기열을 어떻게 진단할 것인가

To the Editor, Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi, which is found over a wide area of eastern Asia and the western Pacific regions. The gold standard test for the serologic diagnosis of scrub typhus is the indirect immunofluorescence assay (IFA). However, while sensitive, the IFA is expensive and requires considerable training. Moreover, the IFA results are delayed several days in most clinics and hospitals in Korea because the tests are performed in external commercial laboratories rather than in in-house facilities. Therefore, alternative diagnostic methods are needed. In the past two decades, the passive hemagglutination assay (PHA) has been used widely for this purpose, but it has a lower sensitivity, especially during the acute phase of the infection [1,2]. Recently, the immunochromatographic test (ICT) to detect antibodies against O. tsutsugamushi was introduced as a rapid diagnostic test to replace the PHA in Korea. Commercially available ICT kits have been evaluated for early rapid diagnosis at the time of hospital admission of febrile patients in Southeast Asia [3,4]. To our knowledge, the performance of the ICT has not been evaluated in Korea where the predominant genotype of O. tsutsugamushi differs from that found in other geographical areas. To evaluate the diagnostic utility of the ICT in Korea, we assessed the diagnostic sensitivity of the ICT for early rapid diagnosis of scrub typhus in Korean patients. This study included patients with IFA-confirmed scrub typhus who underwent the ICT at the time of hospital admission/visit from September to November 2012 at five hospitals in Korea. IFA tests were performed at the Green Cross Reference Laboratory (Yongin, Korea) to detect IgG, IgM, and IgA antibodies against the standard O. tsutsugamushi antigens from the Gilliam, Karp and Boryong strains. A four-fold rise in IFA titer or a single titer ≥ 1:160 was determined as the diagnostic criterion for scrub typhus [2]. The ICT was performed in the microbiology laboratory at each hospital using commercial kits (SD Bioline Tsutsugamushi Assay, Standard Diagnostics, Yongin, Korea). This test employed the 56-kDa major surface protein antigens from representative O. tsutsugamushi including Gilliam, Karp, and Kato strains to detect IgG, IgM, and IgA antibodies to O. tsutsugamushi. Baseline testing was performed using blood samples collected on the same calendar day. Our study was approved by the Institutional Review Board at each hospital. A total of 273 patients with suspicion of scrub typhus were seen during the study period. Of these, 96 patients had IFA-confirmed scrub typhus; 95 of these underwent an ICT and were enrolled in the study. The median age of the participants was 64 years (interquartile range [IQR], 55 to 73), and 50 patients (52.6%) were female. Of the 95 participants, 78 (82.1%) had eschar. The median fever duration before the first serologic test was 7 days (IQR, 5 to 9). The overall sensitivity of the ICT was 72.6% (Table 1). The positive rate of the ICT increased with the fever duration before the first serologic testing. Table 1 Results of the immunochromatographic test in 95 patients with indirect immunofluorescence assay-confirmed scrub typhus Previous studies evaluating the diagnostic accuracies of different ICTs found that the sensitivities and specificities ranged from 46.3% to 67.9% and 67.9% to 95.1%, respectively, depending on the assay kit [3]. These earlier studies were conducted in Thailand where the Gilliam and Karp strains dominate; using the SD Bioline assay kit, the sensitivity and specificity were 66.7% and 98.4%, respectively [4]. In contrast, the SD Bioline test in our study showed slightly higher sensitivity (72.6%) in Korea where the Boryong strain dominates. The package insert of the SD Bioline test displays high positive results with a sensitivity of 99% and specificity of 96% in Korean patients. The discrepancy in the sensitivities of this SD Bioline test between Southeast Asia and Korea cannot be explained by the different distribution of epidemic strains because the SD Bioline test uses Gilliam, Karp, and Kato antigens. The results of this study showed that the SD Bioline test might be more sensitive than the PHA. Previous studies reported that the detection rates of PHA at the acute stage of illness were as low as 41.5% to 54.3% [1]. The results of this study showed that fever duration before the first serologic testing can affect the ICT results. Other studies using the ICT also demonstrated a low sensitivity at the time of admission, but showed a trend of gradual increase in positivity [3,5]. Therefore, when interpreting the ICT results, clinicians should exercise caution because a substantial number of patients with confirmed scrub typhus were negative for this test, particularly in the early days of illness, as with PHA [1,2]. Our study has several limitations. First, a selection bias might have been present since not all patients seen during the study period received both IFA and ICT. Second, we did not confirm the serotype or genotype of the etiologic organisms, and it is possible that the sensitivities of the serologic tests might vary with the type. Third, we could not determine the specificity and positive or negative predictive values because we did not investigate the incidence of the disease. Lastly, interobserver and intraobserver variability might have been introduced in the interpretation of these tests, which were not performed simultaneously at the same laboratory. Nevertheless, we found that the ICT had moderate sensitivity in Korean patients with scrub typhus, but it might have limited utility at the time of an initial visit. Additional studies to assess the accuracy of the ICT in Korea are required for proper use.

