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.

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.

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.

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.

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.

Clinical significance of and outcomes for Bacteroides fragilis bacteremia.

BACKGROUND AND PURPOSE: Bacteroides fragilis is a virulent anaerobic pathogen, resulting in considerable mortality. This study was conducted to investigate the clinical characteristics, significance of polymicrobial bacteremia, and treatment outcomes of B. fragilis bacteremia. METHODS: This retrospective analysis enrolled 199 adult patients with B. fragilis bacteremia, who were admitted to hospital between January 2004 and May 2007. Chi-squared and Fisher's exact tests were used for comparison. A p value of <0.05 was considered statistically significant. RESULTS: 142 patients with B. fragilis bacteremia (71.4%) had at least 1 underlying disease. Malignancy was the commonest comorbidity (n = 62; 31.2%). Intra-abdominal infection accounted for 49.3% of the infection sources. Seventy seven patients (38.7%) had polymicrobial bacteremia and Escherichia coli was the most common concurrent isolate (n = 24). There was no significant difference in septic shock incidence and clinical outcome between the monomicrobial and polymicrobial groups. The overall 30-day crude mortality rate was 30.7%. Inappropriate early antimicrobial therapy did not affect outcome, but a higher mortality rate was noted for patients who never received appropriate antimicrobial therapy (55.2% vs 26.5%; p = 0.002). Independent risk factors for mortality were age 65 years and older (p = 0.010), malignancy (p = 0.001), shock (p < 0.001), thrombocytopenia (p = 0.026), and lack of surgical intervention (p = 0.035). CONCLUSIONS: B. fragilis bacteremia causes a high mortality rate, especially for elderly people and patients with cancer. Clinicians should be alert to the infectious focus, and appropriate surgical intervention may be necessary to improve outcomes.

Group B streptococcal bacteremia in non-pregnant adults.

BACKGROUND AND PURPOSE: An increasing incidence of group B streptococcus (GBS) infection in non-pregnant adults has been noted in recent years. To understand the incidence, clinical characteristics, and outcome of GBS bacteremia in non-pregnant adults, we conducted a retrospective study at a tertiary teaching hospital in Taiwan. METHODS: This retrospective analysis included 94 non-pregnant adults (age >/=18 years) with GBS bacteremia hospitalized between January 2001 and December 2003. RESULTS: The incidence of GBS bacteremia increased from 0.16 cases/1000 admissions in 2001 to 0.30 cases/1000 admissions in 2003 (p=0.017, chi-squared test for trend). The mean age of patients was 64.7 +/- 1.39 years. At least 1 underlying systemic disease was found in 81% of patients, with the most frequent being malignancy (43.6%), diabetes mellitus (42.6%), and liver cirrhosis (16%). The 2 major clinical syndromes were primary bacteremia (34%) and soft tissue infection (31.9%). The overall mortality rate was 20.2%. Staphylococcus aureus and Klebsiella pneumoniae were the 2 most common concurrently isolated bloodstream pathogens. Polymicrobial bacteremia, thrombocytopenia, and shock were independent risk factors for mortality in GBS bacteremia. CONCLUSIONS: The increasing incidence of GBS bacteremia is noteworthy, especially among patients with invasive infections. These infections are also responsible for substantial mortality in elderly patients with underlying diseases. Susceptibility testing indicated that penicillin G remains the drug of choice for GBS bacteremia.

Diagnosis of tuberculous pericarditis and treatment without corticosteroids at a tertiary teaching hospital in Taiwan: a 14-year experience.

Tuberculous (TB) pericarditis is a rare but life-threatening form of extrapulmonary tuberculosis. The diagnostic strategy and optimal therapy for TB pericarditis are not well established. We retrospectively analyzed the diagnostic data, clinical characteristics, treatment and outcome in a total of 19 patients with TB pericarditis treated from January 1988 to July 2002. Based on the finding of echocardiography, 8 of these patients were classified as having early stage and 11 as having advanced-stage disease. There were 15 men and 4 women, with a mean age of 65 years (range, 34 to 80 years). All patients received antituberculosis chemotherapy, and all but 2 underwent at least 1 of the following procedures: pericardiocentesis and biopsy, pericardial window placement, and pericardiectomy. None of the patients received corticosteroids concurrently. Of the 8 patients with early-stage TB pericarditis, 3 (37.5%) developed constrictive pericarditis, while of the 7 patients with advanced-stage disease (excluding 4 who had already developed TB constrictive pericarditis at diagnosis), 6 (85.7%) subsequently developed constriction. These findings underscore the importance of pericardiectomy in patients with advanced-stage TB pericarditis. To avoid potentially lethal cardiac tamponade and constrictive cardiomyopathy, clinicians should have a high index of suspicion of TB pericarditis when encountering a patient with pericardial effusion. Histopathologic study of pericardial tissue sample is the key to timely diagnosis of TB pericarditis. The favorable outcomes of patients in this series suggest that a combination of antituberculosis chemotherapy and timely pericardiectomy may be the optimal therapy for patients with TB pericarditis.