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Background Eosinophilic meningitis is defined as the presence of more than 10 eosinophils per mm3 in the cerebrospinal fluid (CSF), or eosinophils accounting for more than 10 percent of CSF leukocytes in a patient with symptoms or signs suggestive of acute meningitis. Parasites are known to be the most common cause of eosinophilic meningitis worldwide, but there is limited research on patients in South Korea. Methods We retrospectively reviewed patients with eosinophilic meningitis at a tertiary hospital in Seoul, South Korea, from 2004 to 2018. Patients who were suspected of having a non-infectious cause were excluded. Etiology and clinical characteristics such as age, sex, risk factors, symptoms and signs, laboratory and radiologic findings, treatment, and prognosis were identified. Results Of the 35 patients included in this study, 11 (31.4%) had parasitic causes, with 8 (22.9%) diagnosed as neurocysticercosis, and 3 (8.6%) as toxocara meningitis. Four (11.4%) were diagnosed with fungal meningitis, and underlying immunodeficiency was found in 2 of these patients. Tuberculous meningitis was suspected in 4 (11.4%), while viral and bacterial meningitis were rare causes of eosinophilic meningitis, with 2 (5.7%) and 1 (2.9%) patients, respectively. One patient with neurocysticercosis and one patient with fungal meningitis died, while 8 (22.9%) had remaining neurologic sequelae. The etiology was unknown in 13 patients (37.1%). Four of these patients received empirical anti-tuberculosis therapy, while 5 were treated empirically with acyclovir. Conclusion Parasite infections, especially neurocysticercosis and toxocariasis, were the most common cause of eosinophilic meningitis in South Korean patients. Fungal meningitis, while relatively rare, is often aggressive and should always be considered when searching for the cause of eosinophilic meningitis. Disclosures All Authors: No reported disclosures

Background There are limited data in real clinical practice on the diagnostic value of BAL (bronchoalveolar lavage) fluid galactomannan (GM) assay in patients with suspected invasive pulmonary aspergillosis (IPA) who had negative serum GM results. Methods This study was performed at Asan Medical Center, a 2700 bed tertiary-care hospital in Seoul, South Korea between May 2008 and April 2019. All patients with suspected IPA whose serum GM assays revealed negative results and sequentially underwent BAL were enrolled in this study. Patients were classified as proven, probable, possible or not IPA by the revised 2019 EORTC/MSG definition. Results A total of 341 patients with suspected IPA including 4 proven IPA, 38 probable IPA, 107 possible IPA, and 192 not IPA were enrolled. Of these 341 patients, 107 (31%) with possible IPA were excluded from the final analysis. Of 42 patients with proven or probable IPA who had initial negative serum GM results, 24 (57%) revealed positive BAL GM results (n=24) or BAL fungal culture (n=8). Among the remaining 18 (43%), 2 (5%) were diagnosed as proven IPA by the histopathologic exam from transbronchial lung biopsy, 6 (14%) as probable IPA by subsequent sputum fungal culture, and 10 (24%) as probable IPA by repeated serum GM assay after BAL. Of 192 patients with not IPA, 14 (7%) revealed positive BAL GM results (n=14) or BAL fungal culture (n=8). The diagnostic performance of various tests is shown in Table 1. Table 1. Diagnostic performance of various diagnostic tests in patients with suspected IPA who had negative serum GM results Conclusion Sequential BAL in patients with suspected IPA who had initial negative serum GM results provided additional diagnostic yield in about half of patients. Disclosures All Authors: No reported disclosures

Lung transplantation is the only treatment for end-stage lung disease, but the problem of donor shortage is unresolved issue. Herein, we report the first case of living-donor lobar lung transplantation (LDLLT) in Korea. A 19-year-old woman patient with idiopathic pulmonary artery hypertension received her father's right lower lobe and her mother's left lower lobe after pneumonectomy of both lungs in 2017. The patient has recovered well and is enjoying normal social activity. We think that LDLLT could be an alternative approach to deceased donor lung transplantation to overcome the shortage of lung donors., Graphical Abstract

Supplemental Digital Content is available in the text, Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by SFTS virus (SFTSV) which involves multiple organ systems, including lungs. However, there is limited data on lung involvement of SFTS. Therefore, the present study investigated the chest radiographic findings of SFTS, including computed tomography (CT), and compared these with those of scrub typhus, which is the most common tick-borne illness in South Korea and share risk factors and occur in similar settings. Medical records of patients with confirmed SFTS and scrub typhus in a tertiary hospital in Seoul (South Korea), between January 2014 and June 2018, were reviewed. Initial chest radiography and CT were reviewed by 2 experienced radiologists. A total of 39 patients with SFTS and 101 patients with scrub typhus were analyzed. All patients except 3 patients with scrub typhus in both groups received chest radiography. Cardiomegaly (90%) and patchy consolidation with ground glass opacity (GGO) pattern (31%) were more common in SFTS group than scrub typhus group (20%, P

Highlights • We compared severe human metapneumovirus-associated community-acquired pneumonia (CAP) and influenza virus-associated CAP. • Human metapneumovirus accounted for 3.2% of severe CAP cases. • Influenza virus accounted for 7.0% of severe CAP cases. • Coinfection was more common in severe influenza virus-associated CAP patients. • The two groups had similar overall mortality rates., Background The outcomes of severe human metapneumovirus (HMPV)-associated pneumonia have not been adequately evaluated. Objectives We aimed to investigate the incidence and outcomes of severe HMPV-associated CAP and to compare them with those of severe IFV associated CAP. Study design From March 2010 to August 2017, all consecutive adult patients with severe HMPV-associated CAP and severe influenza virus (IFV)-associated CAP who required intensive care unit admission were prospectively identified and followed in a 2,700-bed tertiary care hospital. The characteristics and outcomes of severe HMPV-associated CAP patients were compared with those of severe IFV-associated CAP patients. Results HMPV and IFV were identified in 3.2% (50) and 7.0% (109) of the 1559 patients with severe CAP, respectively. The mortality rates were not significantly different between the HMPV and IFV groups (30-day mortality: 24.0% vs. 32.1%, p = 0.30; 60-day mortality: 32.0% vs. 38.5%, p = 0.43). Oral ribavirin therapy was not associated with improved outcome (60-day mortality: ribavirin therapy group 35.0% [7/20] vs. no ribavirin therapy group 30.0% [9/30], p = 0.71). Subgroup analyses showed no significant differences in mortality among non-immunocompromised (60-day mortality: HMPV 25.6% vs. IFV 31.1%, p = 0.55) and immunocompromised patients (60-day mortality; HMPV 54.5% vs. 54.3%, p = 0.99). The length of ICU and hospital stay did not differ between groups. Conclusions The incidence of HMPV infection was approximately half that of IFV infection in a cohort of patients with severe CAP. The mortality rate of severe HMPV-associated CAP was similar to that of severe IFV associated CAP.

We report the design and synthesis of a novel chemosensor (Rh6G-Cin) rhodamine-based indicator for selective detection of Zn2+ ion. Rh6G-Cin displayed high selectivity towards Zn2+ from various metal ions, including Ca2+, Ag+, Cd2+, Co2+, Cu2+, Al3+, Zn2+, Cr3+, Ba2+, Fe2+, Fe3+, Gd3+, Hg2+, Mg2+, Mn2+, Nd3+, Pb2+, Sr2+ and Ni2+, and the resultant complex is [Rh6G-Cin-Zn2+]. The obvious change from colorless to pink upon the addition of Zn2+ could make it a suitable "naked eye" indicator for Zn2+. More significantly, the sensor displayed a remarkable colorless to yellowish green fluorescence switch in the presence of Zn2+ ions. The ring-opening mechanism of the rhodamine spirolactam was induced by Zn2+ binding, and the 3:1 stoichiometric structure between Rh6G-Cin and Zn2+ was adequately supported by the Job's plot evaluation, optical titration and 1H NMR results.

