Clinical outcomes of patients hospitalized for COVID-19 versus SARS: a meta-analysis.

Estimating the case-fatality rate and clinical outcomes for patients with coronavirus disease 2019 (COVID-19) is crucial because health care systems must adequately prepare for outbreaks and design appropriate policies. A systematic search of PubMed, Embase, and Medline+Journal (via OVID) were conducted for relevant journal publications from database inception to May 4, 2020. Articles that reported the fatality rates and clinical outcomes of patients hospitalized for COVID-19 or severe acute respiratory syndrome (SARS) infection were included. Nine clinical reports (four SARS reports and five COVID-19 reports) with a total of 851 patients (367 and 484 patients with SARS and COVID-19, respectively) were analyzed. A greater proportion of hospitalized patients with COVID-19 had bilateral pneumonia (90.0% [76.3%-96.2%] vs. 35.9% [21.4%-53.6%], p < 0.001) and required ventilators (23.8% [18.8%-29.6%] vs. 15.3% [11.9%-19.4%], p = 0.010) compared with hospitalized patients with SARS. The case-fatality rate was 9.5% (6.5%-13.7%) and 6.1% (3.5%-10.3%) among patients with COVID-19 and SARS, respectively (p = 0.186). The case-fatality rate among hospitalized patients with COVID-19 was comparable to that during the 2003 SARS outbreak. A higher incidence of bilateral pneumonia and increased ventilator usage were noted among patients with COVID-19 compared with patients with SARS.

The High mortality and antimicrobial resistance of Klebsiella pneumoniae bacteremia in northern Taiwan.

INTRODUCTION: Klebsiella pneumoniae, a common hospital- and community-acquired pathogen, is notorious for multidrug resistance. This study aimed to better understand the correlation of clinical presentation and microbiological characteristics of the isolates causing bloodstream infections (BSIs) in Taiwan. METHODOLOGY: We retrospectively collected 150 isolates derived from K. pneumoniae bacteremia patients in Taiwan in both 2014 and 2016. Clinical data, bacterial serotyping and drug susceptibility tests were comparatively analyzed. RESULTS: Demographic data showed that diabetes mellitus (DM) was the most common underlying disease (44.0%). The overall 30-day mortality rate was 19.3%, and higher mortality was found in patients with malignancy than others (P = 0.023). Serotype distribution was diverse. The major isolates belonged to non-PCR-typeable serotypes (58.7%) associated with hospital-acquired infections (P = 0.007) and in non-DM patients (P < 0.001), while K2 and K20 significantly caused infections and in DM patients (P = 0.046 and P = 0.006, respectively); however, only K2 showed more community-acquired infection (P = 0.022) than other typeable serotypes. Resistance to antibiotics in clinical isolates in the year 2016 was > 24%, including cefazolin (54%), ampicillin-sulbactam (25%) and cefuroxime (25%). Susceptibility to gentamicin, flomoxef, and tigecycline reduced between the two time periods (2014 and 2016). However, the isolates remained highly susceptible to amikacin and ertapenem (> 95%). CONCLUSIONS: Patients with cancer had a higher 30-day mortality rate than others. Amikacin and ertapenem are the drugs of choice for the treatment of multidrug-resistant K. pneumoniae BSIs in Taiwan.

Methicillin-resistant Staphylococcus aureus nasal colonization among HIV-infected patients in Taiwan: prevalence, molecular characteristics and associated factors with nasal carriage.

