Validation of the Korean National Healthcare-associated Infections Surveillance System (KONIS): an intensive care unit module report

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.

Five-year decreased incidence of surgical site infections following gastrectomy and prosthetic joint replacement surgery through active surveillance by the Korean Nosocomial Infection Surveillance System

BACKGROUND

Surveillance of healthcare-associated infection has been associated with a reduction in surgical site infection (SSI).

AIM

To evaluate the Korean Nosocomial Infection Surveillance System (KONIS) in order to assess its effects on SSI since it was introduced.

METHODS

SSI data after gastrectomy, total hip arthroplasty (THA), and total knee arthroplasty (TKA) between 2008 and 2012 were analysed. The pooled incidence of SSI was calculated for each year; the same analyses were also conducted from hospitals that had participated in KONIS for at least three consecutive years. Standardized SSI rates for each year were calculated by adjusting for SSI risk factors. SSI trends were analysed using the Cochran-Armitage test.

FINDINGS

The SSI rate following gastrectomy was 3.12% (522/16,918). There was a significant trend of decreased crude SSI rates over five years. This trend was also evident in analysis of hospitals that had participated for more than three years. The SSI rate for THA was 2.05% (157/7656), which decreased significantly from 2008 to 2012. The risk factors for SSI after THA included the National Nosocomial Infections Surveillance risk index, trauma, reoperation, and age (60-69 years). The SSI rate for TKA was 1.90% (152/7648), which also decreased significantly during a period of five years. However, the risk-adjusted analysis of SSI did not show a significant decrease for all surgical procedures.

CONCLUSION

The SSI incidence of gastrectomy and prosthetic joint replacement declined over five years as a result of active surveillance by KONIS.

Trends in the distribution and antimicrobial susceptibility of causative pathogens of device-associated infection in Korean intensive care units from 2006 to 2013: results from the Korean Nosocomial Infections Surveillance System (KONIS)

BACKGROUND

For all countries, information on pathogens causing healthcare-associated infections is important in order to develop proper strategies for preventing and treating nosocomial infections.

AIM

To assess the change in frequencies and antimicrobial resistance of pathogens causing device-associated infections (DAIs) in intensive care units (ICUs) in South Korea between July 2006 and June 2014.

METHODS

Data from the Korean Nosocomial Infections Surveillance System (KONIS) were analysed, including three major DAI types in ICUs.

FINDINGS

The frequency of Gram-negative bacteria gradually increased for central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP) (from 24.6% to 32.6% and from 52.8% to 73.5%, respectively). By contrast, the frequency of Gram-positive bacteria decreased from 58.6% to 49.2% for CLABSI, and from 44.3% to 23.8% for VAP (P < 0.001). Staphylococcus aureus was the most frequent causative pathogen in CLABSI throughout the surveillance period, but for VAP was replaced as the most frequent pathogen by Acinetobacter baumannii as of 2010. Candida albicans was the most frequent pathogen for catheter-associated urinary tract infection. The meticillin resistance rate in S. aureus decreased from 95% to 90.2% (P < 0.001); amikacin resistance in Klebsiella pneumoniae and Escherichia coli decreased from 43.8% to 14.7% and from 15.0% to 1.8%, respectively (P < 0.001); imipenem resistance in A. baumannii increased from 52.9% to 89.8% (P < 0.001).

CONCLUSION

The proportion of Gram-negative bacteria as nosocomial pathogens for CLABSI and VAP has increased. The prevalence of A. baumannii causing DAIs in Korean ICUs has increased rapidly, as has the rate of carbapenem resistance in these bacteria.

Trends in the incidence rate of device-associated infections in intensive care units after the establishment of the Korean Nosocomial Infections Surveillance System

BACKGROUND

The effectiveness of continuous nationwide surveillance on healthcare-associated infections should be investigated in each country.

AIM

To assess the rate of device-associated infections (DAIs) in intensive care units (ICUs) since the establishment of the Korean Nosocomial Infections Surveillance System (KONIS).

METHODS

Nationwide data were obtained on the incidence rate of DAI in ICUs reported to KONIS by all participating hospitals. The three major DAIs were studied: ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CABSI), and catheter-associated urinary tract infection (CAUTI). The pooled and year-wise incidence rates (cases per 1000 device-days) of these DAIs were determined for the period 2006 and 2012. In addition, data from institutions that had participated in KONIS for at least three consecutive years were analysed separately.

FINDINGS

The number of ICUs participating in KONIS gradually increased from 76 in 2006 to 162 in 2012. Between 2006 and 2012, the incidence rate per 1000 device-days for VAP decreased significantly from 3.48 to 1.64 (F = 11, P < 0.01), for CAUTI the rate decreased non-significantly from 1.85 to 1.26 (F = 2.02, P = 0.07), and for CABSI the rate also decreased non-significantly from 3.4 to 2.57 (F = 1.73, P = 0.12). In the 132 ICUs that had participated in KONIS for at least three consecutive years, the VAP rate significantly decreased from the first year to third year (F = 20.57, P < 0.01), but the rates of CAUTI (F = 1.06, P = 0.35) and CABSI (F = 1.39, P = 0.25) did not change significantly.