Objectives Statins, which are lipid-lowering agents, have anti-inflammatory and immunomodulatory properties that may affect the occurrence of various infectious diseases. We assessed whether statins increase the risk of herpes zoster (HZ) with propensity score-matching. Methods The study was based on the National Health Insurance database and its subset database of the “medical check-up” population of South Korea. These cohorts consist of about one million and 570,000 people, respectively, representative of the entire population of South Korea. We identified 103,930 statin users and 430,685 non-statin users. After propensity score-matching, 25,726 statin users and the same number of non-statin users were finally analyzed. The development of HZ was monitored in these matched pairs over the 11 years from 2003 to 2013. Results Statin users had a significantly higher risk of HZ than non-statin users: hazard ratio (HR) 1.25 (95% CI, 1.15 to 1.37) (p < .0001). The risk of HZ associated with statins was especially high in the elderly: HR 1.39 (95% CI, 1.12 to 1.73) in the over 70-year-olds (p = 0.003) and HR 1.18 (95% CI, 1.00 to 1.39) in the 60-to-69-year-olds (p = 0.056). Furthermore, there was a significant p for trend in terms of cumulative dose effect between the risk of HZ and the duration of statin use (p < .0001). Conclusions These epidemiologic findings provide strong evidence for an association between HZ and statin use, and suggest that unnecessary statins should be avoided.

Background Trimethoprim/sufamethoxazole (TMP/SMX) is the recommended treatment for Pneumocystis jirovecii pneumonia (PCP). However, the efficacy and the safety of alternative salvage treatments are less guarauteed especially when patient experiences treatment failure and/or an adverse drug reactions (ADR). The purpose of this study is to recognize potential risk factors imitating successful treatment with TMP/SMX among PCP patients. Materials and methods Ninety one adult patients diagnosed with PCP were included after searching electronical medical records from January 2013 through July 2015 at Asan Medical Center Seoul, Korea. We compared clinical characteristics and laboratory findings including bronchoalveolar lavage (BAL) fluid analysis in patients who experienced TMP/SMX treatment failure or ADR (the case group) versus those who did not (the control group). Results Among the enrolled PCP patients, 39 (42.9%) required salvage treatment owing to either treatment failure (28, 28.6%) and/or ADR (17, 18.7%). The BAL lymphocyte percentage (25% [IQR, 8-40%] vs. 47% [IQR, 15-62%]; P = 0.005) was lower in the case group. Diabetes mellitus (adjusted odds ratio [aOR] 4.98, 95% confidence interval [95% CI] 1.20-18.58), glomerular filtration rate ≤50 mL/min (aOR 4.48, 95% CI 1.08-18.66), and BAL lymphocyte percentage ≤45% (aOR 9.25, 95% CI 2.47-34.58) were independently associated with the case group in multivariate analysis. Conclusion This study suggests that BAL lymphocyte count may play some role during PCP treatment. Further studies should be followed to reveal what the role of BAL lymphocyte is in the PCP treatment.

The detailed kinetics of the cytomegalovirus (CMV)-specific T cell response in hematopoietic stem cell transplant (HCT) recipients have not yet been fully assessed. We evaluated these kinetics of CMV-specific T cell response and factors associated with high CMV-specific T cell responses 1 year after HCT. In HCT recipients, CMV pp65 and IE1-specific ELISPOT assay were performed before HCT (D0), and at 30 (D30), 90 (D90), 180 (D180), and 360 (D360) days after HCT. Of the 51 HCT recipients with donor-positive (D+)/recipient-positive (R+) serology, 26 (51%) developed CMV infections after HCT. The patterns of post-transplantation reconstitution for CMV-specific T cell response were classified into 4 types: 1) an initial decrease at D30 followed by gradual T cell reconstitution without CMV infection (35%), 2) an initial decrease at D30 followed by gradual T cell reconstitution preceded by CMV infection (35%), 3) failure of gradual or constant T cell reconstitution (26%), and 4) no significant T cell reconstitution (4%). There was no significant difference between ELISPOT counts of D360 and those of D0. High CMV-specific T cell responses at D360 were not associated with high CMV-specific T cell response at D0, CMV infection, ganciclovir therapy, graft versus host disease (GVHD), and immunosuppressant use. In conclusion, there are 4 distinct patterns of reconstitution of the CMV-specific T cell response after HCT. In addition, reconstituted donor-origin CMV-specific T cell responses appeared to be constant until day 360 after HCT, regardless of the level of the pre-transplant CMV-specific T cell response, CMV infection, and immunosuppressant use.

Background National surveillance data should be validated to identify data quality issues. This study tested the validity of healthcare-associated infection (HAI) data in the Korean National Healthcare-associated Infections Surveillance System (KONIS), intensive care unit (ICU) module. Methods The validation process consisted of external (EV) and internal (IV) validation phases. For the 10 hospitals that were selected based on the HAI rate, among the 193 participating hospitals between July 2016 and June 2017, both EV and IV were performed. For the EV, the validation team reviewed 295 medical records of 60 patients with reported HAIs, including 20 urinary tract infections (UTIs), 27 bloodstream infections (BSIs), and 13 cases of pneumonia (PNEU), and 235 patients with no reported HAI during 1-day visits conducted in November and December 2017. The reviewer’s diagnosis of HAI was regarded as the reference standard. IV was conducted by the staff of each hospital and evaluated whether UTI or BSI were present. Primary IV was performed for 279 patients who were subject to EV. Secondary IV was performed on 203 patients in another 11 selected participating hospitals that did not report HAIs to KONIS during the 1-year study period. Results In the EV, the diagnosis of UTI in the participating hospitals had a sensitivity of 72.0% and specificity of 99.3%. The sensitivity of BSI and PNEU was 63.2% and 70.6%, respectively, and specificity was 98.8% and 99.6%. The agreement (kappa) between the EV and primary IV was significant, with κ = 0.754 for UTI and κ = 0.674 for BSI. The results of the secondary IV showed that the hospitals that had no reports of HAI had few hospital beds and performed few blood or urine culture tests. In the secondary IV, eight UTIs and three BSIs were newly diagnosed in three hospitals, respectively. The reasons for not reporting the HAIs were presumed to be a lack of understanding of the surveillance standards and fear of the disadvantages of disclosing the HAI. Conclusion This study shows the need for ongoing validation and continuous training of surveillance personnel to maintain the accuracy of surveillance data. We also confirmed that IV can be used as an alternative monitoring method to examine validity and accuracy. Disclosures All authors: No reported disclosures.

Background There is a growing concern on infections with multiple organisms including fungi in patients with mucormycosis. However, limited data are available on co-infection in patients with mucormycosis. Methods Patients with proven mucormycosis were retrospectively enrolled at a tertiary hospital from July 2009 to January 2019. Proven mucormycosis was defined as positive fungal culture result for mucormycosis from a sterile biopsy specimen and/or histologic evidence of tissue invasion of hyphae with positive mucormycosis immunohistochemistry test result. We reviewed other pathogens isolated from sterile or non-sterile sites before and after 7 days from the biopsy for infected tissue that suggested invasive fungal infection. Results A total of 61 patients with proven mucormycosis were analyzed. The primary site of infection was as follows; lung (n = 38, 62.3%), rhino-sinus (n = 21, 34.4%), and orbito-cerebral (n = 15, 24.6%). Based on sterile culture results, 4 patients (6.6%) had the evidence of co-infection with other fungi including Candida species (from 3 cases; C. albicans from 1, C. glabrata from 1 and C. krusei from 1), A. flavus (1), and F. solani (1), and 23 patients (37.7%) had the evidence of co-infection with bacteria including E. faecium (VRE) (8), P. aeruginosa (5),coagulase-negative staphylococci (5), methicillin-susceptible S. aureus (4) and others. Based on non-sterile culture results, 10 patients (16.4%) had the evidence of co-infection with fungi other than mucormycosis including Aspergillus species (5, A. fumigatus from 1, Aspergillus not fumigatus from 1 and A. oryzae from 1), Candida species (5, C. albicans from 2, C. tropicalis from 2 and C. glabrata from 1), Penicillium species (1), S. cerevisiae (1) and P. jirovecii (1), and 24 patients (39.3%) had evidence of bacterial co-infection including S. maltophilia (5), methicillin-resistant S. aureus (5), E. faecium (VSE) (3), K. pneumonia (3), P. aeruginosa (3), and others. Conclusion Bacterial or fungal co-infections appear to frequently occur as appreciated before in patients with mucormycosis. These data provide us important information to select empirical antifungal and antibacterial agents. Disclosures All authors: No reported disclosures.