BACKGROUND: To evaluate nasal carriage, antibiotic susceptibility and molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA), as well as the risk factors of MRSA colonization, in human immunodeficiency virus (HIV)-infected patients in northern Taiwan. METHODS: From September 2014 to November 2015, HIV-infected patients seeking outpatient care at four hospitals were eligible for this study. A nasal specimen was obtained from each subject for the detection of S. aureus and a questionnaire was completed by each subject. MRSA isolates once identified were characterized. RESULTS: Of 553 patients surveyed, methicillin-susceptible S. aureus (MSSA) was detected in 119 subjects (21.5%) and MRSA in 19 subjects (3.4%). Female gender, injection drug use, smoking, hepatitis C virus carrier, cancer and antibiotic use within 1 year were positively associated with MRSA colonization. By multivariate analysis, only cancer (adjust odds ratio (aOR) 7.78, [95% confidence interval (CI), 1.909-31.731]) and antibiotic use within 1 year (aOR 3.89, [95% CI, 1.219-12.433]) were significantly associated with MRSA colonization. Ten isolates were characterized as sequence type (ST) 59/staphylococcal chromosome cassette (SCC) IV or VT, endemic community strains in Taiwan, four isolates as ST 8/SCCmec IV (USA 300) and one isolate as ST 239/SCCmec IIIA, a hospital strain. All the community-associated MRSA isolates were susceptible to trimethoprim-sulfamethoxazole (TMP-SMX). CONCLUSIONS: Nasal MRSA carriage in HIV-infected patients seeking outpatient care was low (3.4%) in northern Taiwan. Most of the colonizing isolates were genetically endemic community strains and exhibited high susceptibility to TMP-SMX and fluoroquinolones. Cancer and antibiotic use within 1 year were associated with MRSA colonization.

Risk factors of treatment failure and 30-day mortality in patients with bacteremia due to MRSA with reduced vancomycin susceptibility.

Bacteremia caused by MRSA with reduced vancomycin susceptibility (MRSA-RVS) frequently resulted in treatment failure and mortality. The relation of bacterial factors and unfavorable outcomes remains controversial. We retrospectively reviewed clinical data of patients with bacteremia caused by MRSA with vancomycin MIC = 2 mg/L from 2009 to 2012. The significance of bacterial genotypes, agr function and heterogeneous vancomycin-intermediate S. aureus (hIVSA) phenotype in predicting outcomes were determined after clinical covariates adjustment with multivariate analysis. A total of 147 patients with mean age of 63.5 (±18.1) years were included. Seventy-nine (53.7%) patients failed treatment. Forty-seven (31.9%) patients died within 30 days of onset of MRSA bacteremia. The Charlson index, Pitt bacteremia score and definitive antibiotic regimen were independent factors significantly associated with either treatment failure or mortality. The hVISA phenotype was a potential risk factor predicting treatment failure (adjusted odds ratio 2.420, 95% confidence interval 0.946-6.191, P = 0.0652). No bacterial factors were significantly associated with 30-day mortality. In conclusion, the comorbidities, disease severity and antibiotic regimen remained the most relevant factors predicting treatment failure and 30-day mortality in patients with MRSA-RVS bacteremia. hIVSA phenotype was the only bacterial factor potentially associated with unfavorable outcome in this cohort.

Clinical and molecular features of MDR livestock-associated MRSA ST9 with staphylococcal cassette chromosome mecXII in humans.

OBJECTIVES: Clonal complex (CC) 9 is a prevalent livestock-associated (LA) MRSA clone in Asia whose pathogenicity in humans remains unknown. METHODS: In 2012, we identified a patient with CC9-MRSA infection linked to livestock. After screening 3328 clinical MRSA isolates from a national database, eight isolates (0.24%) collected between 1998 and 2012 were further confirmed to be of CC9. The detailed molecular features of the nine human CC9 strains and phylogenetic relatedness to animal CC9 strains were characterized with WGS. The antibiotic susceptibilities were determined and the clinical information was abstracted from medical records. RESULTS: WGS grouped the CC9 strains into two clades, which were respectively associated with distinct toxome profiles, resistance gene profiles and staphylococcal cassette chromosomes (SCCmecXII for 7 isolates and SCCmecVT for 2 isolates). The SCCmecXII strains were phylogenetically related to animal CC9-MRSA strains, negative for Panton-Valentine leucocidin and 100% resistant to ciprofloxacin, erythromycin, clindamycin, gentamicin and tigecycline. Four of the seven SCCmecXII isolates were associated with invasive diseases including bacteraemia leading to death (2) and osteomyelitis (2). Two SCCmecXII isolates were from patients with exposure to pigs before development of the MRSA diseases. CONCLUSIONS: The CC9-SCCmecXII MRSA prevailing in pigs in Asia is multidrug resistant and potentially pathogenic to humans. It is critical to continuously monitor the local epidemiology of MRSA and implement effective control measures to limit the spread of LA-MRSA between animals, to humans and in healthcare facilities.

