Group B Streptococcal infection in neonates and colonization in pregnant women: An epidemiological retrospective analysis.

BACKGROUND: Group B Streptococcus (GBS) infection is one of the major causes of neonatal morbidity and mortality. Universal GBS screening with intrapartum antibiotic prophylaxis (IAP) in pregnant women were initiated in 2012 in Taiwan. This study aimed to analyze the most recent maternal GBS colonization rate and the changes in neonatal GBS infection rate from 2011 to 2016. METHODS: All pregnant women and their live born neonates between January 2011 and June 2016 were retrospectively reviewed. Whether GBS screening was done, screening results, presence of risk factors, the use of antibiotics, and neonatal outcome were analyzed. In addition, hospitalized neonates diagnosed with GBS infections were retrieved for comparison of early onset disease (EOD) (<7 days) and late onset disease (LOD) (≥7 days). RESULTS: A total of 9535 women delivered babies during the study period. The maternal GBS screening rate was 71.0% and the colonization rate was 22.6%. The overall neonatal invasive GBS infection rate was 0.81 per 1000 live births and the vertical transmission rate was 1.2%. After 2012, the invasive neonatal GBS infection rate declined from 1.1-1.6‰ to 0.6-0.7‰ in 2014 and thereafter, the GBS EOD incidence rate declined from 2.8‰ to 0.0-0.6‰, but the LOD incidence rate remained approximately 0.7‰. Infants with EOD had strong association with obstetric risk factors. CONCLUSIONS: Taiwan's universal GBS screening with IAP program reduced the incidence rate of neonatal GBS EOD to be lower than 1‰ after 2012. Pediatricians still should pay attention to infants with GBS LOD since its incidence rate remained unchanged.

Risk of cancer in patients with genital warts: A nationwide, population-based cohort study in Taiwan.

BACKGROUND: Condyloma acuminata currently affects around 1% of sexually active adults, and its incidence is increasing. The coexistence of genital warts (GW) and certain cancers and an association between human papillomavirus (HPV) and various malignancies have been reported. Therefore, we conducted this large national study to analyze the risk of malignancies among men and women with GW in Taiwan. METHODS AND FINDINGS: Between January 2000 and December 2013, approximately 3 million patients were reported to the National Health Insurance Research Database of Taiwan. Of these patients, 21,763 were diagnosed with GW. In the same time period, a total of 213,541 cancer cases were reported to the registry, of which 1002 were recorded among patients with GW. The age-specific incidence rates of GW and standardized incidence ratios (SIRs) of malignancies compared to the general population were calculated. Women acquired GW earlier than men, with a mean age at diagnosis of 32.63±12.78 years. The highest incidence rate for both genders peaked at 20-29 years. Of the 1002 patients with GW and malignancies, the SIR was 1.95 (95%CI 1.83-2.07). The most markedly increased risk was found for HPV-related cancers, with a SIR of 9.74 (95%CI 3.70-15.77). Significantly elevated risks were also noted for smoking-related cancers, anogenital cancers, cervix in situ, colon, rectum, lung, kidney, and prostate cancers. Most cancers developed within 10 years after the diagnosis of GW. CONCLUSIONS: Patients with GW have an increased risk of HPV-related cancers, especially anogenital malignancies in Taiwan. The elevated risk of other cancers highlights differences in exposure and risk factors among patients with GW compared to the general population. Cancer screening and HPV vaccination programs should be emphasized for at-risk patients.

Clinical analysis of fever of unknown origin in children: A 10-year experience in a northern Taiwan medical center.

BACKGROUND: Fever of unknown origin (FUO) was first described in 1961 as fever >38.3°C for at least 3 weeks with no apparent source after 1 week of investigations in the hospital. Infectious disease comprises the majority of cases (40-60%). There is no related research on FUO in children in Taiwan. The aim of this study is to determine the etiologies of FUO in children in Taiwan and to evaluate the relationship between the diagnosis and patient's demography and laboratory data. METHODS: Children under 18 years old with fever >38.3°C for >2 weeks without apparent source after preliminary investigations at Taipei Veterans General Hospital during 2002-2012 were included. Fever duration, symptoms and signs, laboratory examinations, and final diagnosis were recorded. The distribution of etiologies and age, fever duration, laboratory examinations, and associated symptoms and signs were analyzed. RESULTS: A total of 126 children were enrolled; 60 were girls and 66 were boys. The mean age was 6.7 years old. Infection accounted for 27.0% of cases, followed by undiagnosed cases (23.8%), miscellaneous etiologies (19.8%), malignancies (16.6%), and autoimmune disorders (12.7%). Epstein-Barr virus (EBV) and cytomegalovirus (CMV) were the most commonly found pathogens for infectious disease, and Kawasaki disease (KD) was the top cause of miscellaneous diagnosis. CONCLUSIONS: Infectious disease remains the most common etiology. Careful history taking and physical examination are most crucial for making the diagnosis. Conservative treatment may be enough for most children with FUO, except for those suffering from malignancies.