Sixty-seven cases of group B streptococcal bacteremia in adults were retrospectively reviewed during the period 1991-2000. Not one case occurred in pregnant women. The mean age of the patients was 57 years, and 67.2% were men. Of the 67 cases of illness, 25.4% were hospital acquired and 11.9% were polymicrobial. Common predisposing diseases included hepatic disease (55.2%), diabetes mellitus (28.4%), malignancy (20.9%), and cardiovascular diseases (17.9%). Primary bacteremia, peritonitis, bone and joint infections, and skin and soft tissue infections accounted for most presentations. Peritonitis was a more common presentation in patients with hepatic disease (P

Malaria is a parasitic infection caused by Plasmodium species. Most of the imported malaria in Korea are due to Plasmodium vivax and Plasmodium falciparum, and Plasmodium ovale infections are very rare. Here, we report a case of a 24-year-old American woman who acquired P. ovale while staying in Ghana, West Africa for 5 months in 2010. The patient was diagnosed with P. ovale malaria based on a Wright-Giemsa stained peripheral blood smear, Plasmodium genus-specific real-time PCR, Plasmodium species-specific nested PCR, and sequencing targeting 18S rRNA gene. The strain identified had a very long incubation period of 19-24 months. Blood donors who have malaria with a very long incubation period could be a potential danger for propagating malaria. Therefore, we should identify imported P. ovale infections not only by morphological findings but also by molecular methods for preventing propagation and appropriate treatment.

Cat-scratch disease is a self-limited zoonotic disease characterized by regional lymphadenopathy and fever. It is caused by Bartonella henselae, less frequently by B. clarridgeiae, and is transmitted to humans by scratches or bites from cats and dogs. Up to now, only a handful of cases have been reported in Korea. However, the number of pet cats and dogs is increasing in Korea and thus more frequent human contact with cats and dogs is expected. We present a case of cat-scratch disease diagnosed by indirect immunofluorescence assay and analysis of polymerase chain reaction results, and twenty a literature review of Bartonella infections in humans and animals in Korea.

Antibiotics are one of the most commonly produced pharmaceutical agents;production amount of antibiotics reached approximately 1.6 trillion won in 2010. From the doctors' perspective, there were important turning points in the use of antibiotics beyond the 21st century. These include implementation ...

Background: The aim of this study is to clarify the epidemiology of swine-origin influenza A (H1N1) virus 2009 (S-OIV) during the first month of outbreak at one of influenza clinic in Seoul, Korea. Methods: We documented the epidemiologic and clinical features of S-OIV-confirmed cases who visited a university hospital in Northeastern Seoul between August 21 and September 20, 2009. Nasopharyngeal swab of patients with acute febrile respiratory illnesses were evaluated with rapid influenza antigen tests and multiplex RT-PCR for S-OIV and seasonal influenza A. Results: A total of 5,322 patients with acute febrile respiratory illnesses were identified at our influenza clinic for the study period. S-OIV was confirmed in 309 patients by RT-PCR. The patients ranged from 2 months to 61 years of age and 189 patients (61.2%) were teenagers. Eighty-one patients had known contact with S-OIV-confirmed patients in schools (N=61), households (N=15), and healthcare facilities (N=3). Frequent symptoms were fever (94.5%), cough (73.1%), sore throat (52.1%), and rhinorrhea (50.5%). Gastrointestinal symptoms were also present in 10 patients (4.9%). Ten patients (4.9%) required hospitalizations. Seventy patients (22.7%) could not take oseltamivir at the first visits, however, all of them recovered without complication. Rapid antigen tests showed the sensitivity of 44.4% (130/294). Patients with positive antigen tests, compared with negative antigen tests, showed higher frequencies of rhinorrhea (60.8% vs 43.3%, P=0.004) and stuffy nose (33.8% vs 20.1%, P=0.012). Conclusion: S-OIV infections spread predominately in school-aged children during the early accelerating phase of the outbreak. Rapid influenza antigen tests were correlated with nasal discharge and obstruction. (Korean J Clin Microbiol 2010;13:103-108)