Influence of borderline cefepime MIC on the outcome of cefepime-susceptible Pseudomonas aeruginosa bacteremia treated with a maximal cefepime dose: a hospital-based retrospective study.

BACKGROUND: We assessed the influence of current cefepime minimal inhibitory concentration (MIC) breakpoints and the maximal cefepime dose on treatment outcomes in patients with bacteremia caused by cefepime-susceptible Pseudomonas aeruginosa. METHODS: Adult patients hospitalized between July 2010 and June 2014 with a positive blood culture for cefepime-susceptible P. aeruginosa and receipt of cefepime as the primary therapy throughout the course were reviewed. Cefepime Etest® MICs and clinical outcomes for P. aeruginosa bacteremia were reviewed to identify the MIC breakpoint influencing treatment outcomes. RESULTS: Of the 90 patients enrolled, 49 (54.4%) were male (mean age = 66.8 years). The mean Acute Physiology and Chronic Health Evaluation II score was 22.01. Sixty patients (66.7%) received a maximal cefepime dose, and the 30-day crude mortality rate was 36.7%. MIC90 of cefepime for P. aeruginosa was 8 mg/L. The cumulative survival rate at 30 days revealed that a lower cefepime MIC (<4 mg/L) for P. aeruginosa was associated with a higher survival rate than a higher MIC (≥4 mg/L) (72.6% vs. 23.5%, p < 0.0001). A cefepime MIC of ≥4 mg/L and age were independent risk factors for mortality, whereas the maximal cefepime dose was the independent protective factor. The use of a maximal cefepime dose did not improve the outcomes of patients with P. aeruginosa bacteremia at a MIC of ≥4 mg/L. CONCLUSIONS: A cefepime MIC of 4 mg/L may predict an unfavorable outcome among patients with serious infections caused by P. aeruginosa, even the MICs still within the CLSI susceptibility breakpoint.

Tigecycline-based versus sulbactam-based treatment for pneumonia involving multidrug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex.

BACKGROUND: The treatment options for pneumonia involving multidrug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii (MDR Acb) complex are limited, and the optimal treatment has not been established. METHODS: To compare the efficacy of tigecycline-based with sulbactam (or ampicillin/sulbactam)-based therapy for pneumonia involving MDR Acb complex, we conducted a retrospective study comparing 84 tigecycline-treated adult patients during the period August 2007 to March 2010 with 84 sulbactam or ampicillin/sulbactam-treated adult patients during the period September 2004 to July 2007. Both groups had the matched Acute Physiology and Chronic Health Evaluation (APACHE) II score and received treatment for at least 7 days. RESULTS: The mean APACHE II score was 20.1 for both groups. More patients in sulbactam group had ventilator use (89.3 % versus 69.0 %), bilateral pneumonia (79.8 % versus 60.7 %) and combination therapy (84.5 % versus 53.6 %), particularly with carbapenems (71.4 % versus 6.0 %), while more patients in tigecycline group had delayed treatment (41.7 % versus 26.2 %) (P <0.05). At the end of treatment, more patients in sulbactam group had airway MDR Acb complex eradication (63.5 % versus 33.3 %, P <0.05). The clinical resolution rate was 66.7 % for both groups. The mortality rate during treatment was 17.9 % in sulbactam group, and 25.0 % in tigecycline group (P = 0.259). The multivariate analysis showed that bilateral pneumonia was the only independent predictor for mortality during treatment (adjusted odds ratio, 2.717; 95 % confidence interval, 1.015 to 7.272). CONCLUSIONS: Patients treated with either tigecycline-based or sulbactam-based therapy had a similar clinical outcome, but tigecycline group had a lower microbiological eradiation rate.

Clinical experience and microbiologic characteristics of invasive Staphylococcus lugdunensis infection in a tertiary center in northern Taiwan.

