High intact fibroblast growth factor 23 levels associated with low hemoglobin levels in patients on chronic hemodialysis.

Introduction: A negative association between C-terminal fibroblast growth factor 23 (cFGF23) and hemoglobin (Hb) levels has been reported in patients with predialysis chronic kidney disease. In dialysis patients, the dominant form of serum FGF23 is intact FGF23 (iFGF23); however, its association with the Hb level remains unclear. Therefore, simultaneously monitoring iFGF23 and cFGF23 levels is crucial. In this study, we investigated the associations between both forms of FGF23 (iFGF23 and cFGF23) and renal anemia in chronic hemodialysis (CHD) patients. Methods: We included 166 CHD patients from two hospitals in this cross-sectional, observational study. The primary predictors were serum iFGF23, cFGF23, and iFGF23/cFGF23 levels. The main outcome was the Hb level. Results: Among the CHD patients included, 60.8% were men with a mean age of 59.4 ± 12.7 years. In the crude analysis, iFGF23 and iFGF23/cFGF23 levels showed a significant negative association (-0.27, p = 0.004 and -0.22, p = 0.034, respectively) with the Hb level. Even after adjusting for multiple variables (a parsimonious model), every increment of natural log transformation by 1 for (ln)iFGF23 and ln(iFGF23/cFGF23) levels showed a negative correlation with the Hb level (estimate: -0.27 [95%CI: -0.44, -0.10, p = 0.001]; -0.19 [95%CI: -0.37, -0.01, p = 0.042], respectively), whereas both were positively associated with erythropoietin-stimulating agent (ESA) hyporesponsiveness (odds ratio [OR]: [95%CI: 2.30, 1.26-4.17], p = 0.006; 1.95 [95%CI: 1.08-3.50], p = 0.025). Moreover, these abovementioned associations were more dominant in patients with diabetes who used angiotensin receptor blockers. Discussion: In conclusion, a negative association between serum iFGF23 or iFGF23/cFGF23 level and the Hb level was observed in our CHD patients. Meanwhile, a higher iFGF23 or iFGF23/cFGF23 level may predispose patients to ESA hyporesponsiveness.

Outcome Analysis of Transition From Peritoneal Dialysis to Hemodialysis: A Population-Based Study.

If a technical failure occurs during peritoneal dialysis (PD), the patients undergoing PD may be transitioned to hemodialysis (HD). However, the clinical outcomes of patients who have undergone such a transition are under studied. This study assessed whether patients undergoing HD who have transitioned from PD have the same clinical outcomes as HD-only patients. This research was a retrospective cohort study by searching a National Health Insurance research database for data on patients in Taiwan who had undergone HD between January 2006 and December 2013. The patients were divided into two groups, namely a case group in which the patients were transitioned from PD to HD and a HD-only control group, through propensity score matching at a ratio of 1:4 (n = 1,100 vs. 4,400, respectively). We used the Cox regression model to estimate the hazard ratios (HRs) for all-cause death, all-cause hospitalization, infection-related admission, and major adverse cardiac events (MACE). Those selected patients will be followed until death or the end of the study period (December, 2017), whichever occurs first. Over a mean follow-up of 3.2 years, 1,695 patients (30.8%) died, 3,825 (69.5%) required hospitalization, and 1,142 (20.8%) experienced MACE. Patients transitioning from PD had a higher risk of all-cause death (HR: 1.36; 95% CI: 1.21-1.53) than HD-only patients. However, no significant difference was noted in terms of MACE (HR: 0.91; 95% CI: 0.73-1.12), all-cause hospitalization (HR: 1.07; 95% CI: 0.96-1.18), or infection-related admission (HR: 0.97, 95% CI: 0.80-1.18) between groups. Because of the violation of the proportional hazard assumption, the piecewise-HRs showed that the risk of mortality in the case group was significant within 5 months of the transition (HR: 2.61; 95% CI: 2.04-3.35) not in other partitions of the time axis. In conclusion, patients undergoing HD who transitioned from PD had a higher risk of death than the HD-only patients, especially in the first 5 months after transition (a 161% higher risk). Therefore, more caution and monitoring may be required for patients undergoing HD who transitioned from PD.