Background Carbapenem-resistant Acinetobacter baumannii (CRAB) infection is an emerging clinical issue and shows high mortality rates. There are a few studies that have evaluated the microbiologic risk factors for mortality in CRAB bacteremia. Aim of this study is to identify the clinical and microbiologic risk factors for mortality in CRAB bacteremia. Methods Adult patients with monomicrobial CRAB bacteremia at a 2,700-bed tertiary hospital between December 2012 and December 2018 were retrospectively enrolled in the study. Risk factors for 30-day mortality were evaluated through a detailed clinical and microbiological analysis of study patients. All isolates collected on the first day of bacteremia were subjected to colistin susceptibility testing by broth microdilution and genotyping by multilocus sequence typing (MLST). Results A total of 164 patients were enrolled and 90 (55%) died within 30 days. Of the 164 patients, 111 (68%) were male and median age was 66.5 years. The most common MLST genotype was ST191 (80 isolates, 49%), followed by ST451 (14%) and ST784 (13%), and 12 (7%) isolates were resistant to colistin (MIC ≥4 mg/L). Deceased patients were more likely to have hematologic malignancy, neutropenia, pneumonia, and primary bacteremia; less likely to have solid tumor, catheter-related infection, and biliary tract infection; more likely to have a high Pitt bacteremia score; and less likely to receive appropriate antibiotic treatment, colistin, and combination therapy with colistin and tigecycline, compared with surviving patients (Table 1). Genotype, colistin MIC, and colistin resistance were not associated with mortality (Figure 1 and 2). In multivariable analysis, neutropenia (aOR, 3.25; 95% CI, 1.18–8.95), catheter-related infection (aOR, 0.33; 95% CI, 0.11–0.99), biliary tract infection (aOR, 0.20; 95% CI, 0.04–0.99), a high Pitt bacteremia score (aOR,1.42; 95% CI, 1.20–1.67), and combination therapy with colistin and tigecycline (aOR, 0.36; 95% CI, 0.14–0.92) were independent risk factors for mortality (Table 2). Conclusion Clinical factors such as the site of infection, severity of bacteremia, and specific combination therapy rather than microbiologic factors contributed to mortality in CRAB bacteremia. Appropriate combination therapy may help improving outcomes in CRAB bacteremia. Disclosures All authors: No reported disclosures.

Background Whereas Clostridium difficile enterocolitis has been well studied, data regarding extraintestinal C. difficile infection remain scarce and anecdotal. We investigated characteristics and prognostic factors in patients with extraintestinal C. difficile infection at a large university hospital over a recent 20-year period. Methods We conducted a retrospective cohort study of patients at a 2,700-bed tertiary care hospital from January 1997 through December 2018 whose extraintestinal clinical specimen revealed C. difficile. Gastrointestinal (GI) disruption was defined as compromised integrity of the GI tract by abdominal surgery, perforation, malignancy, or bleeding. Patients were divided into 3 groups: group A (GI disruption with malignancy, n = 15); group B (GI disruption without malignancy, n = 23); group C (No GI disruption or malignancy, n = 24). The main outcome was 30-day all-cause mortality. Results A total of 62 patients were enrolled, and the incidence of extraintestinal C. difficile infection was 2.81 per 100,000 admissions. Median age was 56 years and 36 (58.1%) of the patients were men. Seven patients (11.3%) had confirmed C. difficile enterocolitis, and 38 patients (61.3%) had a polymicrobial infection. C. difficile bacteremia was identified in 22 patients (35.5%) and was significantly more common in group A (60.0% [9/15]) than groups B (43.5% [10/23]) or C (12.5% [3/24]) (P = 0.01). Thirty-day mortality rates were also significantly higher in group A than groups B or C (60.0% [9/15] vs. 13.0% [3/23] and 16.7% [4/24], respectively; P < 0.001) (Figure 1). C. difficile bacteremia (P = 0.16), polymicrobial infection (P = 0.91), and antimicrobial therapy for C. difficile (P = 0.48) were not significantly associated with 30-day mortality. In a multivariate analysis, group A was an independent risk factor for 30-day mortality. (adjusted odds ratio; 7.29 [95% confidence interval; 1.68–31.68], P = 0.01). Conclusion Extraintestinal C. difficile infection was not commonly associated with C. difficile enterocolitis. Extraintestinal C. difficile infection accompanied by GI disruption with malignancy was associated with significantly poorer outcomes. Disclosures All authors: No reported disclosures.

Background Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne disease often accompanied by immune catastrophic course and subsequent fatal outcome. More than 90% of patients with SFTS had leukopenia and about one-third of those need the admission of intensive care unit (ICU) during the hospital course. So, there has been growing concern about the complications such as invasive pulmonary aspergillosis (IPA) in critical SFTS patients. We thus investigate the incidence and clinical characteristics of IPA in patients with SFTS. Methods All patients who were confirmed as SFTS in a tertiary care hospital, Seoul, South Korea, between January 2013 and October 2018 were enrolled. The modified AspICU algorithm was used to identify cases of putative invasive pulmonary aspergillosis (PIPA) and discriminate these invasive diseases from colonization. Results Of the 45 PCR-confirmed SFTS patients, 16 (36%) received ICU care. Of these 16 patients, 9 (56%) developed PIPA during hospitalization. The median duration from admission to the first evidence of PIPA was 8 days (range, 2–11 days). None of the PIPA cases met the revised EORTC/MSG criterion. Septic shock and corticosteroid administration preceded more frequently in PIPA group than non-PIPA group (100% vs. 19%, P < 0.0001 and 67% vs. 14%, P = 0.003, respectively). Patients complicated by PIPA showed significantly higher mortality than non-PIPA patients (44% vs. 8%, P = 0.048 by log-rank test). Mortality was lower in patients with PIPA who received antifungal treatment (17% [1/6]) than in those with PIPA who did not (100% [3/3]) (log-rank test, P = 0.002). Conclusion More than half of patients with SFTS in ICU were complicated by IPA during early hospital course. Cautious scrutiny for IPA in patients with SFTS followed by early appropriate antifungal therapy for IPA is needed. Disclosures All authors: No reported disclosures.

Background There is a concern that the vancomycin MIC of methicillin-resistant Staphylococcus aureus (MRSA) could be increased by concomitant colistin administered against multidrug-resistant gram-negative pathogen. Methods We confirmed the molecular genotypes of MRSA blood isolates collected in a tertiary hospital in Seoul, South Korea, and selected representative strains from the community-associated MRSA strains (CA-MRSA, ST72-SCCmec IV) and hospital-acquired MRSA strains (HA-MRSA, ST5-SCCmec II). USA CA-MRSA (USA300, ST8-SCCmec IV) and MRSA standard strain (ATCC 43300, ST39-SCCmec II) were also used for comparison with representative. We identified changes of the vancomycin MIC in MRSA by colistin exposure in a checkerboard assay and performed a time-kill assay to evaluate the combined effect of vancomycin and colistin on MRSA. In addition, we administered vancomycin, colistin, and combination of two antibiotics, respectively, to a neutropenic murine thigh infection model to evaluate the in vivo antagonistic effect of colistin on vancomycin treatment. Results In the checkerboard assay, all 4 MRSA strains showed a tendency for the vancomycin MIC to increase along with increasing concentrations of colistin. However, the time-kill assay showed the antagonism of vancomycin and colistin only against ST5-MRSA, when vancomycin concentration was 2 times the vancomycin MIC (Figure 1). No antagonism was observed in other strains. In the murine thigh infection model of ST5-MRSA, vancomycin monotherapy showed a significant log CFU reduction compared with a combination of vancomycin and colistin at 24 hours, demonstrating the antagonistic effect of vancomycin and colistin combination (Figure 2). Conclusion This study showed that exposure of colistin to certain MRSA strains may reduce the susceptibility to vancomycin. Combination therapy with vancomycin and colistin for MDR pathogens infections might result in treatment failure for concurrent MRSA infection. Disclosures All authors: No reported disclosures.