BACKGROUND/PURPOSE: Staphylococcus lugdunensis is a coagulase-negative staphylococcus that cannot be ignored. This study is a comprehensive analysis of the clinical and microbiological characteristics of S. lugdunensis bacteremia and sterile site infection during hospitalization. METHODS: This retrospective study included 48 patients with invasive S. lugdunensis infection. During the period of March 2002 to July 2012, they had been hospitalized in a tertiary center of northern Taiwan. Demographics, clinical characteristics, and risk factors of mortality were analyzed. All isolates were tested for antimicrobial susceptibility. We identified the staphylococcal cassette chromosome mec (SCCmec) gene for oxacillin nonsusceptible isolates. RESULTS: The incidence of S. lugdunensis in coagulase-negative staphylococci bacteremia was 0.87%. Forty-eight patients were enrolled: S. lugdunensis was present in 41 patients with bacteremia, in the ascites of three patients, in the synovial fluid of two patients, in the pleural effusion of one patient, and in the amniotic fluid of one patient. The three most common sources of infection were primary bacteremia (43.8%), catheter-related infection (18.8%), and vascular graft infection (12.5%). All-cause mortality during hospitalization was 20.8% (10/48). All deceased patients were bacteremic. Risk factors associated with in-hospital mortality included a Pittsburgh bacteremia score of 2 or greater, infective endocarditis, and end-stage renal disease. Ten (20.8%) isolates were resistant to oxacillin, and 8 isolates were classified as SCCmec type V. CONCLUSION: The clinical significance of S. lugdunensis should not be ignored, especially in patients with severe comorbidities. An aggressive search for endocarditis is strongly suggested in S. lugdunensis bacteremic cases.

A population-based five-year study on the risk of stroke in patients with osteoporosis in Taiwan.

OBJECTIVES: Osteoporosis and stroke are common diseases in elder patients. The relationship between these two diseases is unclear. This study was intended to estimate the risk of stroke among elder persons aged ≥ 50 years within five years of being diagnosed with osteoporosis. METHODS: We retrieved data from the Longitudinal Health Insurance Database 2005 (LHID2005) in Taiwan to perform a nationwide population-based study. There were 2580 patients with osteoporosis aged 50 years of age and older in the study cohort. All of them had at least 2 ambulatory care claims or at least 1 inpatient service claim. Each osteoporotic patient was matched to 5 non-osteoporotic patients based on gender, age, and the index year. Subjects in both groups were followed up for five years. Risk of developing stroke and 5-year stroke-free survival rates were evaluated. RESULTS: The risk of developing stroke was 1.24 times higher in osteoporotic patients within a 5-year follow-up period compared to an age- and gender-matched cohort without osteoporosis (95% confidence interval = 1.11-1.39; p < 0.001). Patients with osteoporosis also had a significantly lower 5-year stroke-free survival rate. CONCLUSIONS: Our results indicated that patients with osteoporosis history had higher risk for development of stroke.

Clinical significance and outcomes of Clostridium perfringens bacteremia--a 10-year experience at a tertiary care hospital.

BACKGROUND: The mortality rate of patients with Clostridium perfringens bacteremia is 27-44%. Typically, the clinical characteristics of this infection are non-specific, which leads to considerable difficulty with the diagnosis and early initiation of appropriate therapy. METHODS: A retrospective cohort study of patients who were hospitalized between August 2002 and July 2011 with C. perfringens bacteremia was conducted within a 3715-bed teaching hospital in northern Taiwan. The patients identified in this search were included when they had fever or other clinical features suggestive of systemic infection. Multiple logistic regression analysis was applied to determine the independent risk factors of 30-day mortality. RESULTS: A total of 93 patients were identified. Elderly patients with comorbid illnesses, especially renal insufficiency or malignancy, were at risk of developing C. perfringens bacteremia, and 23 patients (24.7%) had nosocomial bacteremia. The 30-day and attributed mortalities were 26.9% (25/93) and 8.6% (8/93), respectively. Nosocomial infection was a significant predictor for mortality within 30 days (odds ratio 19.378, 95% confidence interval 2.12-176.99; p=0.009), independent of other disease parameters. Other independent risk factors included the Charlson weighted index of comorbidity, length of hospitalization, and stay in the intensive care unit. CONCLUSIONS: Early recognition of this critical infection and early initiation of appropriate antibiotic treatment by surgical intervention or drainage is essential.

