신경외과 병동에 적용한 Vancomycin 내성 장구균의 감염관리 전략효과 및 균집락의 위험인자 분석

홍혜경,이꽃실,박성춘,정은경,박미라,김세철,Hong, Hae Kyung,Lee, Kkot Sil,Park, Sung Choon,Chung, Eun Kyung,Park, Mi Ra,Kim, Sae Chul 한국의료질향상학회 2013 한국의료질향상학회지 Vol.19 No.1

Objectives: This study was intended to check if the "Creating Clean Wards" project, which is an innovative reinforced campaign activity targeting infection control strategies and active surveillance cultures for VRE (vancomycin resistant enterococci) high-risk patients to be admitted in the NS (neuro-surgery) wards, would be reduced the incidence rates of VRE acquisition, transmission rates. Methods: 75 subjects of the VRE high-risk patients were surveyed by carrying out active surveillance cultures of VRE colonization 11 times from January to March, 2012. And the retrospective study was conducted dividing them into two groups. Results: The incidence rates of VRE acquisition was reduced to 3.67 cases per 1,000 patients day in the control group and to 2.88 cases in experimental group, which was not statistically significant (p = .753). VRE transmission rates of 0.0015 per day before the project tended to increase to 0.0019, although not statistically significant (p = .650). As a result of multivariate analysis with regard to using glycopeptide antibiotics in order to find out risk factors of VRE colonization, the patients who had been treated with glycopeptide until VRE colonization showed 274.41 times higher rate. Conclusion : For effective VRE infection control in NS wards, We should carry out active surveillance culture regularly, especially patient of using glycopeptide. And block the spread of VRE by strengthening infection control through the strict isolation and the changed mind-set of members motivated by the "Creating Clean Wards" campaign.

1980 년대와 1990 년대의 불명열 원인의 비교분석

김영근(Young Keun Kim),김명수(Myoung Soo Kim),이꽃실(Kkot Sil Lee),허애정(Ae Jung Huh),염준섭(Joon Sup Yeom),홍성관(Sung Kwan Hong),장경희(Kyung Hee Chang),송영구(Young Goo Song),김준명(June Myung Kim) 대한내과학회 2001 대한내과학회지 Vol.61 No.5

N/A Background : Physicians find fever of unknown origin (FUO) a difficult problem to solve. Analysis of the causes of FUO may be useful in the diagnosis of FUO. We investigated the causes of FUO in the last two decades from 1980 to 1999 and compared the two decades to seek for a trend of changes of the causes of FUO. Methods : Among 854 patient s diagnosed as FUO on discharge, we retrospectively reviewed 278 patient s compatible with the Petersdorf`s criteria through inpatient and outpatient medical records . Results : There were 144 (51.5%) men and 134 (48.2%) women. Among the 98 patients in the 1980s, infectious disease was the cause in 37 (37.8%) patients, collagen vascular disease in 17 (17.3%), malignancy in 8 (8.2%), miscellaneous in 11 (11.2%), and unidentifiable cause in 25 (25.5%) patients. Among the 180 patients in the 1990s, infectious disease was the cause in 45 (25.0%) patients, collagen vascular disease in 37 (20.5%), malignancy in 34 (18.9%), miscellaneous in 45 (25.0%), and unidentifiable cause in 19 (10.6%) patients. According t o the order of frequency, the causes of infectious disease were pulmonary tuberculosis (19.4%), extrapulmonary tuberculosis (8.2%), liver abscess (4.1%) in the 1980s and extrapulmonary tuberculosis (17.2%), pulmonary tuberculosis (4.4%), liver abscess (1.1%) in the 1990s. The diagnostic methods for evaluation of FUO were culture (45.6%), radiology (17.6%), serology (16.2%), and biopsy (10.3%) in the 1980s and radiology (31.5%), biopsy (26.9%), culture (21.5%) and serology (20.0%) in the 1990s. Conclusion : Among the causes of FUO, infectious disease decreased and collagen disease and malignancy increased with time. The most common cause of infectious disease was pulmonary tuberculosis in the 1980s but extrapulmonary tuberculosis in the 1990s. Use of radiology and biopsy as diagnostic methods for FUO increased.(Korean J Med 61:546- 552, 2001)