The epidemiology and prognostic factors of mortality in critically ill children with acute kidney injury in Taiwan.

The incidence of acute kidney injury (AKI) in critically ill children varies among countries. Here we used claims data from the Taiwanese National Health Insurance program from 2006 to 2010 to investigate the epidemiological features and identify factors that predispose individuals to developing AKI and mortality in critically ill children with AKI. Of 60,338 children in this nationwide cohort, AKI was identified in 850, yielding an average incidence rate of 1.4%. Significant independent risk factors for AKI were the use of extracorporeal membrane oxygenation, mechanical ventilation or vasopressors, intrinsic renal diseases, sepsis, and age more than 1 year. Overall, of the AKI cases, 46.5% were due to sepsis, 36.1% underwent renal replacement therapy, and the mortality rate was 44.2%. Multivariate analysis showed that the use of vasopressors, mechanical ventilation, and hemato-oncological disorders were independent predictors of mortality in AKI patients. Thirty-two of the 474 patients who survived had progression to chronic kidney disease or end-stage renal disease. Thus, although not common, AKI in critically ill children still has a high mortality rate associated with a variety of factors. Long-term close follow-up to prevent progressive chronic kidney disease in survivors of critical illnesses with AKI is mandatory.

A population-based analysis of children with pneumonia among intensive care units in Taiwan.

BACKGROUND: Pneumonia is a major diagnosis in children that requires intensive care and is a major cause of mortality in critically ill children. A survey on current epidemiology and case fatality-associated conditions is crucial for the care of critically ill children with pneumonia in an intensive care unit (ICU). METHODS: The sex, age, seasonality of admission, area of distribution, and case fatality rate of children younger than 18 years who had pneumonia and were admitted to an ICU during the period 2006-2010 were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan. The enrolled children were grouped by age (0-2 years, 3-5 years, 6-11 years, and 12-17 years). The need for invasive procedures such as endotracheal tube (ET) insertion, mechanical ventilation (MV), tracheostomy, central venous catheter (CVC) insertion, chest tube insertion/drainage, chest surgery, and extracorporeal membranous oxygenation (ECMO) were analyzed to clarify their association with case fatality in critically ill children with pneumonia. RESULTS: Of the 12,577 children enrolled, 7131 (56.7%) were boys and 5446 (43.3%) were girls. The younger age groups had more cases of pneumonia, but less often required invasive procedures. Children 0-2 years old (n = 6083) accounted for approximately one-half (48.4%) of all enrolled children. This group had the lowest case fatality rate (3.1%; 187/6083 children) and lowest need for invasive procedures (31.1%; 1892/6083 children), whereas children in the 12-17 year-old group had the highest case fatality rate (9.9%; 140/1417 children) and the highest need for invasive procedures (59.8%; 847/1417 children) (p < 0.001). The percentage of pneumonia cases was highest in the spring (30.1%) and lowest in the summer (21.7%). The invasive procedures associated with case fatality were ET/MV (OR, 14.31; p < 0.001), CVC insertion (OR, 7.46; p < 0.001), ECMO intervention (OR, 4.59; p < 0.001), and chest tube insertion/drainage (OR, 1.87; p < 0.001). CONCLUSION: The number of cases of pneumonia that required ICU admission was greater among younger children than among older children. Factors associated with the higher case fatality rate included older age at presentation, the need for invasive procedures (e.g., ET/MV, CVC insertion, chest tube insertion/drainage, and ECMO), underlying comorbidities and complications.

Occurrence of human cytomegalovirus glycoprotein B genotypes in immunocompetent and immunosuppressed Taiwanese patients.