Serratia marcescens meningitis: epidemiology, prognostic factors and treatment outcomes.

BACKGROUND/PURPOSE: Serratia marcescens is a rare pathogen of central nervous system infections. This study was to investigate the epidemiology, prognostic factors, and treatment outcomes of S. marcescens meningitis. METHODS: This retrospective analysis included 33 patients with culture-proven S. marcescens meningitis hospitalized between January 2000 and June 2011. RESULTS: Of the 33 patients enrolled, only one did not receive neurosurgery before the onset of S. marcescens meningitis. Patients with S. marcescens meningitis had higher ratios of brain solid tumors (54.5%) and neurosurgery (97.0%) with a mortality rate of 15.2%. The mean interval between the first neurosurgical procedure and the diagnosis of meningitis was 17.1 days (range, 4-51 days). Only one third-generation cephalosporin-resistant S. marcescens isolate was recovered from the patients' cerebrospinal fluid (CSF) specimens. Compared with the favorable outcome group (n = 20), the unfavorable outcome group (n = 13) had a higher percentage of brain solid tumors, more intensive care unit stays, and higher Sequential Organ Failure Assessment score, CSF lactate and serum C-reactive protein concentrations at diagnosis of meningitis. Under the multiple regression analysis, CSF lactate concentration ≥2-fold the upper limit of normal (ULN) was independently associated with unfavorable outcomes (odds ratio, 7.20; 95% confidence interval, 1.08-47.96; p = 0.041). CONCLUSION: S. marcescens meningitis is highly associated with neurosurgical procedures for brain solid tumors. CSF lactate concentration ≥2x ULN may predict an unfavorable outcome. Its mortality is not high and empiric treatment with parenteral third-generation cephalosporins may have a satisfactory clinical response.

Relationship of teicoplanin MICs to treatment failure in teicoplanin-treated patients with methicillin-resistant Staphylococcus aureus pneumonia.

BACKGROUND/PURPOSE: The objective of this study was to determine the predictive value of teicoplanin minimal inhibitory concentrations (MICs) for treatment failure among patients with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. METHODS: In this study, all patients with ≥1 tracheal aspirates or sputum cultures positive for MRSA admitted to the hospital between April 2011 and September 2011 were reviewed. We enrolled patients who are ≥18 years of age, with a diagnosis of pneumonia, and with a receipt of teicoplanin therapy throughout the course. The relationship between teicoplanin Etest MICs and treatment outcomes of MRSA pneumonia was analyzed to identify the breakpoint of teicoplanin MICs influencing treatment outcomes. RESULTS: Of the 80 patients enrolled, 31 had a lower teicoplanin MIC level (<2.0 mg/L) and 49 had a higher MIC level (≥2.0 mg/L) for MRSA. The lower MIC group had a higher clinical resolution rate in 14 days [24 (77.4%) vs. 23 (46.9%), p = 0.007] and a lower treatment failure rate at the end of teicoplanin treatment [4 (12.9%) vs. 18 (36.7%), p = 0.020]. A comparison between the treatment success and failure groups showed that the former had a longer duration of teicoplanin use (18.76 ± 10.34vs.12.41 ± 5.65 days; p = 0.014). Results of a multivariate analysis showed that teicoplanin MICs ≥ 2.0 mg/Land shorter duration of teicoplanin therapy were independent risk factors for treatment failure. CONCLUSION: A higher teicoplanin MIC value (≥2.0 mg/L) may predict the treatment failure among patients with teicoplanin-treated MRSA pneumonia.

Influence of teicoplanin MICs on treatment outcomes among patients with teicoplanin-treated methicillin-resistant Staphylococcus aureus bacteraemia: a hospital-based retrospective study.