Bacterial colonization with balloon uterine stent placement in the uterus for 30 days: a randomized controlled clinical trial.

OBJECTIVE: To assess bacterial colonization following balloon uterine stent placement in the uterus for 30 days. DESIGN: Prospective randomized controlled study. SETTING: Tertiary medical center. PATIENT(S): Sixty-eight women scheduled for hysteroscopy. INTERVENTION(S): Women who were undergoing hysteroscopic surgery were randomly assigned to receive a balloon uterine stent or not. Before starting surgery, the uterine cavity was swabbed for bacterial culture. The device was placed in the uterus after surgery in the stent group. After 30 days, the stent was removed and sent for culture and the uterine cavity also swabbed and cultured. The uterine cavities of the control patients were swabbed before and 30 days after surgery. MAIN OUTCOME MEASURE(S): The primary outcome was the incidence of bacterial colonization of the uterus. Secondary outcomes were pain intensity and species of colonizing bacteria. RESULT(S): Excluding eight women, 30 women in each group were included in this analysis. In the stent group, three women (10.0%) demonstrated bacterial colonization before surgery compared with nine women (30.0%) after 30 days. In the control group, four (13.3%) and ten (33.3%) women had microorganisms detected in the uterus before and after 30 days after surgery, respectively. In neither group did the percentage of women with uterine microorganisms increase significantly after 30 days. The percentages of women with uterine bacterial colonization before and 30 days after surgery were similar between both groups. CONCLUSION(S): Balloon uterine stents may be placed after surgery for up to 30 days without increasing bacterial colonization. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (www.clinicaltrials.gov) NCT01167296.

Trend in vancomycin susceptibility and correlation with molecular characteristics of methicillin-resistant Staphylococcus aureus causing invasive infections in Taiwan: results from the Tigecycline in vitro Surveillance in Taiwan (TIST) study, 2006-2010.

This study was intended to investigate the trend in vancomycin susceptibility and correlation with molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA) causing invasive infections. A total of 670 MRSA isolates were collected from patients with invasive infections as part of bacterial collection in the Tigecycline in vitro Surveillance in Taiwan (TIST) from 2006 to 2010. MICs of the isolates to vancomycin were determined using the agar dilution method. Characteristics of staphylococcal cassette chromosome mec (SCCmec), mec-associated hypervariable region (dru), and accessory gene regulator (agr) of the isolates were identified by polymerase chain reaction methods. MRSA isolates with SCCmec types I, II, and III were molecularly defined as hospital-associated MRSA (HA-MRSA), and those with SCCmec types IV, V, and VT were assigned as community-associated MRSA (CA-MRSA). All but 1 MRSA isolates exhibited vancomycin MICs ≤1 mg/L. A declining trend in vancomycin MICs among MRSA isolates was noted, which was associated with the decline in proportion of HA-MRSA. The percentage of CA-MRSA increased from 25.6% in 2006 to 46.0% in 2010. An increase in the geometric mean of vancomycin MICs was found in MRSA with particular molecular types such as SCCmec types II and III, agr groups I and II, and dru10-14. A significant correlation among particular molecular types was found, including SCCmecII-agr group II-dru4, SCCmecIII-agr group I-dru11-14, SCCmecIV-agr group II-dru9, and SCCmecVT-agr group I-dru9 and dru11. There was no vancomycin creep among MRSA isolates, and the declining trend of vancomycin MIC against MRSA was attributed to the increasing prevalence of CA-MRSA over time.

Soft Tissue Infection Caused by Rapid Growing Mycobacterium following Medical Procedures: Two Case Reports and Literature Review.

Non-tubecrulosis mycobacterium infections were increasingly reported either pulmonary or extrapulmonary in the past decades. In Taiwan, we noticed several reports about the soft tissue infections caused by rapid growing mycobacterium such as Mycobacterium abscessus, Mycobacterium chelonae, on newspaper, magazines, or the multimedia. Most of them occurred after a plastic surgery, and medical or non-medical procedures. Here, we reported two cases of these infections following medical procedures. We also discussed common features and the clinical course of the disease, the characteristics of the infected site, and the treatment strategy. The literatures were also reviewed, and the necessity of the treatment guidelines was discussed.