OBJECTIVES: To investigate the differences of genotypic distributions among isolates between immunosuppressed and immunocompetent patients in a Taiwanese population. METHODS: Human cytomegalovirus (HCMV) isolates from 76 patients with adequate chart data were analyzed. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to define gB genotypes which include gB1 to gB4. The clinical data of the 76 patients were retrospectively collected by chart review and classified into an immunosuppressed (n = 32) or immunocompetent (n = 44) group. RESULTS: Among the 32 immunosuppressed patients, the most commonly identified HCMV genotypes were gB1 (27/32, 84.3%) and gB3 (4/32, 12.5%). 59.1% (26/44) of the immunocompetent patients were infected by gB1 while 38.6% (17/44) of them were infected by gB3. The frequency of gB1 infection in the immunosuppressed group was significantly higher than that in the immunocompetent group (p = 0.025). However, there was no statistically significant difference between gB1 and gB3 distributions by clinical diagnosis within each group. CONCLUSIONS: Only gB1 and gB3 genotypes were identified in this Taiwanese population. Although there is no significant difference between clinical diagnosis and gB genotyping, gB1 infection is significantly more predominant in immunosuppressed patients.

Subcutaneously implanted central venous access device infection in pediatric patients with cancer.

BACKGROUND AND PURPOSE: Subcutaneously implanted central venous access devices (SICVADs) are a common route of intravascular access for pediatric patients with cancer. This study was performed to evaluate the risk for SICVAD-related infection in a large consecutive series of unselected children with cancer in a single medical center. METHODS: The medical charts of 209 pediatric patients with cancer who received a SICVAD from January 1, 2001 to December 31, 2005 were retrospectively reviewed, and the patients were followed-up until June 30, 2006. The demographics, clinicopathologic features, and infectious complications were collected for analysis. RESULTS: There were 137,924 SICVAD days (median, 660 days; range, 16-1962 days). The rate of SICVAD-related infections was 0.15 episodes/1000 SICVAD days. There were 21 episodes of SICVAD-related infection among 17 patients, 18 were bloodstream infection among 14 patients and the other 3 were local infection among 3 patients. Sixteen SICVADs were removed, 13 were associated with bloodstream infection and 3 with local infection. Young age (<2 years) was associated with a high risk for SICVAD-related infection. Staphylococcal spp. and fungi were the most common pathogens associated with SICVADs. CONCLUSIONS: The rate of SICVAD-related infection in children with cancer was low. Children younger than 2 years had a higher risk for SICVAD-related infection than older children. Fungi play an important role in SICVAD-related infection.

Epidemiology and diagnostic methodology for enterovirus infection, including cerebrospinal fluid analysis: a 5-year review.

BACKGROUND AND PURPOSE: Enterovirus is the most common pathogen of human illness, but data on epidemiology and laboratory diagnosis of enterovirus from Taiwan are rare. We reviewed hospital records to determine the types of enterovirus isolated and the adequacy of the laboratory diagnostic methods. METHODS: This retrospective study reviewed hospital records, laboratory results, and medical records of patients infected with enterovirus visiting Taipei Veterans General Hospital, Taipei, Taiwan, during a 5-year period from January 2001 through December 2005. The review included analysis of cell counts and biochemistry of cerebrospinal fluid (CSF). RESULTS: 290 strains were isolated. After rhinoviruses were excluded, 288 strains of enteroviruses were included for evaluation. Coxsackievirus A accounted for 18.8% of isolates. Among coxsackievirus B serotypes B2, B3 and B5, 79/94 isolates (84.0%) replicated in human larynx carcinoma (HEP2) cells, while 42/74 serotype B4 isolates (56.8%) grew in rhabdomyosarcoma (RD) cells. Growth of echovirus in RD and Madin-Darby canine kidney (MRC-5) cells occurred for 23/34 positive isolates (68.0%). Twenty four patients had well-documented cell count and biochemistry of CSF. A predominance of polymorphonuclear cells and increasing protein level of the central nervous system, together with empiric antibiotic therapy, was noted in 15/24 of patients (62.5%). CONCLUSION: Use of multiple cell media and sampling of multiple sites remain the best methods for recovery of enterovirus. To improve the effectiveness of enterovirus isolation and avoid unnecessary use of antibiotics, increased use of rapid, sensitive laboratory diagnostic methods, such as polymerase chain reaction, may be appropriate.