Background Carbapenem-resistant Enterobacteriaceae (CRE) infection is an emerging clinical issue. One of the mechanisms of carbapenem-resistance is carbapenemase production. This study aimed to identify whether clinical outcomes differ by CRE resistance mechanism and to evaluate risk factors for mortality in patients with CRE bacteremia. Methods We conducted a retrospective cohort study comparing 14-day mortality between patients with carbapenemase-producing (CP)-CRE and non-CP-CRE bacteremia during January 2011 to October 2018. Only monomicrobial Escherichia coli or Klebsiella pneumoniae bacteremia were included in the study. A modified carbapenem inactivation method was used for phenotypic detection of carbapenemase production. The presence of a variety of carbapenemase genes was evaluated by PCR with specific primers. Results Of 134 patients with monomicrobial CRE bacteremia, 48 (35.8%) were infected with CP-CRE, and 86 (64.1%) were infected with non-CP-CRE. The most common carbapenemase in CP-CRE isolates was KPC (66.7%), followed by NDM-1 (18.8%), OXA-48-like (10.4%), and VIM (4.1%). Baseline characteristics were similar between the two groups (Table 1). However, the CP-CRE group was significantly more likely to undergo removal of eradicable foci and to have meropenem MIC >8 µg/mL. A total of 33 (24.6%) patients died within 14 days, including 9 (18.8%) in the CP-CRE group and 24 (27.9%) in the non-CP-CRE group. Deceased patients were more likely to have a higher Pitt bacteremia score, nosocomial acquisition, ineradicable or not-eradicated foci, immunosuppressant use, inappropriate definitive treatment (Table 2). Combination therapy for definitive treatment was associated with decreased mortality. In a multivariate analysis including carbapenemase production, a higher Pitt bacteremia score (aOR, 5.15), ineradicable or not-eradicated foci (aOR, 4.05) and combination therapy for definitive treatment (aOR, 0.35) were independent risk factors for mortality. Conclusion Our study suggests that carbapenemase production is not a mortality risk factor in CRE bacteremia and provides additional evidence for early source control and combination therapy. Disclosures All authors: No reported disclosures.

Functional disability may persist after completing treatment for hematogenous pyogenic vertebral osteomyelitis (HPVO). The objective of this study was to identify factors associated with residual sequelae after treatment of HPVO.We conducted a retrospective study of patients diagnosed with HPVO at 5 tertiary-care hospitals between January 2005 and December 2012. Sequelae were defined as an inability to walk without assistance, bladder/bowel incontinence, and/or unresolved pain that required analgesic therapy at 12 months after completing the HPVO treatment.Of the 279 patients with microbiologically proven HPVO, 79 (28.3%) had sequelae at 12 months posttherapy. Independent risk factors for sequelae were neurologic deficit (adjusted odds ratio [aOR], 3.38), recurrence within 12 months (aOR, 2.45), age ≥ 65 years (aOR, 2.05), C-reactive protein level ≥ 10 mg/dL (aOR, 2.01), and epidural/paravertebral abscess (aOR, 2.00). Among 58 patients with neurologic deficit, sequelae rates differed according to the surgical strategy, as follows: 28.6% (early surgery [48 h]), 55.0% (delayed surgery [≥48 h]), and 66.7% (no surgery) (P = 0.03). Among the 170 patients with abscess, early drainage (72 h) was an independent protective factor for sequelae (aOR, 0.35). The 12-month recurrence rates differed according to the total duration of antibiotic treatment, as follows: 20.5% (4-6 weeks), 18.4% (6-8 weeks), and 5.2% (≥8 weeks) (P 0.001).A substantial proportion of patients with HPVO experienced sequelae after completing treatment. Early surgery for neurologic deficit, early drainage of abscess, and antibiotic therapy of appropriate duration to reduce recurrence may prevent development of sequelae in patients with HPVO.

Background: Interferon (IFN)-γ-releasing assay for diagnosing tuberculosis (TB) has shown promise; however, there are only a few reports on usefulness of the QuantiFERON-TB Gold In-Tube test (QFT-GIT) for diagnosing TB vertebral osteomyelitis. Methods: All patients presenting at a tertiary hospital between January 2010 and July 2016 with suspected TB vertebral osteomyelitis were retrospectively enrolled to evaluate the diagnostic performance of QFT-GIT. We used QFT-GIT to measure the IFN-γ response to ESAT-6, CFP-10 and TB7.7. Results: A total of 141 patients were enrolled; 32 (23%) were categorized as having confirmed TB, (1%) as probable TB, 14 (10%) as possible TB and 93 (66%) as not TB. Of these, 16 patients with probable and possible TB were excluded from the final analysis. Chronic granulomas with/without necrosis, acid-fast bacilli stain, M. tuberculosis polymerase chain reaction and cultures for M. tuberculosis were positive in 14 (44%), 12 (38%), 22 (69%) and 28 (88%) patients, respectively, among the 32 patients with confirmed TB. The overall sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio for a positive result, and likelihood ratio for a negative result of the QFT-GIT for TB vertebral osteomyelitis were 91% (95% confidence interval [CI], 75–98%), 65% (95% CI, 54–75%), 50% (95% CI, 42–58%), 95% (95% CI, 86–98%), 2.59 (95% CI, 1.89–3.55) and 0.14 (95% CI, 0.05–0.43), respectively. Conclusion: The QFT-GIT appears to be a useful adjunct test for diagnosing TB vertebral osteomyelitis because the negative test results may be useful for excluding a diagnosis of active TB vertebral osteomyelitis.

Summary Objectives The IFN-γ-release assay (IGRA) cannot differentiate active tuberculosis (TB) from latent TB infection (LTBI). We hypothesized that the TNF-α-release assay (TARA) combined with IGRA might discriminate active TB from not active TB without LTBI. Methods Adult patients with suspected TB, and with unrelated diseases such as herpes zoster as controls, were enrolled in an intermediate TB-burden country. Patients with confirmed or probable TB were regarded as active TB, and patients with not active TB were further classified as those having not active TB with and without LTBI based on IGRA results. The IGRA and TARA by using ELISPOT assays were performed on peripheral mononuclear cells. Results Thirty six patients with active TB and 53 patients including 18 not active TB with LTBI and 35 not active TB without LTBI were finally included. The sensitivity and specificity of the IGRA for those patients found to have active TB were 94% (CI, 80-99) and 66% (CI 52-78), respectively. Combining the IGRA and the TARA substantially increased the specificity for active TB (93%, CI, 82-98; P = 0.001) compared with the IGRA only, without compromising sensitivity (89%, CI, 73-96; P = 0.67). Conclusions Combining the IGRA and TARA appears to be useful for diagnosing active TB.

Background Distinguishing aspergillosis from mucormycosis is clinically important as different antifungal agents are required. However, the sensitivity of fungal culture is suboptimal and histomorphologic diagnosis is not always accurate due to morphologic similarities. We investigated the diagnostic performance of immunohistochemistry (IHC) test for diagnosis of aspergillosis and mucormycosis. Methods Patients who met the criteria for mycologically proven aspergillosis or mucormycosis and in whom formalin-fixed, paraffin-embedded tissues were available were enrolled at a tertiary hospital from January 1992 to October 2017. Mycologically proven invasive fungal infections were defined as there were the histologic evidence of tissue invasion of hyphae and the recovery of Aspergillus species or agents of mucormycosis (Rhizopus spp., Cunninghamella spp., Apophysomycesspp., Saksenaea spp., Absidia spp., Mucor spp.) by culture from sterile specimens. Anti-Aspergillus mouse monoclonal antibody (1:50; clone WF-AF-1; LSBio, WA, USA) and anti-Rhizopus arrhizus mouse monoclonal antibody (1:100; clone WSSA-RA-1; LSBio, WA, USA) were used for IHC test, and we evaluated the diagnostic performance of IHC test using sensitivity and specificity. Results A total of 32 invasive fungal infection including 12 proven mucormycosis and 20 proven aspergillosis were analyzed. The fungal species from sterile sites and diagnostic performance of IHC test for these 30 patients were shown in Table 1. Conclusion The IHC test seems to be useful in compensating the limitations of histomorphologic diagnosis in distinguishing between aspergillosis and mucormycosis. Keywords. Aspergillosis; Mucormycosis; Histomorphology; Immunohistochemistry Table 1: Diagnostic Performance of Mucormycosis and Aspergillosis Immunohistochemistry Tests in Proven Mucormycosis and Proven Aspergillosis IHC Test Result Proven Mucormycosis,No. of Cases (n = 12) Proven Aspergillosis,No. of Cases (n = 20) Diagnostic Performance% (95% CI) Mucormycosis Positive 12 0 Sensitivity: 100(70–100) Negative 0 0 Specificity: 100 (80–100) Aspergillosis Positive 0 18 Sensitivity: 90(67–98) Negative 0 2 Specificity: 100(70–100) Abbreviations: CI, confidence interval; IHC, immunohistochemistry. Disclosures S. H. Kim, the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI): Investigator, Grant recipient.

