The impact of US-style infection control programs in an Asian country.

The impact of US-style infection control programs is global. There are many Asian countries that have translated US-style infection control programs into their own programs, but reports of those efforts are rarely published in English. This article describes the development of infection control in Taiwan and the development of intensive infection surveillance and control programs in a pioneer acute-care medical center that has 3,000 beds. The article also discusses problems that have arisen in translation of US infection control practices.

Multicenter surveillance of antimicrobial resistance of major bacterial pathogens in intensive care units in 2000 in Taiwan.

A susceptibility surveillance study of 1,274 bacterial isolates recovered from various clinical specimens from patients in intensive care units (ICUs) of five major teaching hospitals was carried out from March, 2000, to June, 2000, in Taiwan. This study demonstrated a high rate (66%) of oxacillin resistance in Staphylococcus aureus (ORSA), a high rate of nonsusceptibility to penicillin (intermediate, 50% and highly resistant, 8%), and high rates of cefotaxime nonsusceptibility for S. pneumoniae (intermediate, 29% and resistant, 4%), Enterobacter cloacae (57%), Serratia marcescens (34%), and Citrobacter freundii (60%). High rate of ceftazidime nonsusceptibility for Pseudomonas aeruginosa (22%), and high rates of imipenem nonsusceptibility for P. aeruginosa (15%) and Acinetobacter baumannii (22%) were also found. The percentage (11.9%) of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli was greater than that (11.3%) for Klebsiella pneumoniae. Rates of quinupristin-dalfopristin nonsusceptibility for S. pneumoniae (42%), Enterococcus faecium (71%), and ORSA (39%) were high, but no vancomycin-resistant enterococci were found in this study. The resistance rates of some pathogen varied by institution or type of ICUs. Surveillance for antimicrobial resistance among bacterial pathogens in hospitals, particularly in ICU settings with a preexisting higher resistance burden, is mandatory in establishing and/or modifying guidelines for empirical treatment of severe infections in ICU patients caused by these antimicrobial-resistant pathogens.

Yeast carriage on hands of hospital personnel working in intensive care units.

The frequency and distribution of yeast carriage on the hands of hospital personnel working in intensive care unit (ICUs), was investigated. Hand carriage of yeast and Candida species was 46 and 29%, respectively. Rhodotorula sp. and Candida parapsilosis were most frequently recovered. There was no significant difference in frequency or distribution of yeasts and Candida sp. recovered among the three ICUs. Seventeen C. parapsilosis isolates and three Candida albicans isolates were genotyped by electrophoretic karyotyping using contour-clamped homogenous electric-field gel electrophoresis. Eleven separate types of C. parapsilosis and two types of C. albicans were identified. There was no common genotype among these isolates, even within the same unit. We conclude that yeast carriage on the hands of personnel working in ICU is common, but these yeasts are usually not acquired from a common source in the ICU.

Molecular epidemiology of nosocomial infection associated with multi-resistant Acinetobacter baumannii by infrequent-restriction-site PCR.

Acinetobacter baumannii was considered endemic in a university-affiliated tertiary hospital. A significant increase was noted in the proportion of nosocomial infections associated with this micro-organism from 1996 to 1999, although no apparent clusters could be found. Between July 1998 and February 2000, 58 nosocomial isolates of A. baumannii were collected and characterized by antibiotyping and a genotyping method, infrequent-restriction-site PCR (IRS-PCR). High resistance to the 14 antimicrobial agents examined was observed among the isolates. Of the 13 antibiograms detected, eight were multi-resistant to gentamicin and almost all of the traditional and extended-spectrum beta-lactams. These multi-resistant strains consisted of 41 isolates (71%), distributed amongst different wards and intensive care units (ICUs). By IRS-PCR, 23 types were obtained, with one major type found among 28 (48%) isolates. All of these 28 isolates were collected from surgical ICUs. It appears that a single strain of multi-resistant A. baumannii was responsible for the prevalence of nosocomial infection amongst surgical patients, clearly differentiating this outbreak from the previous endemic situation. An efficient molecular typing method played a vital role in making this discrimination.