대한의학한림원은 지난 31년 동안 우리나라 의학연구 결 과를 조사하여 2007년‘한국 의학연구 업적 보고서 2006’ 을 발표하였다(1, 2). 이에 따르면 우리나라 SCI논문이 기초 의학으로 분류된 미생물학(임상미생물학을 따로 분류하지 않음) 분야는 1974년부터 2004년까지 총 3,235편으로 전체 기초의학 편수(25,339편)의 12.8%를 차지하였으며, 임상의 학으로 분류된 감염 분야는 총 359편으로 전체 임상의학 편 수(33,055편)의 1.1%이었다(1). 최근 보고에서 확인되는 바 와 같이 국내 연구자들이 SCI등재 학술지에 발표하는 해외 논문이 증가하고 있지만(1, 3), 국내 의학 학술지에 게재하는 국내논문 편수는 감소하고 있다고 한다(4). 예를 들어, 2000 년에서 2002년까지 국내 의학 학술지가 69종에서 81종으로 늘었지만 게재 논문 편수는 7,856편에서 7,301편으로 줄었다

Backgrounds :Korean bibliographic databases are used to search and retrieve domestic literature for research purposes. However, doubts about their accuracy, completeness, and coverage have been raised since their development and implementation. There have been controversies as to which database is best for searching domestic medical literature. This study was conducted to investigate the usefulness of Korean bibliographic databases in identifying domestic literature related to microbiology and infectious diseases. Materials and Methods : Four bibliographic databases, including KoreaMed (www.koreamed.org), KISS (kiss.kstudy.com), KMbase (kmbase.medric.or.kr), and RISS (www.riss4u.net), were used for this study. One public bibliographic database, which discontinued its update, and other commercial database services were not evaluated. After performing searches utilizing representative terms related to microbiology and infectious diseases, numbers of retrieved results were compared. The results of bibliographic records gathered by using KoreaMed were compared with those of three other databases; only the journals published from 2001 to 2007 were taken into account. Results : The number of search results retrieved by using each of the four databases ranged from 3 to 5,444 records depending on the search terms. In general, more search results were identified with KMbase and RISS than with KoreaMed and KISS. The concordance rate of the search results, utilizing the same search terms, between KoreaMed and three other databases ranged from 0% to 93.3%. Bibliographic errors including wrong order of authors, misspelled authors’names, use of the old journal title, and duplicate records were found in all databases. Conclusions : Total number of results obtained from each of the four Korean bibliographic databases using the same search terms was different and discordant. Researchers are recommended to take into account their characteristics and limitations when using Korean bibliographic databases for medical researches.

We report on the investigations and interventions conducted to contain an extended outbreak of Serratia marcescens bacteriuria that lasted for years in a neurosurgical intensive care unit (NSICU). A case-control study was performed to identify the risk factors for S. marcescens acquisition in urine. In case patients, urine sampling for tests and central venous catheterization were performed more frequently before the isolation of S. marcescens. Case patients were more frequently prescribed third-generation cephalosporins. Adherence to hand antisepsis was encouraged through in-service educational meetings and infection control measures, especially concerning the manipulation of indwelling urinary catheters, were intensified. The outbreak persisted despite the reinforcement of infection control measures. However, no patient has newly acquired the organism in the NSICU since December 2004. Multiple factors, including inadequate infection control practices and inappropriate antimicrobial usage, possibly contributed to the persistence of this S. marcescens outbreak. Healthcare workers should consistently follow infection control policies to ensure quality care.

