Bacterial colonization patterns in daily chlorhexidine care at the exit site in peritoneal dialysis patients-A prospective, randomized controlled trial.

Bacterial colonization patterns in daily chlorhexidine care at the exit site in peritoneal dialysis (PD) patients were not known. We performed a prospective, randomized controlled trial enrolling 89 PD patients. After stratification by initial Staphylococcus aureus (SA) carrier status, patients were randomly assigned to receive daily 4% chlorhexidine care (intervention group) or normal saline (control group) at the exit site. Monthly, we cultured bacteria from the exit site and nasal swabs for 1 year. The SA colonization rates at exit site at 6 and 12 months were significantly lower in the intervention group than the control group (5.0% vs. 22.9%, p = 0.023 and 8.6% vs. 28.1%, p = 0.037 for 6 and 12 months, respectively). The Methicillin-resistant SA (MRSA) colonization rate at exit site at 6 months was similar (5.7% vs. 2.5%,p = 0.596) in control and intervention group, but significantly lower in the intervention group than the control group at exit site at 12months (0% vs. 12.5%, p = 0.047). The gram-negative bacilli (GNB) colonization rates were similar between the intervention and control groups at 6 and 12 months. Genotyping of all MRSA isolates showed ST (sequence type) 59 was the most predominant clone. In conclusion, chlorhexidine care at the exit site in PD patients may be a good strategy for SA and MRSA decolonization. TRIAL REGISTRATION: ClinicalTrials.gov NCT02446158.

Clinical significance of time to positivity for yeast in candidemia.

PURPOSE: Candidemia is an important issue of nosocomial bloodstream infections, and is associated with a high mortality rate. However, little information is available before final species identification, which takes days after the episode of candidemia. This study tried to determine whether time to positivity (TTP) for yeast helps in predicting the species of candidemia. METHODS: A retrospective cohort study was conducted in Taiwan, which included 434 episodes of nonduplicated candidemia during the period between 2006 and 2009. The demographic features, clinical characteristics, TTP for yeast, and acute illness scores were included for analysis. RESULTS: The mean age of patients with candidemia was 70.4 ± 15.2 years, and the 30-day crude mortality rate was 48.2%. Forty-five percent of patients suffered from shock status with a mean Acute Physiological and Chronic Health Evaluation II score of 27.0 ± 8.7 and a mean Sequential Organ Failure Assessment score of 9.7 ± 4.5, whereas 50% were admitted to the intensive care units. Candida albicans was still the most commonly identified pathogen (58.1%), followed by C. tropicalis (14.7%), C. parapsilosis (13.1%), and C. glabrata (8.3%). Results of multivariate logistic regression showed that TTP for yeast within 48 hours would more favor C. tropicalis (p = 0.044), and less favor C. glabrata (p = 0.025) and C. parapsilosis (p < 0.001). Patients with parenteral nutrition usage were more frequently associated with a TTP for yeast within 48 hours, whereas those with previous exposure to an antifungal agent had a longer TTP for yeast. CONCLUSION: The TTP for yeast might provide a hint of the responsible Candida species before final identification among critical patients with candidemia. The association between antifungal agents and TTP would need more evidence for elucidation.

Rapid identification of Acinetobacter baumannii, Acinetobacter nosocomialis and Acinetobacter pittii with a multiplex PCR assay.

Acinetobacter baumannii, Acinetobacter nosocomialis and Acinetobacter pittii are clinically relevant members of the Acinetobacter calcoaceticus-A. baumannii (Acb) complex and important nosocomial pathogens. These three species are genetically closely related and phenotypically similar; however, they differ in their epidemiology, antibiotic resistance and pathogenicity. In this study, we investigated the use of a multiplex PCR-based assay designed to detect internal fragments of the 16S-23S rRNA intergenic region and the gyrB and recA genes. The assay was capable of differentiating A. baumannii, A. nosocomialis and A. pittii in a reliable manner. In 23 different reference strains and 89 clinical isolates of Acinetobacter species, the assay accurately identified clinically relevant Acb complex species except those 'between 1 and 3' or 'close to 13TU'. None of the non-Acb complex species was misidentified. In an analysis of 1034 positive blood cultures, the assay had a sensitivity of 92.4 % and specificity of 98.2 % for Acb complex identification. Our results show that a single multiplex PCR assay can reliably differentiate clinically relevant Acb complex species. Thus, this method may be used to better understand the clinical differences between infections caused by these species.