Molecular investigation of two clusters of hospital-acquired bacteraemia caused by multi-resistant Klebsiella pneumoniae using pulsed-field gel electrophoresis and in frequent restriction site PCR. Infection Control Group.

Two molecular typing methods, DNA macrorestriction analysis with XbaI resolved by pulsed-field gel electrophoresis (PFGE) and infrequent restriction site PCR (IRS-PCR) assay with adapters designed for XbaI and HhaI restriction sites, were used to investigate two clusters of hospital-acquired bacteraemia associated with multi-resistant Klebsiella pneumoniae which occurred in a paediatric intensive care unit (PICU). A total of 56 K. pneumoniae isolates were analysed. These included 10 bacteraemic isolates from eight patients, 26 isolates obtained during an epidemiological survey, and 20 epidemiologically non-related isolates incorporated as controls. One major pattern was demonstrated in 22 of the 56 isolates analysed. These included nine of the 10 bacteraemic isolates, a single rectal isolate, two hand culture isolates and 10 sink isolates. All of these 22 isolates illustrated identical antibiograms, whilst the other 34 isolates shared six antibiograms and 31 unique patterns by either PFGE or IRS-PCR assay. The two clusters of bacteraemia appeared to be outbreaks induced by the same strain of K. pneumoniae which may have utilized sinks as reservoirs and been transmitted through the hands of medical personnel to patients. IRS-PCR demonstrates concordant results with PFGE analysis in studying the genetic relationships among K. pneumoniae isolates, and serves as an excellent epidemiological tool for this bacterium.

Streptococcus pneumoniae bacteremia in southern Taiwan.

Streptococcus pneumoniae bacteremia was diagnosed in 33 patients between June 1999 and November 2000 at the Chang Gung Memorial Hospital-Kaohsiung in southern Taiwan. Antimicrobial susceptibility and serotyping of the clinical isolates were performed. Pneumonia was diagnosed in 19 patients, primary bacteremia in 13, and meningitis in one. The most common serotypes were types 14, 3, and 23F. Fourteen (42.4%) isolates of S. pneumoniae were non-susceptible to penicillin. High antimicrobial resistance rates were found to erythromycin (81.9%), tetracycline (69.7%), clindamycin (69.7%), trimethoprim-sulfamethoxazole (33.1%), and chloramphenicol (12.1%). The mortality was 42.4% and liver cirrhosis was an independent risk factor for mortality (odds ratio = 9.998; 95% confidence interval, 1.011-98.85; p=0.049). All isolated strains were covered by 23-valent the pneumococcal vaccine. Given the increasing prevalence of penicillin non-susceptible S. pneumoniae infection in the community, ongoing periodic monitoring of the evolutionary clinical situation is needed. Results of this study suggest that patients with liver cirrhosis should be inoculated with pneumococcal vaccine.

Characteristics of group A streptococcal bacteremia with comparison between children and adults.

This retrospective study aimed to compare the characteristics of group A streptococcal bacteremia in children and adults. A total of 76 (12 children and 64 adults) patients with group A streptococcal bacteremia treated from October 1995 through September 2000 at the Linko Chang Gung Memorial Hospital were included. The mean age was 47.6 years (range, 12 days-90 years). Forty-four (57.9%) patients had predisposing medical conditions. Malignant cancer (23.7%) and diabetes (22.4%) were the 2 most common conditions, which occurred only in adults. Two (16.7%) children had chickenpox associated with secondary group A streptococcal bacteremia. Skin and soft tissue infection (60.5%) was the most common clinical manifestation. The mortality rate related to group A streptococcal bacteremia was 25%. Twelve patients met the criteria of streptococcal toxic shock syndrome and 6 (50%) were children (p<0.05). Despite immediate and aggressive treatment, mortality due to streptococcal toxic shock syndrome was 66.7%. The incidence of streptococcal toxic shock syndrome was much higher in children (50%) than in adults (9.4%). Early diagnosis of invasive group A streptococcal infections and streptococcal toxic shock syndrome requires awareness of the presentations and a high level of suspicion. For fulminant group A streptococcal infection, a combination of a beta-lactam antibiotic plus clindamycin and/or adjuvant therapy with intravenous immunoglobulin is recommended.

Endogenous Klebsiella pneumoniae endophthalmitis in diabetic patients.