OBJECTIVES: Higher vancomycin MIC values (≥1.5 mg/L via Etest) may be associated with vancomycin treatment failure among patients with serious methicillin-resistant Staphylococcus aureus (MRSA) infections. As there were limited similar data for teicoplanin, this retrospective cohort study intended to determine the predictive value of teicoplanin MICs for treatment failure among patients with MRSA bacteraemia. PATIENTS AND METHODS: All patients with at least one blood culture positive for MRSA admitted to the hospital between January 2010 and January 2011 were reviewed. Patients with an age ≥18 years and receipt of teicoplanin therapy throughout the course or receipt of <72 h of vancomycin therapy and then teicoplanin for >3 days were enrolled. Teicoplanin Etest(®) MICs and treatment outcomes for MRSA bacteraemia were reviewed to identify the breakpoint of teicoplanin MICs influencing treatment outcomes. RESULTS: Of the 101 patients enrolled, 56 had a lower teicoplanin MIC (≤1.5 mg/L) for MRSA and 45 had a higher MIC (>1.5 mg/L) for MRSA. A lower teicoplanin MIC was associated with a favourable outcome [37 (66.1%) versus 13 (28.9%); P<0.001] and a lower rate of bloodstream infection-related mortality [15 (26.8%) versus 22 (48.9%); P=0.022]. Patients with chronic obstructive pulmonary disease, bacteraemic pneumonia or higher Pittsburgh bacteraemia score had an unfavourable outcome (P=0.028, 0.022 and <0.001, respectively). Multivariate analysis showed that teicoplanin MIC >1.5 mg/L, higher Pittsburgh bacteraemia score and bacteraemic pneumonia were independent risk factors for unfavourable outcome. CONCLUSIONS: A higher teicoplanin MIC value (>1.5 mg/L) may predict an unfavourable outcome and higher mortality rate among teicoplanin-treated MRSA bacteraemic patients.

Coexistence of fatal disseminated invasive aspergillosis and pyoderma gangrenosum: a case report.

OBJECTIVE: To report an unusual case of disseminated aspergillosis involving the lymph nodes, lungs, and skin in a patient with pyoderma gangrenosum (PG) and myelodysplastic syndrome (MDS). CASE PRESENTATION AND INTERVENTION: A 46-year-old man presented with productive cough of 2 weeks' duration. Besides, several painless, fixed lymph nodes were palpated at his left neck. He had PG and MDS diagnosed in June 2004 with regular use of oral dapsone and prednisolone. His skin lesions healed with scar formation and no purulent discharge. A computed tomography scan of the head, neck and chest showed bilateral lung consolidation and abscesses at the left neck, right upper lung and right pleura. The neck abscess culture grew Aspergillus species. Dark reddish macules developed over the right arm, chest and abdominal wall, and the left lower limb 2 weeks after initiation of amphotericin B. The histology of the right arm skin biopsy showed invasive aspergillosis. Caspofungin was started then for suspicion of poor response to amphotericin B. He expired despite 35 days of antifungal therapy. CONCLUSION: This report highlights the rarity of coexistence of disseminated aspergillosis and PG, and should alert physicians to the possibility of invasive fungal infection superimposed on a chronic skin lesion.

Characteristics and outcomes of Fusobacterium nucleatum bacteremia--a 6-year experience at a tertiary care hospital in northern Taiwan.

Fusobacterium nucleatum bacteremia is critical and not well defined. To identify the clinical characteristics and outcomes, we conducted a retrospective review of hospitalized patients from January 2004 to December 2009 at a tertiary center in northern Taiwan. Fifty-seven patients were enrolled. The mean age was 58.1 years, and the mean Pitt bacteremia score was 4.7. Males predominated (59.6%), and the overall 30-day mortality rate was up to 47.4%. Malignancy was the major comorbidity (26/57, 45.6%), especially oropharyngeal and gastrointestinal cancers (19/26, 73.1%). Pneumonia (17/57, 29.8%) was the most common presentation with high rates of respiratory failure (15/17, 88.2%) and mortality (11/17, 64.7%), followed by intra-abdominal infections (7/57, 12.3%). In multivariate analysis, higher Pitt bacteremia score, nosocomial infection, anemia, and intensive care unit stay were the independent factors for 30-day mortality. Nosocomial F. nucleatum bacteremia was a significant mortality predictor independent to other parameters of disease severities.