Trends in the antimicrobial susceptibilities and serotypes of Streptococcus pneumoniae: results from the Tigecycline In Vitro Surveillance in Taiwan (TIST) study, 2006-2010.

Isolates of Streptococcus pneumoniae (n = 530) were collected from 20 hospitals in different parts of Taiwan from 2006 to 2010. MICs to 16 antimicrobial agents were determined by broth dilution method and serotypes were identified by latex agglutination. Based on meningitis (non-meningitis) criteria established by the CLSI, 11.7% (63.2%) of all isolates were susceptible to penicillin and 46.0% (83.8%) were susceptible to ceftriaxone. Of the isolates, 94.3% were non-susceptible to azithromycin and 5.8% and 7.2% were non-susceptible to moxifloxacin and levofloxacin, respectively. Susceptibility to penicillin by meningitis criteria increased significantly (P = 0.0012) with year, and that to clindamycin and amoxicillin/clavulanic acid declined significantly (P < 0.05). Six major serotypes were found, namely 19F (24.0%), 23F (18.5%), 14 (13.6%), 6B (12.5%), 19A (7.5%) and 3 (5.1%). Prevalence of serotypes 19F and 14 remained stationary, that of serotype 6B decreased significantly (P < 0.0001) and that of serotype 19A increased significantly (P < 0.0001) with year. The coverage rate of PCV-7 among the pneumococcal isolates declined from 80.5% in 2006 to 50% in 2010 (P < 0.0001) and that of PCV-13 declined from 91.5% in 2009 to 75% in 2010. The non-susceptibility rate to levofloxacin was highest among serotype 23F isolates (13.3%) and lowest among serotype 19A isolates (2.5%). Rates of resistance to the four agents penicillin, ceftriaxone, azithromycin and clindamycin were highest among serotype 19A isolates (70.0%) and 23F isolates (49.0%). All serotype 3 isolates were susceptible to four of the most commonly used antibiotics (penicillin, ceftriaxone, azithromycin and levofloxacin).

Changing trends in antimicrobial susceptibility of Streptococcus pneumoniae isolates in Taiwan, 2006-2007.

BACKGROUND: Multiple antibiotic-resistant clones of Streptococcus pneumoniae have spread throughout the world and continue to evolve under the selective pressure of antibiotics and vaccines. The aim of this study is to assess the susceptibility of S. pneumoniae isolates and to analyze the resistance trends in Taiwan. METHODS: Antimicrobial susceptibility tests were performed on 152 nonmeningeal isolates of S. pneumoniae that were collected from 13 different hospitals around Taiwan from 2006-2007. Tests were performed using the broth microdilution method according to recommendations of the Clinical and Laboratory Standards Institute. RESULTS: The minimal inhibitory concentrations (MIC(50)/MIC(90)) of penicillin, cefotaxime, vancomycin, and moxifloxacin were 0.5/1.0, 0.25/1.0, 0.25/0.5, and 0.06/0.12 µg/mL, respectively. The susceptibility rates of penicillin, cefotaxime, vancomycin, and moxifloxacin were 99.3%, 99.3%, 100%, and 98.7%, respectively. However, if the meningitis breakpoints were applied to these nonmeningeal isolates, the susceptibility rates of penicillin and cefotaxime were reduced to 18.4% and 76.3%, respectively. Compared with the findings from previous studies in Taiwan, our results show that the percentage of S. pneumoniae isolates with a penicillin MIC of 0.12-1.0 µg/mL increased from 43.3% in 1996-1997 to 73.7% in 2006-2007 (p < 0.001). The percentage of S. pneumoniae isolates with a cefotaxime MIC of 1.0 µg/mL increased from 11.3% in 1996-1997 to 23.0% in 2006-2007 (p < 0.001). Regarding the serial MIC intervals of the four antimicrobial agents, there was no significant difference between bacteremic and nonbacteremic isolates. CONCLUSION: Although nonmeningeal S. pneumoniae isolates remained susceptible to penicillin, the proportion of isolates with a penicillin MIC of 0.12-1.0 µg/mL or cefotaxime MIC of 1.0 µg/mL increased during the past decade in Taiwan. The ever-increasing resistance of S. pneumoniae has a great impact on the treatment of meningitis.