Dissemination of imipenem-resistant Acinetobacter baumannii with new plasmid-borne bla(OXA-72) in Taiwan.

BACKGROUND: The systemic surveillance of imipenem-resistant Acinetobacter baumannii (IRAB) from multicenters in Taiwan revealed the emergence of isolates with bla(OXA-72). This study described their genetic makeup, mechanism of spread, and contribution to carbapenem resistance. METHODS: Two hundred and ninety-one non-repetitive isolates of A. baumannii were collected from 10 teaching hospitals from different geographical regions in Taiwan from June 2007 to September 2007. Minimal inhibitory concentrations (MICs) were determined by agar dilution. Clonality was determined by pulsed-field gel electrophoresis. Plasmid was extracted and digested by restriction enzymes, and subsequently analyzed by electrophoresis and Southern blot for bla(OXA-72). The flanking regions of bla(OXA-72) were determined by inverse PCR. The contribution of bla(OXA-72) to imipenem MIC was determined by transforming plasmids carrying bla(OXA-72) into imipenem-susceptible A. baumannii. RESULTS: Among 142 IRAB in Taiwan, 27 harbored bla(OXA-72); 22 originated from Southern Taiwan, 5 from Central Taiwan, and none from Northern Taiwan. There were two major clones. The bla(OXA-72) was identified in the plasmids of all isolates. Two genetic structures flanking plasmid-borne bla(OXA-72) were identified and shared identical sequences in certain regions; the one described in previous literature was present in only one isolate, and the new one was present in the remaining isolates. Introduction of bla(OXA-72) resulted in an increase of imipenem MIC in the transformants. The overexpression of bla(OXA-72) mRNA in response to imipenem further supported the contribution of bla(OXA-72). CONCLUSIONS: In conclusion, isolates with new plasmid-borne blaOXA-72 were found to be disseminated successfully in Southern Taiwan. The spread of the resistance gene depended on clonal spread and dissemination of a new plasmid. Bla(OXA-72) in these isolates directly led to their imipenem-resistance.

A risk factor analysis of healthcare-associated fungal infections in an intensive care unit: a retrospective cohort study.