Risk factors and outcomes of carbapenem-nonsusceptible Escherichia coli bacteremia: a matched case-control study.

BACKGROUND: Infections due to carbapenem-resistant Enterobacteriaceae have been the emerging problem worldwide. This primary object of this study was to understand the risk factors and clinical outcomes of carbapenem-nonsusceptible Escherichia coli (CNSEc) bacteremia. METHODS: We conducted a matched case-control study in a 3,715-bed tertiary care medical center in northern Taiwan. The controls were selected among patients with carbapenem-susceptible E coli and were matched with CNSEc for bacteremia. RESULTS: Fifty-one patients were included in this study (17 cases and 34 controls). Bivariate analysis showed that prior exposure to carbapenems (p<0.001), stay in intensive care units (p=0.016), placement of central venous catheters (p=0.001), chronic liver diseases (p<0.001), uremia with regular dialysis (p=0.004), and mechanical ventilation (p=0.004) were associated with CNSEc bacteremia. Multivariate analysis revealed that prior exposure to carbapenems [odds ratio (OR), 29.17; 95% confidence interval (CI), 1.76-484.70; p=0.019], uremia with regular dialysis (OR, 98.58; 95% CI, 4.02-999; p=0.005) and chronic liver diseases (OR, 27.86; 95% CI, 2.31-335.83; p=0.009) were independent risk factors for CNSEc bacteremia. Compared with carbapenem-susceptible E coli group, CNSEc group had a longer hospital stay (68.4 days vs. 35.8 days; p=0.04) and a higher disease severity, as indicated by a Pittsburgh bacteremia score greater than or equal to 4 (5.6% vs. 2.5%; p=0.015). Patients with CNSEc bacteremia had a higher overall in-hospital mortality rate (94.12% vs. 50.00%; p=0.002), but there was no difference in the 28-day mortality between these two groups. CONCLUSIONS: CNSEc bacteremia would lead to a poor outcome among patients with prior exposure to carbapenems, chronic liver disease, and uremia with regular dialysis.

Influence of third-generation cephalosporin resistance on adult in-hospital mortality from post-neurosurgical bacterial meningitis.

BACKGROUND/PURPOSE: To investigate the clinical features, etiology and predictors of in-hospital mortality in adults with post-neurosurgical bacterial meningitis. METHODS: This retrospective analysis included 60 adult patients with culture-proven post-neurosurgical bacterial meningitis hospitalized between September 2006 and August 2008. RESULTS: Of the 60 patients, 88.3% had monomicrobial infection and 11.7% had mixed infection. The mean duration from the first neurosurgical procedure to the diagnosis of meningitis was 21 days (range, 1-134 days). The median frequency of neurosurgical procedure before meningitis was 1 (range, 1-5). A total of 69 isolates were identified from the cerebrospinal fluid, the most common pathogens were Gram-negative bacilli (43, 62.3%), followed by Gram-positive bacteria (24, 34.8%). The three most common Gram-negative bacilli were Serratia marcescens (7, 10.1%), Klebsiella pneumoniae (6, 8.7%), and Enterobacter cloacae (4, 5.8%). Pseudomonas aeruginosa and Acinetobacter baumannii isolates comprised less than 3%. Notably, glucose non-fermenting Gram-negative bacilli other than Acinetobacter and Pseudomonas spp. accounted for 11.6% of the total. Of the Gram-negative bacilli, resistance rates to the third-generation cephalosporins, ceftriaxone and ceftazidime, were 58.1% and 34.9%, respectively. The two most common Gram-positive pathogens were Staphylococcus aureus (10, 14.5%) and coagulase-negative staphylococci (including S. epidermidis) (10, 14.5%). The in-hospital mortality rate was 15.0%, which was significantly related to Gram-negative bacilli resistant to third-generation cephalosporins in multivariate analysis (adjusted odds ratio = 33.65; p = 0.047). CONCLUSION: These findings may portend the spread of serious resistance to third-generation cephalosporins in nosocomial Gram-negative bacilli throughout the neurosurgical units, suggestive of the need to reassess the empirical use of third-generation cephalosporins in post-neurosurgical bacterial meningitis.