Trends in susceptibility of vancomycin-resistant Enterococcus faecium to tigecycline, daptomycin, and linezolid and molecular epidemiology of the isolates: results from the Tigecycline In Vitro Surveillance in Taiwan (TIST) study, 2006 to 2010.

Among the 219 vancomycin-resistant Enterococcus faecium isolates collected in 20 Taiwanese hospitals from 2006 to 2010, all were susceptible to linezolid and daptomycin, and 98.6% were susceptible to tigecycline. There was a shift toward higher tigecycline MIC values (MIC(90)s) from 2006-2007 (0.06 µg/ml) to 2008-2010 (0.12 µg/ml). The MIC(90)s of daptomycin and linezolid remained stationary. Although pulsotypes among the isolates from the 20 hospitals varied, intrahospital spreading of several clones was identified in 13 hospitals.

Agreement assessment of tigecycline susceptibilities determined by the disk diffusion and broth microdilution methods among commonly encountered resistant bacterial isolates: results from the Tigecycline In Vitro Surveillance in Taiwan (TIST) study, 2008 to 2010.

The Tigecycline In Vitro Surveillance in Taiwan (TIST) study, initiated in 2006, is a nationwide surveillance program designed to longitudinally monitor the in vitro activity of tigecycline against commonly encountered drug-resistant bacteria. This study compared the in vitro activity of tigecycline against 3,014 isolates of clinically important drug-resistant bacteria using the standard broth microdilution and disk diffusion methods. Species studied included methicillin-resistant Staphylococcus aureus (MRSA; n = 759), vancomycin-resistant Enterococcus faecium (VRE; n = 191), extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli (n = 602), ESBL-producing Klebsiella pneumoniae (n = 736), and Acinetobacter baumannii (n = 726) that had been collected from patients treated between 2008 and 2010 at 20 hospitals in Taiwan. MICs and inhibition zone diameters were interpreted according to the currently recommended U.S. Food and Drug Administration (FDA) criteria and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. The MIC(90) values of tigecycline against MRSA, VRE, ESBL-producing E. coli, ESBL-producing K. pneumoniae, and A. baumannii were 0.5, 0.125, 0.5, 2, and 8 µg/ml, respectively. The total error rates between the two methods using the FDA criteria were high: 38.4% for ESBL-producing K. pneumoniae and 33.8% for A. baumannii. Using the EUCAST criteria, the total error rate was also high (54.6%) for A. baumannii isolates. The total error rates between these two methods were <5% for MRSA, VRE, and ESBL-producing E. coli. For routine susceptibility testing of ESBL-producing K. pneumoniae and A. baumannii against tigecycline, the broth microdilution method should be used because of the poor correlation of results between these two methods.

Trends in the susceptibility of clinically important resistant bacteria to tigecycline: results from the Tigecycline In Vitro Surveillance in Taiwan study, 2006 to 2010.