급성신우신염 환자에서 균혈증의 위험 인자 분석 -단일기관 분석-

황선덕 ( Seun Duk Hwang ),박경석 ( Kyoung Suk Park ),전병수 ( Byung Soo Jeon ),김윤지 ( Yoon Ji Kim ),이상헌 ( Sang Hun Lee ),이꽃실 ( Kkot Sil Lee ),윤수영 ( Soo Young Yoon ),이상철 ( Sang Choel Lee ) 대한신장학회 2009 Kidney Research and Clinical Practice Vol.28 No.5

Purpose: Acute pyelonephritis (APN) is among the most common infectious diseases. Most APN occurs in young women and easily treated. Bacteremia has been associated in approximately 20-30% of those with APN. But recent documents demonstrated that blood cultures provide no useful information toward the clinical management of acute pyelonephritis. Thus we compared demographic and clinical characteristics as related to the bacteremic status, and investigated the risk factors for bacteremia. Methods: One hundred sixty five patients, who visited myongji hospital for APN from January, 2004 to December, 2006 were included. Retrospective data were analyzed by medical record review. Results: Bacteremic patients (N=51, 30.9%) were significantly older than those in nonbacteremic group (p<0.0001), had elevated serum creatinine (p=0.008), decreased platelet counts (p=0.029), lower serum protein (p=0.010), and lower serum albumin (p=0.011) than those without bacteremia. Hematuria was more severe in bacteremic patients (p<0.0001). The bacteremic cases were observed more frequently in patients with complicated APN patients than uncomplicated patients (46.7% vs. 21.4%, p=0.001). No significant difference existed between the bacteremic and non-bacteremic patients in the prevalence of resistance to quinolone of E. coli. In multivariate logistic regression analysis, serum albumin (p=0.023), hematuria (p=0.003), and age (p=0.003) at presentation were found to be independent risk factors for bacteremia in acute pyelonephritis. Conclusion: Our study reveals that patients with bacteremia have different clinical characteristics compared to those without bacteremia. It is recommended to concern about the presence of bacteremia in the treatment of APN.

신종 인플루엔자 A (H1N1) 감염으로 입원한 성인 폐렴 환자의 임상양상

한창훈 ( Chang Hoon Han ),현여경 ( Yu Kyung Hyun ),최유리 ( Yu Ri Choi ),성나영 ( Na Young Sung ),박윤선 ( Yoon Seon Park ),이꽃실 ( Kkot Sil Lee ),정재호 ( Jae Ho Chung ) 대한결핵 및 호흡기학회 2010 Tuberculosis and Respiratory Diseases Vol.69 No.1

Background: A novel 2009 influenza A (H1N1) virus emerged and disseminated to all over the world. There are few reports on the clinical characteristics of patients with complications. We describe the clinical features of pneumonia in adult patients hospitalized, who have novel influenza infection. Methods: There were 43 adult patients enrolled into the study with pneumonia of 528 hospitalized patients confirmed influenza A (H1N1) virus infection by real-time reverse transcriptase polymerase chain reaction testing, between 24 August 2009 and 31 January 2010. The clinical data of patients with pneumonia were collected retrospectively. Results: There were 22 of 43 (51.2%) influenza patients with pneumonia that had higher risk factors for complications. Compared to 28 patients with influenza A (H1N1) viral pneumonia and 15 patients, who had isolated bacteria from cultures, those with mixed viral and bacterial pneumonia were significantly more likely to have unilobar consolidations on chest radiographs (53.3 vs. 10.7%, p<0.01) and higher scores of pneumonia severity index (PSI; 90 [66~100] vs. 53 [28~90], p=0.04). Six patients required mechanical ventilation support in an Intensive Care Unit and were more likely to have dyspnea (83.3 vs. 29.3%, p=0.02) and low levels of PaO2 (48.3 [37.0~70.5] vs 64.0 [60.0~74.5] mm Hg, p=0.02) and high levels of pneumonia severity index (PSI) score (108.0 [74.5~142.8] vs. 56.0 [40.5~91.0], p=0.03). Conclusion: The majority of pneumonia patients infected with novel influenza improved. Chest radiographic findings of unilobar consolidations suggest that mixed pneumonia is more likely. Initial dyspnea, hypoxemia, and high levels of PSI score are associated with undergoing mechanical ventilation support.

