Correlation Between Cefoperazone/Sulbactam MIC Values and Clinical Outcomes of Escherichia coli Bacteremia.

INTRODUCTION: The clinical efficiency of cefoperazone/sulbactam (CPZ/SUL) against Escherichia coli bacteremia was unknown. This study aimed to explore the relationship between CPZ/SUL MIC values and clinical outcomes in Escherichia coli bacteremia. METHODS: A multicenter, retrospective, observational cohort study was conducted in Taiwan between January 2015 and December 2020. Patients treated with CPZ/SUL for E. coli bacteremia were enrolled in the analysis. The CPZ/SUL MICs were determined by using the agar dilution method. The primary outcome was 30-day mortality. RESULTS: Among 247 isolates, 160 (64.8%) isolates were susceptible, 8 (3.2%) were intermediate, and 79 (32.0%) were resistant to cefoperazone. The activity of cefoperazone against cefoperazone-non-susceptible E. coli (n = 87) was restored upon combination with sulbactam, with susceptibility ranging from 0% to 97.7%. The 30-day mortality was 4.5% (11/247) and overall clinical success rate was 91.9% (227/247). Multivariate Cox proportional-hazards model revealed that heart failure [adjusted relative risk (ARR), 5.49; 95% confidence interval (CI) 1.31-23.02; p = 0.020], malignancy (ARR 7.50; 95% CI 2.02-27.80; p = 0.003), SOFA score (ARR 1.29; 95% CI 1.09-1.52; p = 0.003), and CPZ/SUL MIC ≥ 64 mg/L (ARR 11.31; 95% CI 1.34-95.52; p = 0.026) were independently associated with 30-day mortality. No statistically significant differences in 30-day mortality were found between groups with or without cefoperazone susceptibility (3.4% vs. 5.0%, p = 0.751, respectively). CONCLUSIONS: Patients with E. coli bacteremia who were treated with CPZ/SUL had a favorable outcome when the MICs of the isolates were ≤ 16 mg/L and a high risk of mortality with MICs ≥ 64 mg/L.

Changing epidemiology and prognosis of nosocomial bloodstream infection: A single-center retrospective study in Taiwan.

BACKGROUND: Nosocomial bloodstream infection (BSI) remains a significant cause of mortality and morbidity. We evaluate the trend of the pathogens of nosocomial BSI and investigate the distribution of the pathogens to demonstrate the risk factors of mortality. METHODS: In this retrospective study, we collected data from a 2076-bed tertiary referral center that offers a full range of clinical services in central Taiwan during January, 2016 to December, 2017. RESULTS: Five hundred and eighty-four patients were identified with nosocomial BSI. Among the comorbidities of nosocomial BSI patients with, the most frequent were hypertension, in 294 patients (50.3%), malignancy, in 279 patients (47.8%); diabetes, in 278 patients (47.6%); chronic kidney disease, in 171 patients (29.3%); and liver cirrhosis, in 132 patients (22.6%). Gram-positive organisms caused 22.9% of these nosocomial BSIs, gram-negative organisms caused 69.2%, and fungi caused 6.8%. The most common organism causing nosocomial BSIs were Klebsiella spp. (14%), E coli. (14%), and Enterococcus spp. (11%). Multivariate analysis of risk factors for mortality displayed that comorbidity with low body weight, liver cirrhosis, and malignancy, high CRP level, high Charlson Comorbidity Index and internal medicine and hematology/oncology distribution were strikingly associated with mortality (P = 0.0222, 0.0352, 0.0008, 0.0122, <0.001, and 0.041; [OR] = 1.8097, 1.9268, 2.7156, 2.7585, 3.5431, and 2.2449, respectively). CONCLUSION: K. spp. and E coli. became the most common pathogens of nosocomial BSI in recent years. Comorbidities could be important roles to predictive the outcome of nosocomial BSI. The modifiable risk factors of nosocomial BSI may be investigated further to improve the outcome.

Epidemiology and risk factors for invasive fungal infections during induction chemotherapy for newly diagnosed acute myeloid leukemia: A retrospective cohort study.