The Tigecycline In Vitro Surveillance in Taiwan (TIST) study, a nationwide, prospective surveillance during 2006 to 2010, collected a total of 7,793 clinical isolates, including methicillin-resistant Staphylococcus aureus (MRSA) (n = 1,834), penicillin-resistant Streptococcus pneumoniae (PRSP) (n = 423), vancomycin-resistant enterococci (VRE) (n = 219), extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli (n = 1,141), ESBL-producing Klebsiella pneumoniae (n = 1,330), Acinetobacter baumannii (n = 1,645), and Stenotrophomonas maltophilia (n = 903), from different specimens from 20 different hospitals in Taiwan. MICs of tigecycline were determined following the criteria of the U.S. Food and Drug Administration (FDA) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST-2011). Among drug-resistant Gram-positive pathogens, all of the PRSP isolates were susceptible to tigecycline (MIC(90), 0.03 µg/ml), and only one MRSA isolate (MIC(90), 0.5 µg/ml) and three VRE isolates (MIC(90), 0.125 µg/ml) were nonsusceptible to tigecycline. Among the Gram-negative bacteria, the tigecycline susceptibility rates were 99.65% for ESBL-producing E. coli (MIC(90), 0.5 µg/ml) and 96.32% for ESBL-producing K. pneumoniae (MIC(90), 2 µg/ml) when interpreted by FDA criteria but were 98.7% and 85.8%, respectively, when interpreted by EUCAST-2011 criteria. The susceptibility rate for A. baumannii (MIC(90), 4 µg/ml) decreased from 80.9% in 2006 to 55.3% in 2009 but increased to 73.4% in 2010. A bimodal MIC distribution was found among carbapenem-susceptible A. baumannii isolates, and a unimodal MIC distribution was found among carbapenem-nonsusceptible A. baumannii isolates. In Taiwan, tigecycline continues to have excellent in vitro activity against several major clinically important drug-resistant bacteria, with the exception of A. baumannii.

In vitro susceptibilities of aerobic and facultative anaerobic Gram-negative bacilli isolated from patients with intra-abdominal infections at a medical center in Taiwan: results of the Study for Monitoring Antimicrobial Resistance Trends (SMART) 2002-2006.

BACKGROUND AND PURPOSE: The Study for Monitoring Antimicrobial Resistance Trends (SMART) was initiated to monitor the in vitro antimicrobial susceptibility of aerobic and facultative anaerobic Gram-negative bacilli (GNB) isolated from patients with intra-abdominal infections (IAI). This report summarizes the SMART data from 1 of the study centers from 2002 to 2006. METHODS: 492 Gram-negative isolates were collected from 482 patients with IAI. Susceptibilities of these isolates to 12 antimicrobial agents were determined using the broth microdilution method. RESULTS: Enterobacteriaceae comprised 68.3% of the isolates (n = 336). The 4 main species were Klebsiella spp. (n = 129; 26.2%), Escherichia coli (n = 122; 24.8%), Enterobacter spp. (n = 36; 7.3%), and Aeromonas hydrophila (n = 35; 7.1%). The commonest glucose non-fermentative GNB were Acinetobacter baumannii (n = 46; 9.3%) and Pseudomonas aeruginosa (n = 35; 7.1%). Extended-spectrum beta-lactamase (ESBL) production was detected in 70 Enterobacteriaceae isolates (70/336; 21%). The ESBL phenotype was exhibited by 23% of Klebsiella pneumoniae, 26% of E. coli, and 19% of Enterobacter spp. The highest rate of ESBL production was found in 2005 for E. coli (38%) and in 2003 for Klebsiella spp. (38%) and Enterobacter spp. (40%). The incidence of ESBL-producing isolates declined in 2005 and 2006. Low susceptibility rates of E. coli isolates to ciprofloxacin (58%) and levofloxacin (64%) were noted. Ertapenem (99%), imipenem (99%), and amikacin (94%) were the most potent agents against Enterobacteriaceae spp. CONCLUSIONS: Continuous surveillance is crucial to monitor the trend of antimicrobial resistance patterns among GNB isolated from IAI.

Nationwide surveillance in Taiwan of the in-vitro activity of tigecycline against clinical isolates of extended-spectrum beta-lactamase-producing Enterobacteriaceae.

Tigecycline In-vitro Surveillance in Taiwan (TIST), initiated in 2006, is a nationwide surveillance programme designed to monitor longitudinally the in-vitro activity of tigecycline against commonly encountered resistant bacteria. This study compared the in-vitro activity of tigecycline against clinical isolates of resistant Gram-negative bacteria determined by the broth microdilution and Etest methods. A total of 622 isolates were collected from patients treated at 20 teaching hospitals. Tigecycline had excellent in-vitro activity against extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (N = 275) with MIC(90) 0.5 microg/mL and a 99.6% susceptibility rate, and also against ESBL-producing Klebsiella pneumoniae (N = 324) with MIC(90) 2 microg/mL and a 98.5% susceptibility rate. For ESBL-producing Proteus mirabilis (N = 15) the MIC(90) was 4 microg/mL with a 73.3% susceptibility rate. For ESBL-producing Klebsiella oxytoca (N = 8) the MIC(50) and MIC(90) were 0.5 and 1 microg/mL, respectively, with a 100% susceptibility rate. Limited agreement (<80%) was found between the broth microdilution and the Etest methods when determining the in-vitro activity of tigecycline against ESBL- producing K. pneumoniae and K. oxytoca.