후천성 면역 결핍증 환자에서 조직생검으로 확진된 진행성 다발성 백질뇌병증 1예

이중민,박윤선,최석훈,한상훈,진범식,신소연,최준용,이꽃실,박윤수,조정호,장경희,송영구,김준명 대한감염학회 2004 감염과 화학요법 Vol.36 No.1

세포면역결핍 상황에서 병발하는 진행성 다발성 백질뇌병증은 후천성 면역결핍증의 유병률이 감소하면서 그 발생률 또한 같이 증가하고 있다. 진단을 위해서는 임상양상과 방사선 검사에 추가해서 뇌척수액의 분자생물학적 검사 또는 뇌조직 검사를 시행하여야 한다. 본 예는 뇌생검을 통해 진행성 다발성 백질뇌병증이 확진되었으며 항레트로바이러스 치료 후 양호한 경과를 보였기에 문헌고찰과 함께 보고하는 바이다. In Korea, as the prevalence of acquired immune deficiency syndrome (AIDS) increases, various opportunistic infections are becoming a problem. Progressive multifocal leukoencephalopathy (PML) is postulated to be associated with impaired cellular immunity and can be more frequently encountered these days primarily due to increasing incidence of AIDS. Neurologic deficits and brain imaging study together strongly suggest PML, but confirmatory diagnosis can be made only by cerebrospinal fluid study or tissue biopsy. In Korea few cases of confirmed PML in AIDS patients have been reported, and herein we offer our experience of a case of PML who underwent brain biopsy for confirmative diagnosis.

국내 HIV 감염자에 있어서 항레트로바이러스 치료제의 부작용

이꽃실,장경희,최준용,박윤선,한상훈,진범식,최석훈,송영구,김준명 대한감염학회 2003 감염과 화학요법 Vol.35 No.2

목적 : 최근 HIV 감염의 치료는 역전사 효소억제제와 단백분해 효소억제제의 병용요법으로 괄목할 만한 치료 효과가 관찰되었으나, 국내에서 이들 약제에 대한 부작용의 보고는 미미한 실정이다. 이에 국내에 항레트로바이러스 치료제가 도입된 1990년대 초부터 최근 병용요법 투여까지 국내 감염자에서 발생한 부작용을 조사하고, 기존에 보고된 외국 감염자에서의 부작용과의 차이에 대하여 문헌고찰을 통하여 비교하여 인종에 따른 차이가 있는지 알아보고자 하였다. 방법 : 연세대학교 의과대학 세브란스 병원에서 1992년부터 2002년까지 항레트로바이러스 치료제를 투여받은 126예의 HIV 감염자를 대상으로 약제 부작용, 종류와 빈도, 그에 따른 약제 중단 유무 등을 후향적으로 조사하였다. 결과 : HIV 감염자의 치료 시작시 평균 연령은 34.4±8.3세였고, 남자가 112예이고 여자가 14예이었다. Zidovudine에 따른 부작용은 120예 중 40예(33.3%)에서 나타났으며, 골수 억제가 16예(13.3%), 위장관계 증상 14예(11.7%), 두통 5예(4.2%) 그리고 간기능 이상 3예(2.5%) 등이 있었다. Lamivudine에 따른 부작용은 119예 중 2예(1.7%)에서 나타났는데 모두 위장관계 증상이었고, didanosine에 의한 부작용은 29예 중 14예(48.3%)로 위장관계 증상이 7예(24.1%), 설사가 4예(13.8%), 발진 1예(3.4%), 그 외 말초신경병증, 간기능 이상, 췌장염, 치아시림, 비전형적인 흉통 등이 있었다. Indinavir에 의한 부작용은 114예 중 66예(57.9%)에서 나타났는데 고빌리루빈 혈증 43예(37.7%), 측배통이 24예(21.1%), 지방이형성증 6예(5.3%)에서 있었다. Nelfinavir에 의한 부작용은 21예 중 각각 1예(4.8%)에서 설사와 발진이 있었고 efavirenz에 따른 부작용은 11예 중 3예(27.3%)로 중추신경계 장애가 있었다. 항레트로 바이러스 약제 투여 중 64.3%에서 부작용을 경험하였으며, 36예(28.6%)에서 약제를 교체하였다. zidovudine이 17예 였으며 그 중 위장관 불편감이 7예, 두통이 5예, 골수억제가 4예로 나타났다. Indinavir로 총 8예에서 약제를 교체하였는데 측배통과 위장관 불편감이 각각 5예와 3예를 차지하였다. 대부분의 부작용은 보존적인 치료와 일시적인 투여 중단으로 회복되어 약제를 유지할 수 있었고, 부작용으로 인해 사망한 경우는 없었다. 결론 : HIV의 감염 치료를 위해 국내에 다양한 항레트로바이러스 치료제가 도입되어 약제에 따른 다양한 부작용이 발생되고 있으며, 이에 대해 주의 및 경각심이 필요하리라 생각한다. Purpose : Antiretroviral toxicity is an increasingly important issue in the management of HIV-infected individuals. However, adverse effects and long term safety in Koreans are hardly known. We evaluated the incidence of adverse effects of various antiretroviral drugs in Koreans, and difference among races was also studied. Methods: One hundred and twenty six Koreans with HIV infection and AIDS treated with antiretroviral drugs at Yonsei University College of Medicine from 1992 to 2002 were investigated. We analyzed the prevalence of adverse effects of various drugs. Results: The mean age of subjects at initial treatment was 34.4?.3 years. One hundred and twelve subjects were male, and 14 subjects were female. Adverse effects were found in 40 subjects (33.3%) out of 120 subjects who received zidovudine. The prevalence of adverse effects of didanosine and indinavir were 48.3% (14 out of 29 subjects) and 57.9% (66 of 114 subjects), respectively. Frequent toxicities of the subjects who received zidovudine were bone marrow suppression (13.3%), followed by gastrointestinal intolerance (11.7%), headache (4.2%), and hepatic dysfunction (2.5%). Frequent toxicities of the subjects who received didanosine were gastrointestinal intolerance (24.1%), followed by diarrhea (13.8%), rash (3.4%), peripheral neuropathy (3.4%), and pancreatitis (3.4%). Adverse effects of indinavir were as follows: hyperbilirubinemia (37.7%), flank pain (21.1%), gastrointestinal intolerance (6.1%), and lipodystrophy (5.3%). The main adverse effect of efavirenz was impaired concentration (27.3%). The overall incidence of adverse effects from antiretroviral drugs was 64.3% (81 out of 126 subjects) in HIV-infected Koreans. Change of antiretroviral regimens was inevitable in 36 subjects (28.6%). In most cases, the subjects recovered from adverse effects by conservative management. Conclusion: Clinicians should be aware of toxicity profiles in various races in the management of long term treatment with antiretroviral drugs, since the toxicity hazards of these drugs may easily outshadow the success of antiretroviral therapy.