CONCLUSION

The decreased incidence rate of VAP in ICUs in Korea might be associated with the continuous prospective surveillance provided by KONIS.

Local recurrence after curative resection in patients with colon and rectal cancers

BACKGROUND AND AIMS

There are a range of rates and a number of prognostic factors associated with the local recurrence of colorectal cancer after curative resection. The aim of this study was to identify the potential prognostic factors of local recurrence in patients with colon and rectal cancers.

MATERIALS AND METHODS

A retrospective review of 1,838 patients who underwent curative resection of non-metastatic colorectal cancer was conducted. The patients were treated between 1994 and 2004, and had a minimum follow-up of 3 years.

RESULTS

There were 994 patients with colon cancer and 844 patients with rectal cancer. The median duration of follow-up was 60.9 +/- 24.5 months. With respect to colon cancer, the local recurrence rate was 6.1% (61 patients). With respect to rectal cancer, 95 patients had a local recurrence (11.3%), the rate of which was statistically greater than the local recurrence rate for colon cancer (p < 0.001). The overall recurrence rate was 16.4% (301 patients), and the local recurrence rate, with or without systemic metastases, was 8.5% (156 patients). Local recurrences occurred within 2 and 3 years in 59.9% and 82.4% of the patients, respectively. In patients with colon and rectal cancer, the pathologic T stage (p = 0.044 and p = 0.034, respectively), pathologic N stage (p = 0.001 and p < 0.001, respectively), and lymphovascular invasion (p = 0.013 and p = 0.004, respectively) were adverse risk factors for local recurrence. The level of the anastomosis from the anal verge was an additional prognostic factor (p = 0.007) in patients with rectal cancer.

CONCLUSION

Compulsive follow-up care of patients with colon and rectal cancers is needed for 3 years after curative resection, especially in patients who have adverse risk factors for local recurrence.

Characteristics of early colorectal carcinoma with lymph node metastatic disease

BACKGROUND/AIMS

Endoscopic resection may safely and effectively remove early colorectal cancers. However, additional surgical treatment is needed in cases with metastatic lymph nodes for curative treatment. The purpose of this study was to investigate the correlation between lymph node metastasis and various pathological parameters in early colorectal cancers.

METHODOLOGY

The clinicopathological records of 3,557 colorectal adenocarcinoma patients who underwent surgical resection at the Samsung Medical Center from August 1995 to June 2005 were reviewed. One hundred forty seven tissue samples with early colorectal cancer were used in this study. Various parameters were studied including gender, location, macroscopic appearance, differentiation, lymphatic tumor emboli, and the depth of tumor invasion.

RESULTS

Twenty five patients (17.0%) had lymph node metastasis. Male gender, left colon, macroscopically depressed lesions, moderately or poorly differentiated carcinoma, depth of tumor invasion (Sm2 or Sm3), and presence of lymphatic tumor emboli were the risk factors for lymph node metastasis.

CONCLUSIONS

Early colorectal cancers with male gender, location in the left colon, macroscopically depressed lesion, moderate or poor differentiation, depth in Sm2 or Sm3, and the presence of lymphatic tumor emboli have higher risk of lymph node metastasis than those without. The early colorectal cancers with these risk factors should have surgical resection.

Oxygenation reactions of various tricyclic fused aromatic compounds using Escherichia coli and Streptomyces lividans transformants carrying several arene dioxygenase genes

Bioconversion (biotransformation) experiments on arenes (aromatic compounds), including various tricyclic fused aromatic compounds such as fluorene, dibenzofuran, dibenzothiophene, carbazole, acridene, and phenanthridine, were done using the cells of Escherichia coli transformants expressing several arene dioxygenase genes. E. coli carrying the phenanthrene dioxygenase (phdABCD) genes derived from the marine bacterium Nocardioides sp. strain KP7 converted all of these tricyclic aromatic compounds, while E. coli carrying the Pseudomonas putida F1 toluene dioxygenase (todC1C2BA) genes or the P. pseudoalcaligenes KF707 biphenyl dioxygenase (bphA1A2A3A4) genes was not able to convert these substrates. Surprisingly, E. coli carrying hybrid dioxygenase (todC1::bphA2A3A4) genes with a subunit substitution between the toluene and biphenyl dioxygenases was able to convert fluorene, dibenzofuran, and dibenzothiophene. The cells of a Streptomyces lividans transformant carrying the phenanthrene dioxygenase genes were also evaluated for bioconversion of various tricyclic fused aromatic compounds. The ability of this actinomycete in their conversion was similar to that of E. coli carrying the corresponding genes. Products converted from the aromatic compounds with these recombinant bacterial cells were purified by column chromatography on silica gel, and identified by their MS and 1H and 13C NMR analyses. Several products, e.g., 4-hydroxyfluorene converted from fluorene, and cis-1,2-dihydroxy-1,2-dihydrophenanthridine, cis-9,10-dihydroxy-9,10-dihydrophenanthridine, and 10-hydroxyphenanthridine, which were converted from phenanthridine, were novel compounds.