We describe 12 patients with endogenous endophthalmitis caused by Klebsiella pneumoniae seen between 1983 and 1988. Three patients had bilateral involvement. Eleven patients had diabetes mellitus, either newly diagnosed or poorly controlled. In six cases the infection was associated with a liver abscess. In all eyes the outcome was light perception or worse; nine eyes had no light perception. Six eyes were enucleated or eviscerated.

Bacteremic cellulitis caused by non-O1 Vibrio cholerae: report of a case.

A 44-year-old man presented with a fever of a two-day duration and bullous cellulitis of the lower extremities. He had prepared and eaten saltwater fish three days prior to admission. Both blood and bullous fluid cultures showed non-O1 Vibrio cholerae. The bacteremic cellulitis resolved gradually after four weeks of intravenous cefamandole therapy and surgical debridement. Non-O1 V. cholerae bacteremia is rarely reported in the English-language literature and is almost always associated with saltwater exposure, ingestion of seafood, or immunocompromised hosts, particularly those with hematologic malignancies, or liver cirrhosis. Our patient was an alcoholic, but there was no evidence of liver cirrhosis from the physical examination or abdominal sonogram. He is the fourth reported case of non-O1 V. cholerae bacteremic cellulitis in the English-language literature and the first proven case in Taiwan.

Invasive fungal infection in systemic lupus erythematosus: an analysis of 15 cases and a literature review.

OBJECTIVE: To analyse 15 cases of invasive fungal infection and mortality parameters in the largest series in the last 35 yrs of patients with systemic lupus erythematosus (SLE) at a single medical centre. METHODS: Fifteen patients with SLE and invasive fungal infections were retrospectively enrolled. Clinical and laboratory data, fungal species and infected sites, corticosteroid and immunosuppressant doses and SLE disease activity index were assessed retrospectively. Comparison and correlation analyses utilized Fisher's exact test, the chi-square test, Mann-Whitney U-test or the Wilcoxon signed-rank test where appropriate. RESULTS: In contrast to other review reports, Cryptococcus neoformans was the most commonly identified fungus in this Taiwanese series. Notably, the prevalence of autoimmune haemolytic anaemia and positive results for the anti-cardiolipin antibody in this study were significantly higher than those in SLE patients in general (P < 0.0001 and P < 0.0001, respectively). Fungal infection contributed to cause of death in 7 of 15 (46.7%) patients, of which Cryptococcus neoformans accounted for six of these infections. Low-dose prednisolone (<1 or <0.5 mg/kg/day based on arbitrary division) prior to fungal infection tended to correlate with 1 yr mortality after diagnosis of SLE (P = 0.077 or P = 0.080). However, following fungal infection, patients who died from infection itself had been prescribed with higher prednisolone dose or equivalent than surviving patients (P = 0.016). All SLE patients with fungal infections had active SLE (SLEDAI >7). CONCLUSIONS: Cryptococcus neoformans infection accounted for most fatalities in SLE patients with fungal infections in this series. Active lupus disease is probably a risk factor for fungal infection in SLE patients. Notably, low prednisolone doses prior to fungal infection or high prednisolone doses following fungal infection tended to associate with or correlated to fatality, respectively. Therefore, we suggest that different prednisolone doses prescribed at various times impact the incidence of fungal infection and its associated mortality.

The antimicrobial activity of imipenem/cilastatin and its treatment in critical ill patients with polymicrobial and mixed infection.

The antimicrobial activity of imipenem/cilastatin (IPM/CS) was determined for a broad spectrum of 7,157 organisms isolated from the Clinical Microbiology Laboratory of Chang Gung Memorial Hospital, Linkou Medical Center, between April 1 and June 30, 1988. Ninety eight point one percent of 4,389 gram negative aerobes, 95.8% of 2391 gram positive rods, and 95.9% of 507 anaerobes, were shown to be sensitive to IPM/CS. Ninety nine point two percent of 837 Pseudomonas aeruginosa isolates were sensitive to this antibiotic. This study also disclosed that this agent was much more active against Pseudomonas aeruginosa than any other tested aminoglycosides (gentamicin, amikacin, netilmicin) or third generation cephalosporins (cefotaxime, latamoxef, ceftazidime). Twelve critically ill patients with polymicrobial and mixed infection were recruited into this trial. All patients received IPM/CS 500 mg intravenously every six hours except one patient with poor renal function had 250 mg every six hours. The average duration of therapy was 12.5 days. All patients were evaluated according to the selection criteria. IPM/CS achieved favorable clinical response in 83.7 percent. The antibiotic was well tolerated. One patient discontinued treatment because of jaundice. One patient had superinfection of fungemia. The results suggested that IPM/CS is very useful in the treatment of patients with mixed infections due to gram positive, gram negative, and anaerobic bacteriae, even when empirical therapy with other antibiotics fails.