Trichosporonosis is a potentially life-threatening infection with Trichosporon beigelii, the causative agent of white piedra. The systemic infection by this fungus has been most frequently described in immunocompromised hosts with neutropenia. Here, we report the first patient with disseminated infection by T. beigelii in Korea, acquired during a period of severe neutropenia after chemo-therapy for myelodysplastic syndrome. The patient recovered from the infection after an early-intensified treatment with amphotericin B and a rapid neutrophil recovery. The disseminated infection by T. beigelii is still rare, however, is an emerging fatal mycosis in immunocompromised patients with severe neutropenia.

연구배경: 기존의 양압환기법은 기관내관이나 기관절개술을 통해서만 시행되어 왔으나 최근 이러한 인공기도에 의한 기도합병증을 피하기 위한 방법으로 안연 또는 코마스크를 환자~인공환기기 사이의 매체로 이용하는 비침습적 환기법 (noninvasive positive pressure ventilation, 이하 NIV라 함)이 시도되고 있다. 이에 저자 등응 급성호흡부전 환자들에서 NIV의 적용 가능성, 치료성공율 및 치료성공과 연관된 지표를 알아보고자 본 연구를 시행하였다. 방법: 대상응 급성 환기부전 (acute vemilarory failure, 이하 VF : $PaCO_2$ > 43 mrn Hg & pH $PaO_2/FIO_2$ $pH{\geq}7.35$ )으로 기계호흡이 필요했던 환자 106 예 중 NIV 시도가 가능한 환자 26명이었으며, 총 VF 19예 중 11 예 (57.9%) (남 : 여 =7 : 4, $55.4{\pm}14.6$ 세), 총 OF 87예 중 15 예 (17.2%) (남 : 여 =12 : 3, $50.6{\pm}15.6$ 세)에서 NIV 시도가 가능하였다. 결과: 1. 기관내삽관 없이 NIV로 기계호흡 이탈까지 성공한 환자는 VF에서 81.8% (9/11), OF에서 40%(6/15)였다. NIV 의 합병증은 코부위 피부괴사와 가스성 위장 팽대 각 1예씩 이었다. 2. 환기부전 환자의 NIV 성공 예 에서 분당호흡 수는 기저치에 비해 NIV 시작 12시간 후(각각 $34{\pm}9$ 회, $26{\pm}6$ 회, p=0.045)에 유의한 감소를 보였다. $PaCO_2$ 와 pH는 모두 기저치에 비해 NIV 시작 24시간 후( $PaCO_2$ 각각 $87.3{\pm}20.6$ , $81.2{\pm}9.1$ mm Hg, p $7.26{\pm}0.04$ , $7.32{\pm}0.02$ , p $PaCO_2$ 는 NIV 시작전 (각각 $59.8{\pm}9.2$ , $76.0{\pm}22.8$ mm Hg), NIV 시작 후 30분 (각각 $121.5{\pm}20.2$ , $99.6{\pm}35.8$ mm Hg,), 6시간 (각각 $100.0{\pm}26.4$ , $76.2{\pm}22.3$ mm Hg) 및 12시간 ( $88.7{\pm}28.7$ , $74.3{\pm}16.7$ mm Hg)에 서로 유의한 차이가 없었으나 (모두 p > 0.05), $PaO_2/FIO_2$ 비는 NIV 성공 예에서는 각각 $120.0{\pm}19.6$ , $218.9{\pm}98.3$ , $191.3{\pm}55.2$ 및 $232.8{\pm}17.6$ mm Hg (p=0.0211)로 상승한 반면, 실패 예에서는 $127.9{\pm}63.0$ , $116.8{\pm}24.4$ , $100.6{\pm}34.6$ 및 $129.8{\pm}50.3$ mm Hg (p=0.5319)로 유의한 상승이 관찰되지 않았다. 결론: 비침습적 환기법은 급성 환기부전군에서 급성 산소화부전에 비해 적용성과 성공율이 높으며, 환기부전의 NIV 성공 예에서는 분당호흡수의 감소가 선행하고 $PaO_2$ 와 pH의 호전이 뒤따랐고 산소화부전에서는 NIV 시작 30분 후의 $PaO_2/FIO_2$ 비가 성공적 NIV 적용 여부의 한 예측 지표가 될 수 있을 것으로 사료되었다. 【Background : We prospectively evaluated the applicability and effect of noninvasive ventilation (NIV) in acute respiratory failure and tried to find out the parameters that could predict successful application of NIV. Methods : Twenty-six out of 106 patients with either acute ventilatory failure (VF: $PaCO_2$ > 43 mm Hg with pH $PaO_2/AO_2$ $pH{\geq}7.35$ ) requiring mechanical ventilation were managed by NIV (CPAP + pressure suppon, or BiPAP) with face mask. Eleven out of 19 cases with VF (57.9%) (M : F=7 : $55.4{\pm}14.6$ yrs) and 15 out of 87 cases with OF (17.2%) (M : F=12 : 3, $50.6{\pm}15.6$ yrs) were s uilable for NIY. Respiratory rates, arterial blood gases and success rate of NIV were analyzed in each group. Results: 81.8% (9/11) of YF and 40% (6/15) of OF were successfully managed on NIV and were weruled from mechanical ventilator without resorting to endotracheal intubation. Complications were noted in 2 cases (nasal skin necrosis 1, gaseous gastric distension 1). In NIV for ventilatory failure, the respiration rate was significantly decreased at 12 hour of NIV ( $34{\pm}9$ /min pre-NIV, $26{\pm}6$ /min at 12 hour of NIV, p=0.045), while $PaCO_2$ ( $87.3{\pm}20.6$ mm Hg pre-NIV, $81.2{\pm}9.1$ mm Hg at 24 hour of NIV) and pH ( $7.26{\pm}0.04$ , $7.32{\pm}0.02$ , respectively, p $PaCO_2$ were not different between the successful and the failed cases at pre-NIV and till 12 hours after NIV. The $PaO_2/FIO_2$ ratio, however, significantly improved at 0.5 hour of NIV in successful cases and were maintained at around 200 mm Hg (n=6 : at baseline, 0.5h, 6h, 12h : $120.0{\pm}19.6$ , $218.9{\pm}98.3$ , $191.3{\pm}55.2$ , $232.8{\pm}17.6$ mm Hg, respectively, p=0.0211), but it did not rise in the failed cases (n=9 : $127.9{\pm}63.0$ , $116.8{\pm}24.4$ , $100.6{\pm}34.6$ , $129.8{\pm}50.3$ mm Hg, respectively, p=0.5319). Conclusion : From the above results we conclude that NIV is effective for hypercapnic respiratory failure and its success was heralded by reduction of respiration rale before the reduction in $PaCO_2$ level. In hypoxic respiratory failure, NIV is much less effective, and the immediate improvement of $PaO_2/FIO_2$ ratio at 0.5h after application is thought to be a predictor of successful NIV.】