Severe acute respiratory distress syndrome (ARDS) is a life-threatening disease with a high mortality rate. Although many therapeutic trials have been performed for improving the mortality of severe ARDS, limited strategies have demonstrated better outcomes. Recently, advanced rescue therapies such as extracorporeal membrane oxygenation (ECMO) made it possible to consider lung transplantation (LTPL) in patients with ARDS, but data is insufficient. We report a 62-year-old man who underwent LTPL due to ARDS with no underlying lung disease. He was admitted to the hospital due to influenza A pneumonia-induced ARDS. Although he was supported by ECMO, he progressively deteriorated. We judged that his lungs were irreversibly damaged and decided he needed to undergo LTPL. Finally, bilateral sequential double-lung transplantation was successfully performed. He has since been alive for three years. Conclusively, we demonstrate that LTPL can be a therapeutic option in patients with severe ARDS refractory to conventional therapies.

Summary Objectives Clinical and radiologic deterioration is sometimes observed during neutrophil recovery in patients with invasive pulmonary aspergillosis (IPA). This deterioration can be caused by immune reconstitution inflammatory syndrome (IRIS) as well as by progression of the IPA. However, there is limited data on IRIS in neutropenic patients. Methods Over a 6-year period, adult patients with neutropenia who met the criteria for probable or proven IPA by the revised EORTC/MSG definition were retrospectively enrolled. IRIS was defined as de novo appearance or worsening of radiologic pulmonary findings temporally related to neutrophil recovery, with evidence of a decrease of 50% in serum galactomannan level. Results Of 153 patients, 36 (24%, 95% CI 18%–31%) developed IRIS during neutrophil recovery. More of these patients received voriconazole than did those with non-IRIS (42% vs. 25%, P = 0.05). Thirty- and ninety-day mortalities were lower in the patients with IRIS than in those with non-IRIS (11% vs. 33%, P = 0.01, and 33% vs. 58%, P = 0.01, respectively). Conclusion IRIS is relatively common among neutropenic patients with IPA, occurring in about one quarter of such patients. It is associated with voriconazole use and has a good prognosis.

The usefulness of bronchoalveolar lavage (BAL) fluid cellular analysis in non-human immunodeficiency virus (HIV)-infected patients with Pneumocystis jirovecii pneumonia (PCP) has not been adequately evaluated. The objective of this study was to analyze the cellular profiles of BAL fluid and to evaluate their prognostic significance in non-HIV-infected patients with PCP. A 7-year retrospective cohort study of 166 non-HIV-infected adult patients with PCP who underwent BAL was performed in a tertiary care hospital. The median total BAL fluid white blood cell count was 180/μl (interquartile range, 80 to 330) and was unaffected by the severity of PCP. The median percentages of BAL fluid neutrophils, lymphocytes, and alveolar macrophages were 13.1%, 31.7%, and 30.2%, respectively. The median percentage of BAL fluid neutrophils was significantly higher in severe than in mild-to-moderate PCP (20.4% versus 6.0%, P < 0.001), as was the absolute neutrophil count (24/μl versus 13/μl, P = 0.001). The percentage of BAL fluid neutrophils was an independent predictor of 30-day (adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI], 1.01 to 1.03) and 60-day (aOR, 1.02; 95% CI, 1.01 to 1.04) mortalities. The 30-day and 60-day mortalities increased at rates of 15% ( P = 0.006) and 21% ( P < 0.001) per 10% increment of BAL fluid neutrophil levels, respectively. The degree of BAL fluid pleocytosis was relatively low without regard to the severity of PCP. The percentage of BAL fluid neutrophils can be used as a prognostic marker in non-HIV-infected patients with PCP.

Background Human rhinoviruses (HRVs) have increasingly been reported to be associated with lower respiratory tract infections. HRV-C has been associated with more severe respiratory illnesses in children. Objectives We investigated the clinical and molecular characteristics of HRV-A, HRV-B, and HRV-C in adults with pneumonia. Study design HRV genotyping and quantitative real-time reverse-transcriptase polymerase chain reaction were performed on 392 adult respiratory specimens consecutively collected from June 2012 to May 2013. Pneumonia was identified by review of medical records and chest radiographs. Results Adult patients with pneumonia and identified HRV genotypes ( n = 165) were included. HRV-A, HRV-B, and HRV-C were identified in 97, 28, and 40 patients, respectively. No differences in underlying diseases, APACHE II score, or frequency of co-infection were observed between the HRV species. Compared with HRV-A, HRV-B was more often associated with neutropenia (21.4% vs. 7.2%, p = 0.07), hospital acquisition (32.1% vs. 7.2%, p = 0.048), and fever (78.6% vs. 49.3%, p = 0.003). Mean viral load (copies/ml) was lower for HRV-B (10 2.6 vs. 10 4.1 in HRV-A and 10 4.3 in HRV-C), and high viral loads (≥10 4 ) occurred most frequently with HRV-C (70.0% vs. 57.7% for HRV-A and 21.4% for HRV-B). The incidence of severe pneumonia was similar for HRV-A (18.6%), HRV-B (21.4%), and HRV-C (20.0%), and in-hospital mortality rates did not differ significantly (15.5%, 10.7%, and 12.5%, respectively). Conclusions In contrast to previous pediatric studies, no differences were observed in clinical severity or outcomes between the different HRV species in adult patients with pneumonia.

Background We performed a randomized trial of isoniazid treatment based on interferon-γ-releasing assay (IGRA) in kidney transplant (KT) recipients in an intermediate-TB-burden country. Methods All adult patients admitted to a KT institute between June 2010 and May 2013 were enrolled. The IGRA (T-SPOT.TB assay) was performed on all patients, and isoniazid treatment was given to those with clinical risk factors for latent TB infection (LTBI). Patients with positive IGRA who had no clinical risk factors for LTBI were randomly assigned to isoniazid treatment or a control group. The development of TB after KT was monitored between June 2010 and November 2013. The primary endpoint was the development of TB. Results Of the 784 patients who had no clinical risk factors for LTBI, 445 (57%) gave negative results in the IGRA, 76 (10%) indeterminate results and 263 (33%) positive results. Of the latter, 131 were allocated to isoniazid treatment and 132 to the control group. Three (2%) of the control group developed TB, whereas none of the isoniazid treatment group developed TB (rate difference 1.22 per 100 person-years, P = 0.09). Of the 521 patients with negative or indeterminate IGRA results, 4 [0.8%, 0.43 per 100 person-years (95% CI 0.12–1.09)] developed TB after KT. Conclusions IGRA-based isoniazid treatment has a trend towards reducing TB development in KT recipients without clinical risk factors, but careful monitoring of TB development is needed in negative-IGRA KT recipients.

Background Rhinoviruses (RVs) may cause pneumonia, but the characteristics of RV-associated pneumonia have not been adequately evaluated. Objective We aimed to compare characteristics, complications, and outcomes between severe RV- and influenza virus (IFV)-associated pneumonia in adults. Study design We used prospective cohort data of adult patients with severe pneumonia who had been admitted to the medical intensive care unit of a tertiary care hospital over a 4-year period. The clinical features and outcomes of 27 patients with RV-positive bronchoscopic bronchoalveolar lavage (BAL) fluid were compared to those of 51 pneumonia patients with IFV-positive BAL fluid or IFV-positive nasopharyngeal specimens. Results Of 356 patients who underwent bronchoscopic BAL and respiratory virus polymerase chain reaction (PCR), RV was the most commonly identified virus (8.1%) from BAL fluid. Patients with RV-associated pneumonia were more likely to be immunocompromised than patients with IFV-associated pneumonia (81.5% vs. 33.3%, p

This paper analyzes the differences in the organizational behavior of domestic Metro employees between enter-prises with ISO quality management implemented and those without. Based on the required guidelines in ISO quality man-agement, an empirical study on the effect of employee education and training, work processes, job satisfaction, andleadership on customer satisfaction performance is conducted. The results demonstrate that the work process in the ISOquality management certified enterprises exhibits a positive effect on customer satisfaction performance; however, theemployee education and training did not exhibit immediate effects. In addition, job satisfaction and leadership are identifiedto have a mediating effect on the correlation between the work process, education and training, and customer satisfaction. Keywords : ISO quality management, Education and training, Customer satisfaction performance, Job satisfaction, Leadership초록본 연구는 국내 도시철도운영기업에 종사하는 종사원을 대상으로 ISO품질경영을 도입한 운영기업과 그렇지 않은 기업 간의 조직행동 분석을 연구주제로 삼았다. ISO품질경영에서 요구하는 지침 항목들을 근거로 한종사원 교육훈련, 업무프로세스, 직무만족, 리더십이 고객만족성과에 미치는 영향을 실증적으로 검증하였다. 분석결과, ISO품질경영 인증기업의 경우 업무프로세스는 고객만족성과에 정(+)의 영향을 미쳤지만 종사원 교육훈련은 고객만족성과에 직접적인 영향을 미치지 않았다. 또한, 업무프로세스 및 교육훈련과 고객만족성과 간의 영향관계에 있어서 직무만족과 리더십은 매개효과가 있음을 알 수 있었다. 주요어