Clearance of funguria with short-course antifungal regimens: a prospective, randomized, controlled study.

The effects of short-course antifungal regimens on funguria were studied in 180 hospitalized adults who did not have ascending urinary or deep fungal infections but did have > 1,000 cfu of yeast/mL in two consecutive urine cultures. Before treatment, efforts were made to eliminate factors conducive to funguria. No additional interventions were implemented in the management of the control group (group A), whereas five experimental groups received short-course therapy as follows: oral administration of fluconazole (group B); single-dose intravenous administration of amphotericin B (group C); and intermittent bladder irrigation with amphotericin B at low, medium, and high concentrations (groups D, E, and F, respectively). Urine was cultured on days 1 and 7 after antifungal treatment. The rate of spontaneous clearance of funguria in the control group was 40.0%. Rates of clearance in experimental groups B through F were 58.6%, 55.2%, 82.1% (P < .01), 86.7% (P < .001), and 83.3% (P < .001), respectively, on day 1 and 77.3% (P < .01), 72.0% (P < .05), 42.9%, 68.4%, and 68.2% (P < .05), respectively, on day 7. The decrement in yeast count was 60.8% for the control group. Decrements for experimental groups B through F were 80.5%, 74.2%, 94.2% (P < .01), 86.7% (P < .05), and 95.3% (P < .001), respectively, on day 1 and 85.5% (P < .05), 80.7%, 75.7%, 87.9% (P < .05), and 76.4%, respectively, on day 7.(ABSTRACT TRUNCATED AT 250 WORDS)

Ceftriaxone once daily compared with four daily doses of cefotaxime in the treatment of severe gram-negative septicemia or pyemia: a randomized study.

In a randomized comparative study, adult patients suffering from Gram-negative septicemia or pyemia were treated either with a single daily dose of 1.5g of ceftriaxone in most patients or 6g of cefotaxime divided into four daily doses. K. pneumoniae and E. coli were commonly isolated in both groups. Altogether 17 patients treated with ceftriaxone and 14 with cefotaxime completed the treatment with a success rate of 88.2% and 85.6% respectively. There were two deaths in patients treated with ceftriaxone (12%) and one with cefotaxime (7.2%). Despite the severity of the disease, antibiotic treatment was relatively short: 7 patients (41%) were treated with ceftriaxone for only 7 days, 2 with cefotaxime for 7 days, 5 for 10 days. Others were treated for a longer period with a maximum duration of 22 days. This study confirms in Asian patients the previous reports that a single daily dose of ceftriaxone is as efficacious as four daily doses with cefotaxime in treating patients with severe infections.

[Epidemiology of scrub typhus in Matsu Peikang Island].

A retrospective survey of the epidemiology of scrub typhus in 1990 in Matsu Peikang Island was made at the end of December of 1990. The diagnosis of scrub typhus was based on the presence of escar, typical clinical manifestation and good response to tetracycline treatment. There were 89 cases of scrub typhus studied, and except for one civilian, the other 88 cases were military personnel, occurring in 2.2% of the total military personnel on the island. However it occurred in 0.08% of the civilian population. Seasonal distribution of scrub typhus was limited to between June and October of 1990. The peak incidence occurred in July. Scrub typhus was distributed over the whole island. A higher incidence of scrub typhus occurred in soldiers and sergeants than in officers. A significant different incidence was found in different units. No fatalities were reported. Different units. No fatalities were reported. Different military activities, duties and the location of the military unit may affect the incidence of scrub typhus. The scrub typhus epidemic was also related to temperature.