Characteristics of Chlamydia trachomatis infection in hospitalized infants with lower respiratory tract infection.

BACKGROUND AND PURPOSE: To study the epidemiology, presentation and laboratory findings of Chlamydia trachomatis pneumonia in hospitalized infants younger than 6 months. METHODS: Between January 2001 and December 2005, infants younger than 6 months admitted to the children's medical center of Taipei Veterans General Hospital with the diagnosis of acute bronchiolitis, bronchopneumonia or pneumonia were prospectively studied. Chest radiograph findings were reviewed in all patients. Basic laboratory examinations performed included white blood cell count and eosinophil count. C. trachomatis was detected via enzyme-linked immunosorbent assay antigen test and the titers of immunoglobulin G and immunoglobulin M by indirect immunoperoxidase assay. RESULTS: A total of 60 infants, 32 males and 28 females, were included. C. trachomatis infection was detected in 30% of patients (18/60). The median age was 2.5 months (range, birth to 6 months). Fever was not detected in 72% of patients (13/18). Only 22% (4/18) of these patients had the characteristic staccato cough. The mean duration of symptoms before admission was 8 days (range, 1 day to 2 months). Rhinorrhea was a prodromal symptom in 67% (12/18) of patients, with a mean pre-onset duration of 7 days (range, 1 to 14 days). Eighty three percent (15/18) of the patients had tachypnea, with a mean duration of 3.2 days (range, 1 to 7 days). Conjunctivitis was noted before admission in 6 patients (33%). Only peripheral eosinophils showed statistically significant difference between Chlamydia-positive and -negative disease (p=0.046), and may be clinically useful in cases of suspected C. trachomatis infection. Mixed infection with other pathogens including adenovirus, respiratory syncytial virus, Mycoplasma pneumoniae, cytomegalovirus and Streptococcus pneumoniae was found in 27% (5/18) of patients. CONCLUSIONS: C. trachomatis is not infrequent and plays an important role in infants younger than 6 months old hospitalized due to lower respiratory tract infection.

Comparison of clinical characteristics of adenovirus and non-adenovirus pneumonia in children.

Forty-eight cases of adenovirus pneumonia in children were treated in the Department of Pediatrics of Taipei Veterans General Hospital from January 1998 through December 2000. The clinical characteristics of these patients were compared with those of a control group of 70 patients with non-adenovirus pneumonia mostly caused by Mycoplasma pneumoniae and other viruses during the same period. No difference was found between the adenovirus and non-adenovirus groups in age, sex, duration of fever, and hospitalization days. Chest retraction and extrapulmonary manifestations were significantly more common in the adenovirus group, especially conjunctivitis, gastroenteritis, lymphadenopathy, bleeding diathesis, and exanthema. C-reactive protein levels were significantly higher in the study group than in the control group. In the adenovirus group, 2 patients died and 5 had permanent lung damage after adenovirus infections. No mortality or long-term sequelae were found in the non-adenovirus group. Adenovirus may cause diseases manifesting predominantly as fever and lower respiratory tract infection that may require hospitalization. Extrapulmonary manifestations were observed in more than half of children with adenovirus infections. Adenoviral pneumonia can be fatal and permanent lung damage may be noted during the follow-up period.

Fibrous dysplasia of mandible with chronic osteomyelitis in a child: report of one case.

We report here a 6-year-old girl with fibrous dysplasia (FD) of the mandibular bone. She had a growing mass with local pain over right chin after a severe trauma, which was thought to be chronic osteomyelitis (OM). After failure of antibiotic treatment, malignant bone tumor was suspected from imaging studies including magnetic resonance imaging (MRI). FD of the mandible with chronic OM was confirmed one year after its onset by repeated biopsy performed at our hospital. Causes of delayed diagnosis may include (1) FD of the mandibular bone and chronic OM have similar characteristics clinically and radiographically, (2) the previous biopsy was not performed at appropriate site, and (3) failure to include fibrous dysplasia in the differential diagnosis. In this report, we also review the features in radiology and MRI of OM and FD, which may help differentiate the diagnosis. When a patient with mandibular FD has acute symptoms, the possibility of superimposed OM or malignant change should be considered.