Objectives Community-associated MRSA (CA-MRSA) has emerged in the community and has recently been spreading in healthcare settings. The objectives of this study were to evaluate the clinical outcomes and bacterial virulence factors of the Korean CA-MRSA (ST72-SCCmecIV) strain, which causes bloodstream infections. Methods All adult patients with MRSA bacteraemia were prospectively enrolled. Clinical outcomes, microbiological characteristics and 40 bacterial virulence factors were evaluated. Results Of the 352 typed MRSA isolates, 342 isolates (97.2%) belonged to three Panton–Valentine leucocidin-negative strains: ST5-SCCmecII (70.2%), ST72-SCCmecIV (22.4%) and ST239-SCCmecIII (4.6%). The remaining 10 (2.8%) isolates from minor strains were excluded from the final analysis. After controlling for several confounding factors, ST72-SCCmecIV was associated with the lowest mortality (compared with ST5-SCCmecII, adjusted OR = 0.26; 95% CI = 0.13–0.54). However, MRSA isolates with vancomycin MICs of ≥1.5 mg/L were more common in ST72-SCCmecIV compared with ST5-SCCmecII (84.8% versus 66.7%; P = 0.002). Reduced vancomycin susceptibility and vancomycin heteroresistance were not associated with mortality. Compared with ST5-SCCmecII isolates, ST72-SCCmecIV isolates were less likely to harbour multiple virulence genes. Of these genes, three staphylococcal superantigen genes were associated with mortality: sec (OR = 2.31; P = 0.002), sel (OR = 2.55; P = 0.003) and tst (OR = 2.76; P Conclusions After controlling for confounding factors, ST72-SCCmecIV was independently associated with lower mortality compared with ST5-SCCmecII, suggesting this CA-MRSA strain to be of lower virulence. The lack of virulence genes, including staphylococcal superantigen genes, may play a role in the lower virulence of this strain.

A rhodamine-based fluorescent chemosensor (Rh6G-2HC) was synthesized easily by a one-step condensation reaction. The structure was characterized using NMR, MS and EA spectroscopies. As soon as Cu2+ was added into the chemosensor solution, a color change from colorless to pink color was observed, and a considerable change in the absorption and fluorescence spectra. However, no spectral changes were indicated for other heavy metals such as Ag+, Zn2+, Cd2+, and Co2+. In order to provide a more detailed metal sensing performance, the optical and structural properties for the Cu2+ sensing effect were investigated using UV-Vis, fluorescence and H-NMR spectroscopies.

We developed a scoring system to differentiate severe fever with thrombocytopenia syndrome (SFTS) in 21 patients with SFTS and 91 with scrub typhus; it provided 100% sensitivity and 97% specificity (score > 1). Criteria included altered mental status, leukopenia, prolonged activated partial thromboplastin time, and normal C-reactive protein (1-point each).

We evaluated the diagnostic usefulness of polymerase chain reaction (PCR) analysis for detecting varicella-zoster virus (VZV) infection and reactivation of VZV, using DNA extracted from saliva and plasma specimens obtained from subjects with suspected herpes zoster and from healthy volunteers during stressful and nonstressful conditions.There were 52 patients with a diagnosis of herpes zoster (group 1), 30 with a diagnosis of zoster-mimicking disease (group 2), and 27 healthy volunteers (group 3). Saliva and plasma samples were evaluated for VZV DNA by real-time PCR analysis.Among patients with suspected herpes zoster (ie, patients in groups 1 and 2), the sensitivity of PCR analysis of salivary DNA for detecting VZV (88%; 95% confidence interval [CI], 74%-95%) was significantly higher than that of PCR analysis of plasma DNA (28%; 95% CI, 16%-44%; P.001), whereas the specificity of PCR analysis of salivary DNA (100%; 95% CI, 88%-100%) was similar to that of PCR analysis of plasma DNA (100%; 95% CI, 78%-100%; P.99). VZV DNA was not detected in saliva and plasma samples from group 3 (0%; 95% CI, 0%-14%).Real-time PCR analysis of salivary DNA is more sensitive than that of plasma DNA for detecting VZV among patients with suspected herpes zoster. We found no subclinical reactivation of VZV in group 3 following exposure to common stressful conditions.

Paragonimiasis is a parasitic disease caused by Paragnonimus species. The primary site of infection is the lung, and extrapulmonary involvement is also reported. When infected with Paragonimus westermani, which is the dominant species in Korea, the central nervous system is frequently involved along with the liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall. Ectopic paragonimiasis raises diagnostic challenge since it is uncommon and may be confused with malignancy or other inflammatory diseases. Here, we report an ectopic paragonimiasis case initially presented with recurrent abdominal pain. The patient developed abdominal pain 3 times for the previous 3 years and the computed tomography (CT) of the abdomen revealed fluid collection with wall enhancement. Recurrent diverticulitis was initially suspected and part of the ascending colon was resected. However, the specimen showed intact colon wall without evidence of diverticulitis and multiple parasite eggs and granulomas were found instead. The size of about 70 μm, the presence of an operculum and relatively thick egg shell suggested eggs of Paragonimus species. With appropriate exposure history and a positive antibody test, the definitive diagnosis was made as peritoneal paragonimiasis.

We performed a retrospective study involving 21 patients with chronic disseminate candidiasis (CDC) and 38 patients with candidemia. Neutropenia of >2 weeks' duration was more common in those with CDC (71%) than in those with candidemia (26%, P < .001), and the azole-resistant rate in patients with CDC (5%) was lower than that in those with candidemia (29%, P = .03). Of the 21 patients with CDC, five (24%) needed adjuvant corticosteroid therapy due to persistent debilitating fever (median, 19 days). Rapid defervescence (median, 5 days) occurred after adjuvant corticosteroid therapy. However, there were no significant differences in 90-day mortality between CDC patients with and without corticosteroid therapy. Further prospective data are needed to define the role of steroids in this setting.

Summary Background National surveillance data should be validated to identify methodological problems within the surveillance programme and data quality issues. Aim To test the validity of healthcare-associated infection (HAI) rate data from the Korean National Healthcare-associated Infections Surveillance System (KONIS). Methods Records from intensive care units of 12 (14.8%) of 81 participating hospitals for January–March 2014 were examined. The validation team reviewed 406 medical records of 110 patients with 114 reported HAIs – including 34 urinary tract infections (UTIs), 57 bloodstream infections (BSIs) and 23 cases of pneumonia (PNEU) – and 296 patients with no reported HAIs during one-day visits conducted in August and September 2014. The reviewers' diagnosis of HAI was regarded as the reference standard; in ambiguous cases, the KONIS Steering Committee confirmed the diagnosis of HAI. Findings Sensitivity values for UTIs, BSIs and PNEU were 85.3%, 74.0% and 66.7%, and specificity values were 98.7%, 99.1% and 98.7%, respectively. Positive predictive values were 85.3%, 94.7% and 78.3%, and negative predictive values were 98.7%, 94.6% and 97.7%, respectively. Sensitivity for PNEU was lower than that for UTIs and BSIs. The hospitals participating in KONIS infrequently reported conditions that were not HAIs. Sensitivity for BSIs was lower in this study than in KONIS validation studies conducted in 2008 and 2010. Conclusions KONIS data are generally reliable; however, sensitivity for BSIs exhibited a decrease. This study shows the need for ongoing validation and continuous training of surveillance personnel to maintain the accuracy of surveillance data.

The plasmid-mediated colistin resistance gene, mcr-1, was identified for the first time from a hospitalized patient in South Korea. The mcr-1 gene was successfully transferred to E. coli J53 recipient and conferred resistance to colistin in the recipient. The mcr-1-harboring plasmid possessed a typical IncI2 group and did not have the mcr-1-associated ISApl1 element.