This study investigated the epidemiology and risk factors associated with invasive fungal infections (IFIs) during induction chemotherapy in a cohort of Taiwanese patients with newly-diagnosed acute myeloid leukemia (AML). IFIs are a significant complication in the management of immunocompromised cancer patients; such infections are associated with a high incidence of morbidity and mortality, particularly in many South-Asian countries, where IFI rates are increasing. We retrospectively analyzed IFI incidence data from 105 patients with newly diagnosed AML at a single center undergoing their first course of induction chemotherapy without primary antifungal prophylaxis between November 2008 and December 2014. Of 21 cases documented as proven/provable IFIs 16 (76%) were invasive aspergillosis, 2 (10%) were mucormycosis infections, and 3 (14%) were proven yeast infections. The lung was the most commonly affected site (n = 16; 76%); 2 patients (10%) developed fungal sinusitis. IFI cases were more often males (P = 0.020). In multivariate analysis, patients with neutropenia lasting>30 days were more than twice as likely to develop IFI (OR, 2.24 [95% CI, 2.81-31.11], P<0.001). We also confirmed patients with smoker and receiving parenteral nutrition during chemotherapy were significant associated with IFIs. Our findings suggest that antifungal prophylaxis should be considered for patients with AML during induction chemotherapy, particularly in patients from Southeastern Asia, an area of potentially high IFI rates. We recommend that clinicians determine which patients receiving induction chemotherapy for AML are at high risk of developing IFI, to allow for targeted therapeutic prophylaxis.

Clinical characteristics, treatments, and outcomes of hematogenous pyogenic vertebral osteomyelitis, 12-year experience from a tertiary hospital in central Taiwan.

BACKGROUND: In Taiwan, studies about hematogenous pyogenic vertebral osteomyelitis (HPVO) are limited. We conducted a retrospective study to evaluate the clinical presentations, treatment, and outcomes of patients with the diagnosis of HPVO. METHOD: This 12.5-year retrospective study included patients with a diagnosis of HPVO. Medical records of all HPVO patients were thoroughly reviewed and their clinical data were analyzed by the SPSS software. RESULT: 414 HPVO cases were included and the mean age was 61.6 ± 13.4 years. The mean duration of symptoms was 29 ± 35.3 days and pain over the affected site was reported by most patients (86.0%). Gram-positive bacteria, especially Staphylococcus aureus (162/399 = 40.6%), were the main HPVO pathogens. Escherichia coli (42/399 = 10.5%) was the most common gram-negative isolate. Surgery was performed in 68.8% of cases and the mean duration of total antibiotic treatment was 104.7 ± 77.7 days. All-cause mortality and recurrence rates were 6.3% and 18.8%, respectively. In multivariate analysis, polymicrobial infection (OR: 4.154, 95% CI: 1.039-16.604, p = 0.044), multiple vertebral body involvement (OR: 2.202, 95% CI: 1.088-4.457, p = 0.028), abscess formation treated with antibiotics alone (OR: 2.912, 95% CI: 1.064-7.966, p = 0.037), and the duration of antimicrobial treatment less than 4 weeks (OR: 3.737, 95% CI: 1.195-11.683, p = 0.023) were associated with HPVO recurrence. CONCLUSION: In Taiwan, HPVO mainly affected the elderly and S. aureus remained the most common HPVO pathogen. In patients with risk factors associated with HPVO recurrence, a longer duration (≥6 weeks) of antimicrobial therapy is suggested.

Determinants of women's likelihood of vaginal self-sampling for human papillomavirus to screen for cervical cancer in Taiwan: a cross-sectional study.

BACKGROUND: Many Taiwanese women (43.8%) did not participate in regular cervical screening in 2011. An alternative to cervical screening, self-sampling for human papillomavirus (HPV), has been available at no cost under Taiwan's National Health Insurance since 2010, but the extent and likelihood of HPV self-sampling were unknown. METHODS: A cross-sectional study was performed to explore determinants of women's likelihood of HPV self-sampling. Data were collected by questionnaire from a convenience sample of 500 women attending hospital gynecologic clinics in central Taiwan from June to October 2012. Data were analyzed by descriptive statistics, chi-square test, and logistic regression. RESULTS: Of 500 respondents, 297 (59.4%) had heard of HPV; of these 297 women, 69 (23%) had self-sampled for HPV. Among the 297 women who had heard of HPV, 234 (78.8%) considered cost a priority for HPV self-sampling. Likelihood of HPV self-sampling was determined by previous Pap testing, high perceived risk of cervical cancer, willingness to self-sample for HPV, high HPV knowledge, and cost as a priority consideration. CONCLUSIONS: Outreach efforts to increase the acceptability of self-sampling for HPV testing rates should target women who have had a Pap test, perceive themselves at high risk for cervical cancer, are willing to self-sample for HPV, have a high level of HPV knowledge, and for whom the cost of self-sampling covered by health insurance is a priority.

Report of a 63-case series of Candida empyema thoracis: 9-year experience of two medical centers in central Taiwan.