Recurrence of Fusarium solani abscess formation in an otherwise healthy patient.

Fusarium spp. are usually considered opportunistic fungi in humans. A case of Fusarium solani abscess formation of the foot in an immunocompetent patient in whom recurrence occurred even after intravenous amphotericin B treatment is presented here.

Tuberculous splenic abscess--a case report and literature review.

Splenic involvement of tuberculosis is common, especially in cases of miliary tuberculosis. However, abscess formation due to tuberculosis in the spleen is extremely rare. We present a tuberculous splenic abscess in an otherwise healthy male patient. This patient presented with fever of unknown origin (FUO). The chest X-ray was consistent with old pulmonary tuberculosis, inactive on presentation. Due to the nonspecific clinical picture the patient remained undiagnosed until laparotomy. We have also reviewed literatures on tuberculous splenic abscess and try to make some inference about the diagnosis and treatment of this disease.

Hospital-acquired pneumonia. Attributable mortality and morbidity.

A total of 1,001 consecutive episodes of nosocomial pneumonia in 901 patients was identified by routine surveillance at the University of Virginia Medical Center between 1979 and 1983 (8.6 episodes/1,000 admissions). When only initial episodes were examined, 890 patients comprised the study sample. The overall case fatality rate was 30%. Stepwise logistic regression indicated that time from admission to pneumonia (p = 0.0006), age (p less than 0.0001), prior use of mechanical ventilation (p = 0.0032), and neoplastic disease (p = 0.0062) were associated with mortality. Multiple regression analysis indicated that the factors associated with increased length of hospitalization included posttracheostomy status (p = 0.0001), prior mechanical ventilation (p = 0.0001), immunosuppressive or leukopenic status (p = 0.0009), nasogastric intubation (p = 0.0003), and prior bacteremia (p = 0.0127). A sampled, individually matched cohort study (n = 74 pairs) was conducted to determine the proportion of mortality in cases that was attributable to infections (33%) and to determine excess hospital stay (seven days) among the patients with nosocomial pneumonia. Excess stay was statistically significant (p less than 0.0001), but proportional mortality was only marginally significant (p = 0.0892). Our findings suggest that nosocomial pneumonia accounts for approximately 33% of the crude mortality and contributes significantly to the economic burden associated with prolonged hospitalization.

Penicillium marneffei fungemia in an AIDS patient: the first case report in Taiwan.

We report a 36-year-old man with acquired immunodeficiency syndrome (AIDS), presenting systemic Penicillium marneffei (PM) infection. Fungal culture from the blood isolated PM. PM-induced enteritis was also suspected in this patient although there was no direct evidence. He also had other manifestations of immunocompromised status, including military tuberculosis and oral candidiasis. He died of respiratory failure in spite of prompt treatment for infection. This is the first confirmed case of PM infection in Taiwan.

Vibrio parahemolyticus bacteremia: case report.

Vibrio parahemolyticus (V. parahemolyticus) is a halophilic gram-negative bacillus that lives in the ocean. It is the leading cause of infectious diarrhea in Taiwan and sometimes produces soft tissue infections, but it is rarely a cause of bacteremia. There have been only 11 cases reported in the literature. Most of the cases involved a history of ingestion of seafood or exposure to seawater. In addition, those patients were all immunosuppressed, especially with leukemia and cirrhosis. We report a 60-year-old male patient with chronic hepatitis C and adrenal insufficiency. He developed V. parahemolyticus bacteremia following ingestion of seafood one week prior to admission. His condition was complicated with neck and right lower leg soft tissue infection, as well as multiple organ failure. The patient survived after intravenous ceftazidime, oral doxycycline, and surgical debridement. To our knowledge, this is the 12th reported cases on Medline, and the second bacteremic case in Taiwan. After reviewing the literature, we suggest that all patients with immunosuppressed conditions or adrenal insufficiency should eat foods that are well cooked and avoid raw seafood. Moreover, when patients who are at risk to develop fever, diarrhea, and soft tissue infection after ingestion of seafood, V. parahemolyticus infection should be suspected. All culture specimens should be inoculated on Vibrios selective media.