Aspergillus fumigatus에 대한 Apolactoferrin의 성장억제 효과

이꽃실,장경희,김명수,김영근,김자경,최성희,허애정,염준섭,송영구,김준명 대한감염학회 2001 감염 Vol.33 No.5

Background : The incidence of aspergillosis is rising with the increased use of antimicrobial agents and immunosuppressive drugs for the treatment of malignant diseases, acquired immunodeficiency syndrome, or organ transplant recipients. However, treatment failures are also increasing which brings up the need for the development of new and more effective agents and/or compounds which support the activity of common antifungal agents. Apolactoferrin is one of the nonspecific host defence factors present in saliva that exhibit antifungal activity. We studied the in vitro antifungal effect of apolactoferrin in combination with amphotericin-B against Aspergillus fumigatus. Methods : Preparation of the inoculum and the growth conditions used were those recommended by the National Committee for Clinical Laboratory Standards M38-P (Conidium-forming filamentous fungi : proposed standard). Aspergillus fumigatus test inoculum was prepared to a concentration of 0.4×104~5×104 cells/mL. Appropriate concentrations of the antifungal agents were added to the wells (50 □L) and after inoculation, plates were incubated for 48 h at 35℃. Turbidity measurement was performed at 48 h at 630 nm and the MIC was defined as the lowest concentration of antifungal agents that inhibited growth of the organism as detected visually. Results : In the combination of experiments, we observed a pronounced cooperative activity against growth of Aspergillus fumigatus by using apolactoferrin and amphotericin-B. The MIC of amphotericin-B was reduced by 1/10 in the presence of apolactoferrin. Conclusion : The combined use of apolactoferrin and amphotericin-B against severe infections with Aspergillus fumigatus is an attractive therapeutic option. Clinical studies to further elucidate the potential utility of this combination therapy have been initiated. (Korean J Infect Dis 33:325~330, 2001)