Biotransformation of phenanthrene and 1-methoxynaphthalene with Streptomyces lividans cells expressing a marine bacterial phenanthrene dioxygenase gene cluster

The phdABCD gene cluster in a marine bacterium Nocardioides sp. strain KP7 codes for the multicomponent enzyme phenanthrene dioxygenase. phdA encoding an iron-sulfur protein large subunit alpha, phdB encoding its small subunit beta, phdC encoding ferredoxin, and phdD encoding ferredoxin reductase, were replaced in such a way that the termination codons of the preceding open reading frames were overlapped with the initiation codons of the following genes. This manipulated phdABCD gene cluster was positioned downstream of the thiostrepton-inducible promoter PtipA in a high-copy-number vector pIJ6021, and introduced into the gram-positive, soil-inhabiting, filamentous bacterium Streptomyces lividans. The recombinant S. lividans cells converted phenanthrene into a cis-diol form, which was determined to be cis-3,4-dihydroxy-3,4-dihydrophenanthrene by its UV spectral data as well as HPLC property, using the authentic sample for comparison. This biotransformation proceeded very efficiently; 200 microM and 2 mm of phenanthrene were almost completely converted to its cis-diol form in 6 h and 32 h, respectively. In addition, the S. lividans cells carrying the phdABCD gene cluster were found to transform 1-methoxynaphthalene to two products, which were identified to be 8-methoxy-2-naphthol in addition to 8-methoxy-1,2-dihydro-1,2-naphthalenediol by their EI-MS, 1H- and 13C-NMR spectral data.

Malignant colorectal obstruction: treatment with a flexible covered stent

PURPOSE

To evaluate the usefulness of flexible covered stents for treatment of acute colorectal obstruction secondary to malignant colorectal carcinoma.

MATERIALS AND METHODS

Twenty patients with acute colorectal obstruction secondary to malignant colorectal carcinoma were treated by means of intubation of a flexible stent with fluoroscopic guidance with occasional endoscopic assistance. Two types of stents were placed (type 1, completely covered, type 2, two-thirds of proximal part uncovered). Of 15 patients with primary colorectal carcinoma, 12 underwent placement of a stent for presurgical decompression of colorectal obstruction; three, for palliative decompression. In three patients with rectosigmoid seeding from advanced gastric carcinoma and two patients with recurrent colonic carcinoma, stents were placed for palliative decompression.

RESULTS

Stent placement was successful in 18 (90%) of 20 patients. Symptoms of obstruction resolved within 24 hours in 15 (75%) patients. Eight patients underwent elective single-stage surgery without complications 5-7 days after stent placement. Two patients underwent tumor resection and colostomy. In eight patients, stents provided palliative decompression of the colon. Type 1 stents migrated in four (50%) of eight patients; type 2 stents were used thereafter.

CONCLUSION

Flexible stents effectively relieved acute colonic obstruction secondary to malignant rectosigmoid neoplasm. Stent placement allowed patients to undergo single-stage surgery in most cases and provided palliative decompression in cases of inoperable or disseminated disease.

Bestatin analogue from Streptomyces neyagawaensis SL-387

A bestatin analogue, (2S,3R)-3-amino-2-hydroxy-4-phenylbutanoyl-L-valine (AHPA-Val), from the culture filtrate of Streptomyces neyagawaensis SL-387 was obtained in a chemically defined medium containing DL-3-amino-3-phenylpropionic acid. AHPA-Val was 6 times (IC50 = 1.2 micrograms/ml) as strong as bestatin (IC50 = 7.0 micrograms/ml) against porcine kidney microsomal aminopeptidase N, and 4 times (5.6 micrograms/ml) as strong as bestatin (IC50 = 20.7 micrograms/ml) against aminopeptidase N of human metastatic fibrosarcoma HT1080. To the best of our knowledge, this is the first report on the microbial production of AHPA-Val.

Intraoperative reasons for abandoning ileal pouch-anal anastomosis procedures

PURPOSE

Ileal pouch-anal anastomosis (IPAA) has become the operation of choice for most patients with chronic ulcerative colitis and familial adenomatous polyposis. However, because of technical or disease factors at the time of pouch construction, IPAA must sometimes be abandoned. A retrospective review was conducted to find reasons for IPAA failure or abandonment.

METHODS

Since 1981, 103 patients have had to have an IPAA procedure at the George Washington University Medical Center in Washington, DC. All charts were reviewed and data retrospectively collected.

RESULTS

Six of 103 patients (six percent) were unable to have IPAA constructed. Five patients ultimately received a standard end ileostomy, and one had an ileorectal anastomosis. The reasons for abandoning the IPAA procedure were an ischemic pouch, failure to reach the anus, poorly controlled presacral hemorrhage, desmoid of the mesentery, and finding incurable colon carcinoma.

CONCLUSIONS

Information regarding the risk of failure or abandonment during the IPAA procedure should be discussed with the patient during preoperative counseling and must be included as an element of informed consent.