Background We estimated the nationwide burden of nosocomial S. aureus bloodstream infection (SA-BSI), a major cause of nosocomial infection, in South Korea. Methods To evaluate the nationwide incidence of nosocomial SA-BSI, cases of SA-BSI were prospectively collected from 22 hospitals with over 500 beds over 4?months. Data on patient-days were obtained from a national health insurance database containing the claims data for all healthcare facilities in South Korea. The additional cost of SA-BSI was estimated through a matched case?control study. The economic burden was calculated from the sum of the medical costs, the costs of caregiving and loss of productivity. Results Three hundred and thirty nine cases of nosocomial SA-BSI were included in the study: 254 cases of methicillin-resistant SA-BSI (MRSA-BSI) and 85 cases of methicillin-susceptible SA-BSI (MSSA-BSI). Death related to BSI occurred in 81 cases (31.9%) of MRSA-BSI and 12 cases (14.1%) of MSSA-BSI. The estimated incidence of nosocomial MRSA-BSI was 0.12/1,000 patient-days and that of nosocomial MSSA-BSI, 0.04/1,000 patient-days. The estimated annual cases of nosocomial BSI were 2,946 for MRSA and 986 for MSSA in South Korea. The additional economic burden per case of nosocomial SA-BSI was US $20,494 for MRSA-BSI and $6,914 for MSSA-BSI. Total additional annual cost of nosocomial SA-BSI was $67,192,559. Conclusion In view of the burden of nosocomial SA-BSI, a national strategy for reducing nosocomial SA-BSI is urgently needed in South Korea. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0590-4) contains supplementary material, which is available to authorized users.