Background Ciprofloxacin is the antibiotic most frequently used in the treatment of Crohn's disease (CD). We attempted to identify the microorganisms present in CD-related intra-abdominal abscesses, their ciprofloxacin resistance patterns, and the clinical impact. Methods Microorganisms, their ciprofloxacin resistance, and clinical outcomes were retrospectively analyzed in 78 CD patients with intra-abdominal abscesses, who underwent percutaneous drainage between March 1991, and November 2011. Results The median time from diagnosis of CD to abscess drainage was 59.5 months (range, 1 to 178 mo). As for bacteriology, the no-growth proportion was 38.5% (n=30), and 69 microorganisms belonging to 11 genera were isolated from the other 48 (61.5%) patients. Of the 69 microorganisms, 65 were bacteria, including 30 (43.4%) gram-positive, 28 (40.6%) gram-negative aerobes, 7 (10.1%) gram-negative anaerobes, and 4 (4.1%) fungi. Streptococci spp. (25, 36.2%) were the most common bacteria, followed by Escherichia coli (18, 26.1%). Nineteen of the 28 gram-negative aerobes (67.9%) were resistant to ciprofloxacin, including 14 of 18 (77.8%) E. coli isolates. When we compared clinical characteristics and treatment outcomes in 17 patients with ciprofloxacin-resistant and 8 with ciprofloxacin-sensitive bacteria, we found that disease duration from diagnosis to drainage (97.2 vs. 50.7 mo, P=0.03) and median length of hospitalization (40 vs. 31 d, P=0.03) was significantly longer in the former. Conclusions When gram-negative aerobes were isolated from abscesses in CD patients, more than two thirds were resistant to ciprofloxacin. Providers should consider this high rate of ciprofloxacin resistance when choosing first-line antibiotic treatment for CD-related intra-abdominal abscesses.

Summary Objective To evaluate the clinical characteristics and outcomes of patients with hematogenous vertebral osteomyelitis (HVO) caused by gram-negative bacteria (GNB). Methods We conducted a retrospective chart review of adult patients with HVO from three tertiary-care hospitals over a 7-year period. Results Of the 313 microbiologically diagnosed HVO cases, GNB was responsible for 65 (20.8%) cases. Compared with patients with MSSA HVO, patients with GNB HVO were more likely to be female ( P = 0.03) and have diabetes ( P = 0.03), but less likely to have epidural abscess ( P = 0.02) and paravertebral abscess ( P = 0.003). Clinical outcomes were similar between the GNB and MSSA groups, including in-hospital mortality (4.6% vs. 7.8%; P = 0.53), recurrence (9.7% vs. 4.3%; P = 0.20), and sequelae (31.7% vs. 32.2%; P = 0.95). Among GNB-infected patients, recurrence rates differed according to the total duration of antibiotic treatment: 40.0% (4–6 weeks), 33.3% (6–8 weeks), and 2.1% (≥8 weeks) ( P = 0.002). Conclusions GNB HVO was responsible for 20.8% of adult cases of HVO. Despite some differences in clinical and radiological presentation, clinical outcomes were similar between GNB and MSSA HVO. Antibiotic therapy for ≥8 weeks may benefit patients with GNB HVO.

A new clone of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), sequence type (ST) 72-staphylococcal chromosomal cassette mec (SCCmec) type IV/IVA without the Panton-Valentine leucocidin (PVL) genes, has been the major clonal type in Korea since 2007. However, there have been no evaluations of the clinical features, risk factors and outcomes associated with CA-MRSA bacteraemia in Korea.Adult patients with community-acquired S. aureus bacteraemia (SAB) were enrolled between 1 January 2004 and 31 September 2012. We compared the clinical features and outcomes of CA-MRSA bacteraemia with those of community-acquired methicillin-susceptible S. aureus (CA-MSSA) bacteraemia and evaluated the risk factors for CA-MRSA infection. A microbiological study of the CA-MRSA isolates was also conducted.In total, 169 patients were included, i.e. 31 (18%) patients with CA-MRSA bacteraemia and 138 (82%) patients with CA-MSSA bacteraemia. Bone and joint infection [45.2% (14/31) versus 22.5% (31/138); adjusted OR, 2.61; 95% CI, 1.09-6.21] was an independent predictor of CA-MRSA bacteraemia. There were no significant differences in relapse of bacteraemia and mortality within 12 weeks after SAB between the two groups. ST72-SCCmec type IV/IVA without the PVL genes was the most common genotype, especially among bone and joint infections (64%, 9/14) as well as among the CA-MRSA isolates (71%, 22/31).CA-MRSA accounted for 18% of community-acquired SAB and was significantly associated with bone and joint infection. Our study suggests that CA-MRSA should be considered in patients with bone and joint infection and that empirical therapy against MRSA should be included.

Background Staphylococcus aureus can cause various types of infection, but involvement of biliary tract is rare. There were only few case reports and no clinical studies. We assessed the clinical characteristics and outcomes of S. aureus bacteremia from a biliary source (biliary SAB) in a large cohort of SAB patients and compared the cases with those of catheter-related SAB. Methods We performed a matched case–control study within a prospective observational cohort of patients with SAB at a 2,700-bed tertiary hospital. All adult patients with SAB were observed for 12 weeks from July 2008 to July 2018. Biliary SAB was defined as the case of S.aureus isolated from blood culture with appropriate clinical biliary infection symptoms (fever, abdominal pain, or jaundice) and signs (abdominal tenderness or liver enzyme elevation with obstructive pattern). Biliary SAB cases were matched 1:3 to control patients with catheter-related SAB based on age, gender, ward, and case year. Results A total of 1,818 patients with SAB were enrolled in the entire cohort, and 42 (2%) were biliary SAB. Among patients with biliary SAB, 32 (76%) had solid tumor involving pancreaticobiliary tract or liver, 30 (71%) had biliary drainage stent, 14 (33%) were biliary procedure-related infection, and 24 (57%) had recent broad-spectrum antibiotics exposure (Table 1). When biliary SAB patients were compared with 126 patients with catheter-related SAB, they were significantly more likely to have community-onset SAB, solid tumor, and lower APACHE II score; and less likely to have metastatic infection (P = 0.03) (Table 2). Biliary SAB, solid tumor, and a high Charlson comorbidity index were associated with 12-week mortality. In multivariate analysis, biliary SAB (aOR, 5.5; 95% CI, 2.47–12.25) and a high Charlson comorbidity index (aOR, 1.32; 95% CI, 1.12–1.54) were independent risk factors for 12-week mortality. Conclusion Biliary SAB was relatively rare and developed mainly in pancreaticobiliary cancer patients and in recent broad-spectrum antibiotic users. High mortality was probably attributable to underlying cancers. When biliary tract infection caused by S. aureus is clinically suspected, early aggressive treatment for SAB should be considered. Disclosures All authors: No reported disclosures.

The epidemiology of invasive fungal infections (IFIs) after liver transplantation (LT) is continuing to evolve in the current era of antifungal prophylactic therapy. This multicenter retrospective cohort study aimed to evaluate the epidemiology, risk factors, and outcomes of IFIs among LT recipients in the current era. We analyzed a total of 482 LT recipients aged 18 years and older who were admitted to 3 tertiary hospitals in Korea between January 2009 and February 2012. Twenty-four episodes of IFIs occurred in 23 patients (4.77%; 23/482). Of these episodes, 20 were proven cases and 4 were probable cases according to EORTC/MSG criteria. Among these cases, IFI developed within 30 days of transplantation in 47.8% of recipients, from 31 to 180 days in 34.8% of recipients, and from 181 to 365 days in 17.4% of recipients. The most common isolates were Candida species (n = 12, 52.2%; Candida albicans, 6 cases; Candida tropicalis, 1 case; Candida glabrata, 1 case; Candida parapsilosis, 1 case; and unspecified Candida species, 1 case) and Aspergillus species (n = 7, 30.4%). The mortality in patients with IFIs was significantly higher than that in patients without IFIs (47.83% [11/23] vs 7.18% [33/459], P

To evaluate the clinical characteristics and therapeutic outcomes of patients with hematogenous vertebral osteomyelitis (HVO) caused by methicillin-resistant Staphylococcus aureus (MRSA).We performed a cohort study of adult patients diagnosed with S. aureus HVO at a tertiary-care hospital over a 7-year period.Of the 139 patients with S. aureus HVO, MRSA caused 62 (44.6%) cases. In multivariate analysis, compared with methicillin-susceptible S. aureus (MSSA), MRSA was associated with a higher risk of persistent bacteremia (≥7 days) (8.40 fold; P 0.001) and relapse (4.83 fold; P = 0.03), and increased hospital stay (1.69 fold; P = 0.001). Among the MRSA cases, relapse rates differed according to duration of antibiotics: 41.7% (4-6 weeks), 25.0% (6-8 weeks), and 5.6% (≥8 weeks) (P = 0.007). Bacteremia was more likely to persist for ≥7 days in patients with an initial vancomycin trough15 mg/L than in those with an initial trough ≥15 mg/L (79.3% vs. 20.0%; P = 0.001).MRSA HVO was associated with more frequent persistent bacteremia (≥7 days) and relapse, and longer hospital stay compared to MSSA HVO. Antibiotic therapy for ≥8 weeks and targeting a vancomycin trough of ≥15 mg/L may be benefit patients with MRSA HVO.