Prognostic factors of tuberculous meningitis in adults: a 6-year retrospective study at a tertiary hospital in northern Taiwan.

BACKGROUND/PURPOSE: To investigate the clinical features, laboratory test results, imaging data, and prognostic predictors of tuberculous meningitis (TBM) in adults. METHODS: We retrospectively reviewed 108 adult patients with a diagnosis of TBM over a 6-year period. Patients were divided into "definite" and "probable" groups, depending on the diagnosis made by (1) positive culture, or polymerase chain reaction, of Mycobacterium tuberculosis (TB) from the cerebrospinal fluid (CSF); or (2) the isolation of TB elsewhere, or chest radiography consistent with active pulmonary TB, or imaging studies of the brain consistent with TBM, or clinical improvement on treatment. These two groups were compared for their clinical features, images, laboratory test results, and 9-month mortality rates to identify prognostic predictors. RESULTS: Compared with the "probable" group (n = 62), the "definite" group (n = 46) had a higher mortality rate (50.0%vs. 30.6%, p = 0.041) and more consciousness disturbance (78.3%vs. 51.6%, p = 0.005), hydrocephalus (63.4%vs. 40.7%, p= 0.029) and isolation of TB from extra-CSF specimens (41.3%vs. 22.6%, p = 0.037). Old age (p = 0.002), consciousness change (p = 0.032), and hydrocephalus (p = 0.047) were poor prognostic indicators in the "definite" group as assessed by univariate analysis. Severity of TBM at admission and delayed anti-TB therapy resulted in a poor prognosis for all patients. Multiple logistic regression analysis showed that old age and hydrocephalus were independent factors for mortality. Adjunctive steroid therapy over 2 weeks improved survival in both the "definite" (p = 0.002) and "probable" (p = 0.035) groups, but more than 4 weeks of use had no significant effect on mortality. Steroid treatment, therefore, may improve the outcome of patients with TBM. CONCLUSION: Old age, advanced stage of TBM at admission, hydrocephalus, and positive TB culture or polymerase chain reaction of CSF are factors associated with a poor prognosis for TBM. Early diagnosis and treatment, including short term steroid use, are mandatory for clinical care of adult patients with TBM.

Fusobacterium bacteremia: clinical significance and outcomes.

BACKGROUND AND PURPOSE: Fusobacterium bacteremia is uncommon, accounting for approximately 0.9% of patients with bacteremia. The objectives of this study were to evaluate the incidence and clinical significance of blood cultures positive for Fusobacterium spp., risk factors for mortality, and the impact of antimicrobial therapy on clinical outcomes. METHODS: This was a 5-year retrospective study in which the medical records of patients with Fusobacterium bacteremia treated at the Division of Infectious Diseases, Chang Gung Memorial Hospital, Taoyuan, Taiwan, from 2002 to 2006 were analyzed. RESULTS: Fusobacterium spp. accounted for 0.74% of 16,676 positive blood cultures. 123 patients were included in the study, 53 of whom had polymicrobial bacteremia (43.1%). Fusobacterium nucleatum was the most common species identified (41.5%). The mean age +/- standard deviation of the patients was 62.6 +/- 18.9 years. The most common sources of bacteremia were the gastrointestinal tract, lower respiratory tract, and skin and soft tissue. Thirty four patients (27.6%) had no definite loci of infection. The overall mortality rate was 40.7% (50 patients), which was not associated with inappropriate empirical antibiotic therapy (p = 0.950), Fusobacterium spp., source of infection, or polymicrobial bacteremia. Shock, lack of fever at presentation, and underlying diseases (heart failure, renal insufficiency, or malignancy) were independent risk factors for mortality. CONCLUSIONS: Fusobacterium bacteremia was associated with a high mortality rate for patients with renal insufficiency, heart failure, or malignancy. Delayed start of appropriate antimicrobial therapy did not impact the outcomes.