Nationwide surveillance in Taiwan of the in-vitro activity of tigecycline against clinical isolates of Gram-positive cocci.

Tigecycline In-vitro Surveillance in Taiwan (TIST), initiated in 2006, is a nationwide surveillance programme designed to monitor longitudinally the in-vitro activity of tigecycline against commonly encountered resistant bacteria in Taiwan. This study, part of TIST-2006 study, aimed to compare the in-vitro activity of tigecycline against clinical isolates of Gram-positive bacteria. A total of 805 isolates of Gram-positive bacteria were collected from patients treated at 20 teaching hospitals. Minimum inhibitory concentrations (MICs) of tigecycline for these isolates were determined by the broth microdilution method according to the guidelines of the Clinical and Laboratory Standards Institute, and by the Etest as per the manufacturer's instructions. Susceptibility results were interpreted by the MIC criteria recommended by the US FDA. Agreement between the two methods was low: 80.7% for methicillin-resistant Staphylococcus aureus (MRSA), 27.2% for Streptococcus pneumoniae, 22.8% for other Streptococcus spp., and 30.8% for vancomycin-resistant E. faecium (VRE). There were no very major or major errors noted. Tigecycline exhibited excellent in-vitro activity against Gram-positive cocci, including MRSA, VRE, S. pneumoniae and other Streptococcus spp. isolates in Taiwan. Correlation between MIC values determined using the broth microdilution and Etest methods for these organisms was poor.

In-vitro activity of tigecycline against clinical isolates of Acinetobacter baumannii in Taiwan.

We performed susceptibility testing using the microdilution method to determine the in-vitro activity of tigecycline against 393 Acinetobacter baumannii clinical isolates collected in 2006 from 19 hospitals in Taiwan. Significant proportions of the isolates were resistant to imipenem (44%), ciprofloxacin (75%), amikacin (69%), sulbactam (34%) and all four antibiotics (22%), and susceptibility to tigecycline among these different resistant phenotypes of A. baumannii varied from 71% to 82%. The minimum inhibitory concentration (MIC) of tigecycline ranged from 0.6 to 16 microg/mL (MIC(50) 2 microg/mL; MIC(90) 4 microg/mL). The cumulative curve of tigecycline MICs showed that when the MIC cut-offs were set at 2 microg/mL and 4 microg/mL, 80.9% and 93.1% of the isolates were susceptible, respectively. As tigecycline will be used in the future for infections caused by multidrug-resistant A. baumannii because of limited antibiotic choice, and as resistance to tigecycline in A. baumannii isolates may develop following antibiotic exposure, continuous monitoring of the susceptibility of A. baumannii isolates to tigecycline is warranted.

In-vitro activity of tigecycline against clinical isolates of Acinetobacter baumannii in Taiwan determined by the broth microdilution and disk diffusion methods.

A total of 393 isolates of A. baumannii were collected from patients treated at 19 teaching hospitals in Taiwan. Minimum inhibitory concentrations (MICs) and inhibitory zone diameters for tigecycline were determined by the broth microdilution method and the disk diffusion method, respectively. The MIC results were interpreted using the US FDA tigecycline susceptibility breakpoints for Enterobacteriaceae (susceptible [S] or=8 microg/mL). The disk diffusion results were interpreted by criteria recommended by Jones et al. (S >or=16 mm; I 13-15 mm; R or=19 mm; I 15-18 mm; R

The impact of an intensive antimicrobial control program in a Taiwanese medical center.