급성 심낭염이 동반된 출혈열 신증후군이 의심되었던 1예

김용수,최준용,김명수,김영근,이꽃실,박우일,장경희,염준섭,허애정,송영구,김준명 대한감염학회 2002 감염 Vol.34 No.6

신 및 신주위 농양의 최근 임상 경향

최준용,김명수,김영근,이꽃실,장경희,허애정,염준섭,송영구,김준명 대한화학요법학회 2002 대한화학요법학회지 Vol.20 No.2

목적 : 신 및 신주의 농양의 최근 임상 양상에 대해 알아보고자 하였다. 방법 : 1997년 1월부터 2001년 6월까지 세브란스 병원에서 신농양 및 신주의 농양으로 진단 받은 34예를 대상으로 연령 분포, 성별, 입원 전 증상의 지속 기간, 검사실 소견, 원인균, 유발인자, 방사선 소견 및 진단과 치료 등에 대하여 후향적으로 조사하였다. 결과 : 신농양은 16예, 신주위 농양은 18예였다. 평균 연령은 52.9±12.9(19-82세)세였고 성별비는 1:1.4였다. 기저 상태로는 당뇨 18례(52.9%), 간질환 7례(20.5%), 스테로이드 복용 5례(14.7%), 악성종양 3례(8.8%), 신경원성 방광 2례(5.8%), 다낭신 2례(5.8%), 신결석 1례(2.9%) 등이 있었다. 입원 시 증상은 발열(82.3%)과 측복부 동통(67.6%)이 대부분이었다. Escherichia coli, Klebsiella pneumoniae 등의 그람 음성균이 가장 흔한 원인균이었다. 신 및 신주위 농양의 치료에 있어 항생제 치료, 경피적 배농, 수술적 치료가 재원 기간, 치료 기간 등의 치료 양상에 있어 유사한 결과를 나타냈다. 신농양과 신주위 농양간에 임상적 특성은 유의한 차이를 나타내지 않았다. 결과 : 본 연구를 통해 신 및 신주위 농양에서 원인균, 치료방법, 예후 등의 임상 양상이 외국의 보고와 비슷한 양상으로 변화했다는 점을 확인할 수 있었고, 향후 신 및 신주위 농양의 치료에 있어 비수술적인 치료 방법의 치료 효과에 대한 보다 많은 예에서의 전향적인 연구가 필요하리라 생각된다. Background : The clinical aspects of renal or perirenal abscess has changed over the decades. In Korea, there were no recent reports about clinical aspects of renal or perirenal abscesses. Methods : We retrospectively reviewed charts of 34 patients diagnosed as renal or perirenal abscesses about age, sex, clinical manifestations, laboratory findings, culture studies, underlying conditions, radiologic findings, treatment modalities, duration of treatment, and treatment outcomes. Results : A total of 54 patients with renal or perirenal abscess was identified. The mean age of overall patients was 52.9?12.9 years. Underlying conditions were diabetes mellitus(52.9%), liver disease(20.5%), steroid use(14.7%), malignancy(8.8%), neurogenic bladder(5.8%), polyeystic kidnev(5.8%) and renal stone(2.9%). Common clinical manifestations were fever(82.3%) and flank pain(67.6%). Gram negative strains such as Escherichia coli, Klebsiella pneumoniae were common causative organisms. Mean size of abscess was 5.27 ±3.05㎝(0.5-13.0㎝). There were no significant differences in the hospital days or treatment duration between treatment modalities such as antibiotics, percutaneous drainage and surgery. There were no significant differences in the clinical characteristics between renal and perirenal±renal abscess. Conclusion : In our study, there were changes of clinical characteristics such as causative organisms or treatment modalities similar with that in foreign countries. The prospective study should be processed about treatment outcomes of noninvasive treatment in renal or perirenal abscess.

해외에서 유입된 뎅기열 1예

김명수,김자경,김영근,이꽃실,염준섭,허애정,장경희,송영구,김준명 대한내과학회 2002 대한내과학회지 Vol.62 No.5

Dengue fever (DF) is an acute febrile viral disease frequently presenting with headache, bone or joint and muscular pain, rash and leukopenia. Dengue hemorrhagic fever (DHF) is characterized by four major clinical manifestations: high fever, hemorrhagic phenomena, often with hepatomegaly and in severe cases, signs of circulatory failure. Such patients may develop hypovolemic shock resulting from plasma leakage. This is called dengue shock syndrome (DSS) and can be fatal. The disease is one of the leading causes of hospitalization and death in children in several Asian, central and south American and African countries. Dengue fever and Dengue hemorrhagic fever have steadily increased in both incidence and distribution over the past 40 years. With an increased air travel, more travelers to the tropics and subtropics are returning within the incubation period of acute febrile infection. We experienced a Korean engineer with complaints of fever, chill, headache, nausea and myalgia after return from Malaysia and confirmed as dengue fever.