BACKGROUND: Candida empyema thoracis is a serious complication of invasive candidiasis with high mortality. However, the treatment for Candida empyema remains controversial. We conducted a 9-year retrospective study to analyze the treatments and factors associated with the mortality of patients with Candida empyema thoracis in two medical centers in central Taiwan. METHODS: The medical records of all patients with positive Candida culture from pleural effusion between October 2002 and September 2011 were reviewed. The demographic data, treatment regimens, and factors associated with mortality were analyzed. RESULTS: During the period of this study, 102 patients were identified. Sixty-three of these patients fulfilled the enrollment criteria, and their data were analyzed. Three-quarters of these patients were male, and the median age of these patients was 69. Thirty-five (55.6%) patients had contiguous infection. The crude mortality rate was 61.9%. Candida albicans was the most common isolate, and malignancy was the most common underlying disease. Patients with advanced age, a higher Charlson's score, shock status, respiratory failure, and noncontiguous infection had a higher mortality rate. Those who had received surgical intervention had a better outcome. In multivariate analysis, the shock status, respiratory failure, and noncontiguous infection source were associated with a higher mortality risk. CONCLUSION: Candida empyema thoracis is a severe invasive candidiasis with high mortality rate. Shock status, respiratory failure, and noncontiguous infection were factors associated with a higher mortality rate. Surgical intervention or drainage may improve the treatment outcome, especially in patients with contiguous infection.

Correlation of virulence genes to clinical manifestations and outcome in patients with Streptococcus dysgalactiae subspecies equisimilis bacteremia.

BACKGROUND/PURPOSE: Streptococcus dysgalactiae subsp. equisimilis (SDSE) is increasingly recognized as a human pathogen responsible for invasive infection and streptococcal toxic shock syndrome (STSS). The pathogen possesses virulence genes that resemble those found in Streptococcus pyogenes (GAS). We analyzed the association between these specific toxic genes, clinical presentations, and outcome in patients with SDSE infections. METHODS: Patients (older than 18 years) with community-acquired invasive bacteremia caused by SDSE bacteremia who were undergoing treatment at China Medical University Hospital from June 2007 to December 2010 were included in this study. Multiplex polymerase chain reaction was performed to identify virulence genes of the SDSE isolates. Demographic data, clinical presentations, and outcome in patients with SDSE infections were reviewed and analyzed. RESULTS: Forty patients with 41 episodes of SDSE bacteremia were reviewed. The median age of the patients with SDSE infection was 69.7 years; 55% were female and 78% had underlying diseases. Malignancy (13, 33%) and diabetes mellitus (13, 33%) were the most common comorbidities. The 30-day mortality rate was 12%. Compared with the survivors, the non-survivors had a higher rate of diabetes mellitus (80% vs. 26%), liver cirrhosis (60% vs.11%), shock (60% vs.17%), STSS (60% vs. 8%), and a high Pittsburgh bacteremia score >4 (40% vs. 6%). Most isolates had scpA, ska, saga, and slo genes, whereas speC, speG, speH, speI, speK, smez, and ssa genes were not detected. speA gene was identified only in one patient with STSS (1/6, 17%). All isolates were susceptible to penicillin, cefotaxime, levofloxacin, moxifloxacin, vancomycin, and linezolid. CONCLUSION: In invasive SDSE infections, most isolates carry putative virulence genes, such as scpA, ska, saga, and slo. Clinical SDSE isolates in Taiwan remain susceptible to penicillin cefotaxime, and levofloxacin.

Dose-dependent folic acid and memantine treatments promote synergistic or additive protection against Aß(25-35) peptide-induced apoptosis in SH-SY5Y cells mediated by mitochondria stress-associated death signals.

Increased dietary folic acid (FA) is associated with reduced risks of Alzheimer's disease (AD). The AD drug memantine (Mn) has had limited therapeutic effects for the treatment of patients with moderate to severe AD. This study investigated whether and the underlying mechanisms by which the combination of Mn and FA may have synergistic or additive effects in protecting against amyloid-ß(25-35) peptide (Aß)-induced neurocytotoxicity. Aß treatment of human neuroblastoma SH-SY5Y cells significantly induced a 6-fold increase of apoptotic cells compared with the Aß-untreated group. Preincubation of Aß-exposed cells with FA (500 µM) or Mn (20 µM) caused a 22% and 10% reduction of apoptotic cells, respectively, whereas the combo-treatments at such doses synergistically alleviated Aß-induced apoptosis by 60% (P<0.05). The apoptotic protection by the combo-treatments coincided with attenuating Aß-elicited mitochondrial (mt) membrane depolarization and abolishing Aß-induced mt cytochrome c release to the cytosol. Increased levels of FA at 1000 µM in combination with 20 µM Mn exerted an additive protection against Aß(25-35)-induced-apoptosis as compared to the isolate Mn group (P<0.05). The combo-treatments reversed Aß-elicited mt membrane depolarization, attenuated Aß-elicited mt cytochrome c release to the cytosol, and diminished Aß-promoted superoxide generation. The apoptotic-protection by such combo-treatments was partially abolished by carbonyl cyanide 3-chlorophenylhydrazone (mt membrane potential uncoupler) and sodium azide (mt cytochrome c oxidase inhibitor). Taken together, the data demonstrated that dose-dependent FA and Mn synergistically or additively protected SH-SY5Y cells against Aß-induced apoptosis, which was partially, if not completely, mediated by mt stress-associated death signals.