Summary Objectives Limited data are available regarding the incidence and outcomes of lymphadenopathy after completing tuberculosis (TB) treatment. Methods We prospectively evaluated the incidence and outcomes of post-treatment lymphadenopathy in 154 patients with newly diagnosed lymph node TB (group 1) and in 12 patients previously treated for TB (group 2). We assessed the rates of microbiological recurrence, clinical recurrence, and post-treatment paradoxical response (PR) (defined as no microbiological recurrence with spontaneous improvement). Results Post-treatment lymphadenopathy occurred in 24 (15.6%) patients of group 1 and in 12 patients of group 2. Re-biopsy was performed in 23 of these 36 patients. AFB stain was positive in four (17.4%) cases, and TB-PCR was positive in 11 (47.8%), but all samples were sterile (no microbiological recurrence). Granuloma was present in 12 (52.2%) histological specimens. Thirty-three (91.7%) of the 36 patients with lymphadenopathy improved spontaneously (post-treatment PR) and 3 (8.3%) were improved with retreatment (clinical recurrence). The overall incidence of post-treatment PR in patients with lymph node TB (group 1) was 8.6 per 100 person-years (95% CI, 5.8–12.7). Conclusions Lymphadenopathy after TB treatment was more likely to be associated with post-treatment PR rather than with microbiological recurrence, and it should be monitored until PR resolve.

Background Discrepancies between histomorphologic finding and indirect test results such as galactomannan (GM) assay make diagnosis of invasive fungal infection difficult. We investigated the frequency and clinical characterisitics of positive GM assay results in patients with mucormycosis. Methods Patients who met the modified criteria for proven or probable mucormycosis and had serum and/or bronchoalveolar lavage (BAL) fluid GM assay result were enrolled at a tertiary hospital from July 2009 to October 2017. Proven mucormycosis was defined as histologic evidence of tissue invasion of hyphae with positive mucormycosis immunohistochemistry (IHC) test result and the recovery of agents of mucormycosis (Rhizopus spp., Cunninghamella spp., Apophysomyces spp., Saksenaea spp., Absidia spp., Mucor spp.) by culture from sterile specimens. Probable mucormycosis was defined as histologic evidence of tissue invasion of hyphae with positive mucormycosis IHC test result with or without recovery of agents of mucormycosis by culture from nonsterile specimens. Results Among 50 patients of proven or probable mucormycosis, 20 (40%) patients were positive for serum and/or BAL fluid GM assay results; 13 of 20 (65.0%) were positive in serum, nine of 12 (75.0%) were positive in BAL fluid, and two of 12 (16.7%) were positive in both. There were more patients with gastrointestinal infections (4 of 20 [20%] vs. 0 of 30 [0%], P = 0.021) and diagnosed as histomorphologically aspergillosis (6 of 20 [30%] vs. 1 of 30 [3%], P = 0.012) in GM positive group than GM negative group. Conclusion These results suggest that positive GM assay results are not uncommon in mucormycosis. GM assay results from the patients with mucormycosis appear to be related with gastrointestinal infections and histomorphologic diagnosis of aspergillosis. Further studies are needed on the mechanism of positive GM results in patients with mucormycosis and possible coinfection with other fungi such as Aspergillus species in these patients. Disclosures S. H. Kim, the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI): Investigator, Grant recipient

Background The decision of catheter removal in neutropenic patients with candidemia is difficult because they usually have surgically implanted catheter, and CRC are less frequent than in non-neutropenic patients. However, there are limited data on distinguishing CRC from non-CRC before catheter removal. We thus evaluated the diagnostic performances of DTP to diagnose CRC in neutropenic cancer patients with suspected CRC. Methods All adult neutropenic cancer patients with candidemia were enrolled in a tertiary care hospital from July 2012 to December 2016. Definite CRC was defined if ≥15 CFU of Candida spp. in a removed catheter tip. Probable CRC was defined if (1) one to 14 CFU in catheter tip, and clinical improvement within 48 hours after catheter removal with antifungal agent therapy or (2) the infection was refractory to antifungal therapy alone but improved within 48 hours after catheter removal. Non-CRC was defined if any of the following conditions were satisfied: (1) catheter tip cultures were negative and a noncatheter source of candidemia was found by culture, (2) the catheter tip cultures within 24 h before the start of antifungal therapy were negative, or (3) the clinical improvement before or without catheter removal. If the above conditions are not met, they were grouped into indeterminate, and were excluded from the final analysis. We defined the DTP as the difference in the time to positivity between blood cultures drawn simultaneously from the central vein and a peripheral vein. Results A total of 35 neutropenic patients with candidemia were enrolled. Of these, 15 patients (43%) with CRC (6 definite and nine probable) and 17 (48.5%) with non-CRC were finally analyzed, excluding threeindeterminate candidemia. On the basis of the receiver operating characteristics (ROC) curve, the optimal cut-off was ≥1.45 hours and the area under the ROC curve was 0.89 (95% CI, 76 to 100) in diagnosing CRC. Of the 15 patients with CRC, 11 (73%) revealed positive DTP, whereas none of the 17 patients with non-CRC exhibits positive DTP. The sensitivity and specificity of DTP for the diagnosis of CRC were 73% (95% CI, 58 to 94) and 100% (95% CI, 71 to 100), respectively. Conclusion DTP appears to be useful to rule in CRC and DTP ≥ 1.45 hours to be the optimal cut-off for CRC in neutropenic cancer patients. Disclosures All authors: No reported disclosures.

Background Interferon-γ releasing assays (IGRAs) are useful for diagnosing LTBI. However, there are limited data on the efficacy of IGRA-based isoniazid (INH) treatment with/without back-up tuberculin skin test (TST) to prevent the development of TB in solid-organ transplant recipients. Methods All adults patients admitted to a KT unit from January 2014 to December 2016 were retrospectively reviewed in a 2,700-bed, tertiary-care hospital in Seoul, South Korea. The IGRA (i.e., QuantiFERON-In-Tube) with/without TST was performed on all recipients before KT, and 9-month INH treatment was given to patients with clinical risk factors for LTBI regardless of IGRA results. Our hospital policy on LTBI diagnosis and treatment was changed as follows. Period 1 (January 2014–September 2015) adopted IGRA-based INH treatment. We administered INH treatment to all patients with positive IGRA results. Period 2 and period 3 adopted IGRA-based followed by back-up TST-based INH treatment. Period 2 (October 2015–December 2015) included the temporary shortage of Mantoux test, so INH treatment was not given to the patients with positive IGRA since back-up TST was not performed. In Period 3 (January 2016–December 2016), we administered INH treatment to the patients with positive IGRA results followed by back-up TST¡Ã10 mm. The development of TB after KT as the primary endpoint was observed from January 2014 to April 2018. Results The study flow is shown in Figure 1. Of the 1,150 KT recipients, 14 (1.2%) developed TB (incidence rate 0.63 per 100 person-years, 95% CI 0.35–1.06). The median time for TB development was 9.4 months (IQR 4.7–14.5). Seven (3.2%) of 216 patients with positive IGRA without INH treatment developed TB, whereas none of 106 patients with positive IGRA with INH treatment developed TB (rate difference 2.43 per 100 person-years, P = 0.008) and 7 (0.8%) of 828 patients with negative or indeterminate IGRA results developed TB (rate difference 2.0 per 100 person-years, P < 0.001). The number needed to treat (NNT) for IGRA-based INH treatment was 31 (95% CI 18–114). Conclusion IGRA-based INH treatment is effective to prevent the development of TB in KT recipients without clinical risk factors for LTBI with reasonable NNT. Disclosures All authors: No reported disclosures.