OBJECTIVE: The study evaluates the short term impacts of an intensive control program for the appropriate us of antimicrobials, and to provide a novel strategy for antimicrobial control in inpatient wards in Taiwan. METHOD: In September 2002, a dual intensive antimicrobial control program was implemented within a 921-bed medical center in Taiwan. The study sample included all patients admitted to the medical center during the basal period (October-December 2001) and the intervention period (October-December 2002), where at least one type of parenteral antimicrobial was administered. The sample comprised of 5046 patients during the basal period and 5054 patients during the intervention period. MAIN OUTCOME MEASURE: Analysis of the impact of the intensive antimicrobial control program was undertaken by comparing clinical outcomes, parenteral antimicrobial consumption and bacterial susceptibilities, before and after the establishment of the intensive antimicrobial control program. RESULTS: No statistical differences were found between the basal and intervention periods with regard to either the demographic variables, such as age and gender, or the incidence of nosocomial infections. The clinical outcomes, including length of stay in the medical center, mortality and readmission rates, were also similar for both periods. As compared to the basal period, the consumption of parenteral antimicrobials--in defined daily doses (DDDs) per 100 patient days (PDs)--declined by 13.2% during the intervention period (71.2 vs. 61.8). There were significant increases in the susceptibilities of Pseudomonas aeruginosa to both amikacin and ciprofloxacin, and Serratia spp. to ciprofloxacin (P < 0.05), while all others remained stable. CONCLUSION: This study reports positive responses to intensive antimicrobial control measures among health professionals within a Taiwanese medical center. Following the implementation of the intensive control program, both prescriptions and consumption levels of parenteral antimicrobials were reduced without compromising the clinical outcomes of patients, while the susceptibility patterns of bacterial organisms mostly remained stable. Long-term control of parenteral antimicrobials under such a program may well produce significant benefits for inpatients through the overall rationalization of antimicrobial usage, leading to potential reductions in both the incidence of adverse effects and the burden of resistant organisms. A method of incorporating this intensive control program into a computerized prescription order system is currently under construction.

Establishing a clinical decision rule of severe acute respiratory syndrome at the emergency department.

STUDY OBJECTIVE: In the absence of reliable rapid confirmatory tests during severe acute respiratory syndrome (SARS) endemics, we designed a 2-phase cohort study to establish a scoring system for SARS and to evaluate whether it could improve the sensitivity and specificity of the World Health Organization (WHO) criteria. METHODS: According to the clinical characteristics and initial laboratory findings of 175 suspected cases defined by the WHO criteria (20 confirmed as cases of SARS) in 3 university teaching hospitals in Taipei between March 1 and April 20, 2003, the scoring system for SARS was designed by multivariate analysis and stepwise logistic regression as the simple arithmetic sum of point values assigned to 7 parameters. We thereafter applied the scoring system for SARS to the consecutive 232 patients (the validation group) who met the WHO criteria of suspected cases from April 21 to May 22, 2003. Final diagnosis of SARS was determined by the results of real-time polymerase chain reaction and paired serum. RESULTS: The scoring system for SARS was defined as radiographic findings of multilobar or bilateral infiltrates (3 points), sputum monocyte predominance (3 points), lymphocytopenia (2 points), history of exposure (1 point), lactate dehydrogenase more than 450 U/L (1 point), C-reactive protein more than 5.0 mg/dL (1 point), and activated partial prothrombin time more than 40 seconds (1 point). Of the validation group, 60 patients (group A) were confirmed as having cases of SARS, and the other 172 (group B) patients tested negative for SARS. The total points of the scoring system for SARS at initial presentation were significantly higher in the SARS group (median 9; range 6 to 11) than in the non-SARS group (median 4; range 3 to 7; P<.001). At the cutoff value of 6 points, the sensitivity and specificity of the scoring system for SARS in diagnosing SARS were 100% and 93%, respectively. The positive and negative predictive values of the scoring system for SARS were 83% and 100%, respectively. CONCLUSION: The scoring system for SARS can provide a rapid and reliable clinical decision to help emergency physicians detect cases of SARS more accurately in the endemic area.