Effect of rehabilitation on a patient suffering from a tuberculous brain abscess with Gerstmann's syndrome: case report.

There are few reports in the literature of tuberculous brain abscess. Tuberculous brain abscess usually occurs in an immunocompromised host. Almost all previously documented cases have involved acquired immune deficiency syndrome. We encountered a 53-year-old right-handed immunocompetent male who was initially suspected of having a cerebrovascular accident due to acute-onset right hemiparesis and paresthesia. A tentative diagnosis of brain tumor versus brain abscess was made on imaging studies. The patient was finally diagnosed with a tuberculous brain abscess based upon deterioration on imaging and a positive tuberculosis culture. The tuberculous brain abscess was located in the left parietal lobe, which resulted in Gerstmann's syndrome and right-sided apraxia. Stereotactic surgery was performed. He was also given antituberculosis chemotherapy and comprehensive rehabilitation. Considerable improvement was noted after rehabilitation. The patient even returned to a normal life and work. Our case demonstrates that an aggressive intensive inpatient rehabilitation program combined with stereotactic surgery and effective antituberculosis therapy play an important role in improving the outcome for patients with tuberculous brain abscess, Gerstmann's syndrome, and right-sided apraxia.

Infection in liver transplant recipients--analysis of 68 cases at teaching hospital in Taiwan.

BACKGROUND: In Taiwan, liver transplantation is a common treatment of end-stage liver diseases. Infection has a negative impact on the survival of these patients and their grafts. We evaluated the timing and frequency of infections, and the risk factors associated with infection and mortality in liver transplant recipients from Taiwan. METHODS: This retrospective study enrolled all adult patients who underwent orthotopic liver transplantation from January 2004 to November 2008 at a tertiary hospital in Taiwan. RESULTS: Sixty-eight patients were enrolled (male/female = 46/22) and average age was 51.3 years. Bacterial infection (26/68, 38.2%) was the most common infectious disease, with a rate of 0.3/1,000 person-days in the perioperative period, 0.27/1,000 person-days in the early operative period, and 0.38/1,000 person-days in the late-operative period. Operation-related complications increased the risk of bacterial infection. Biliary stricture was the most common operation-related complication, and this was associated with biliary tract infection (p < 0.001). The average time from first stent placement for biliary stricture by endoscopic retrograde cholangiography to biliary tract infection was 34.5 days. The overall mortality rate was 11.7%, and the mortality rate was 14% for patients with infections. CONCLUSIONS: Bacterial infection was the most common type of infection in liver transplant recipients. Surgery-related complication, especially biliary tract stricture was risk factor for infection. We suggest that the current recommendations about the timing of endoscopic retrograde cholangiography intervention be reevaluated.

Spinal tuberculosis in non-HIV-infected patients: 10 year experience of a medical center in central Taiwan.

BACKGROUND/PURPOSE: Tuberculosis (TB) is an endemic disease in Taiwan and it usually affects the lung. Spinal TB accounts for 1-3% of all TB infections. The purpose of this study was to investigate the clinical manifestations, management, outcomes and drug susceptibility of Mycobacterium tuberculosis in non-HIV-infected patients with spinal TB. METHODS: From January 1998 to December 2007, we retrospectively reviewed the medical charts of adult patients with a diagnosis of spinal TB. Only those with positive culture results and/or characteristic pathologic findings were enrolled. Demographic data, clinical manifestations and susceptibility to anti-TB drugs were reviewed and analyzed. RESULTS: During the study period, 38 patients (23 men, 15 women) with spinal TB were identified and the mean age was 68 years. The median duration of symptoms was 60 days (range, 3-720 days). Amongst the 38 patients, back pain (100%) was the most common clinical symptom, followed by weakness (53%) and numbness (26%). The lumbar spine (15 patients, 39%) was the most commonly involved site, followed by the thoracic spine (14 patients, 37%). Concomitant pulmonary TB was found in 12 patients (32%). Three patients (8%) had concurrent bacterial or fungal infections. Almost all of the patients (35 patients, 92%) were successfully treated with surgery and anti-TB medications. The erythrocyte sedimentation rate was followed up in 16 patients before and after therapy and a significant decline was observed after treatment (p = 0.004). No mortality was related to spinal TB. CONCLUSION: Insidious clinical course and ambiguous manifestations of spinal TB often delay and hinder the accuracy of diagnosis of spinal TB. In addition to pyogenic osteomyelitis, spinal TB should be included in the differential diagnosis especially in elderly patients with chronic back pain accompanied by elevated erythrocyte sedimentation rate, and those living in the TB endemic area.