BACKGROUND: The incidence of fungal healthcare-associated infection (HAI) has increased in a major teaching hospital in the northern part of Taiwan over the past decade, especially in the intensive care units (ICUs). The purpose of this study was to determine the factors that were responsible for the outbreak and trend in the ICU. METHODS: Surveillance fungal cultures were obtained from "sterile" objects, antiseptic solutions, environment of infected patients and hands of medical personnel. Risk factors for comparison included age, gender, admission service, and total length of stay in the ICU, Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission to the ICU, main diagnosis on ICU admission, use of invasive devices, receipt of hemodialysis, total parenteral nutrition (TPN) use, history of antibiotic therapy before HAI or during ICU stay in no HAI group, and ICU discharge status (ie, dead or alive). Univariable analysis followed by multiple logistic regression analysis was performed to identify the independent risk factors for ICU fungal HAIs and ICU mortality. RESULTS: There was a significant trend in ICU fungal HAIs from 1998 to 2009 (P < 0.001). A total of 516 episodes of ICU fungal HAIs were identified; the rates of various infections were urinary tract infection (UTI) (54.8%), blood stream infection (BSI) (30.6%), surgical site infection (SSI) (6.6%), pneumonia (4.5%), other sites (3.5%). The fungi identified were: yeasts (54.8%), Candida albicans (27.3%), Candida tropicalis (6.6%), Candida glabrata (6.6%), Candida parapsilosis (1.9%), Candida species (0.8%), and other fungi (1.9%). Candida albicans accounted for 63% of all Candida species. Yeasts were found in the environment of more heavily infected patients. The independent risk factors (P < 0.05) of developing ICU fungal HAIs from all sites were TPN use, sepsis, surgical patients, mechanical ventilation and an indwelling urinary catheter. The independent risk factors for ICU fungal UTI included TPN use, mechanical ventilation and an indwelling urinary catheter. The independent risk factors for ICU fungal BSI included TPN use, sepsis, and higher APACHE II score. The independent risk factors for ICU fungal pneumonia included TPN use, surgical patients. The independent risk factors for ICU fungal SSI included surgical patients, and TPN use. The odds ratios of TPN use in various infection types ranged from 3.51 to 8.82. The risk of mortality in patients with ICU fungal HAIs was over 2 times that of patients without ICU HAIs in the multiple logistic regression analysis (P < 0.001). CONCLUSIONS: There was a secular trend of an increasing number of fungal HAIs in our ICU over the past decade. Patients with ICU fungal HAIs had a significantly higher mortality rate than did patients without ICU HAIs. Total parenteral nutrition was a significant risk factor for all types of ICU fungal HAIs, and its use should be monitored closely.

Associated clinical characteristics of patients with candidemia among different Candida species.

BACKGROUND: The rising incidence of non-albicans Candida (NAC) infection has been associated with a potentially adverse outcome for patients with candidemia. However, categorizing various species causing candidemia into a single NAC group might lead to inappropriate conclusions due to heterogeneity in species. Thus we examined the associated factors among patients with candidemia caused by different species. METHODS: This retrospective study was conducted at a tertiary medical center in Taiwan from 2006 to 2009. Mortality rate, demographic and clinical characteristics, albumin levels, and severity scores of acute illness of patients at the onset of candidemia were analyzed. RESULTS: A total of 447 episodes among 418 patients were included for analysis. The overall 30-day crude mortality was 48.2%, with no significant difference between C. albicans and NAC candidemia, but apparently C. parapsilosis candidemia was associated with a lower mortality rate. Time to positivity for yeast was significantly different between species. Compared with infection involving C. albicans, more frequent use of total parenteral nutrition, lower Sequential Organ Failure Assessment score and higher albumin levels were observed for C. parapsilosis candidemia. CONCLUSION: Identifying associated factors for each species may be a more effective approach than single NAC grouping. Time to positivity may be a hint for treatment guidance in candidemia. More frequent use of total parenteral nutrition and less virulent nature were noted for C. parapsilosis candidemia.

Evaluation of the effect of appropriate antimicrobial therapy on mortality associated with Acinetobacter nosocomialis bacteraemia.

Appropriate antimicrobial therapy is effective for severe infections caused by Acinetobacter baumannii, but efficacy for other Acinetobacter species remains to be established. The current study was designed to determine whether appropriate antimicrobial therapy reduces the mortality of patients with Acinetobacter nosocomialis bacteraemia. A 9-year retrospective study of 266 patients with monomicrobial A. nosocomialis bacteraemia was conducted at a large teaching hospital in Taiwan. Multivariable analysis was performed to evaluate the impact on 14-day mortality according to clinical characteristics, severity of disease and use of appropriate antimicrobial therapy. The influence of APACHE II score on the impact of appropriate antimicrobial therapy was analysed by including an interaction term. The overall 14-day mortality was 9.4%. Multivariable analysis revealed that APACHE II score was the only factor significantly associated with mortality (odds ratio, 1.18; 95% confidence interval, 1.11-1.25; p <0.001). Appropriate antimicrobial therapy was not associated with reduced mortality regardless of disease severity. In the subgroup analyses in patients with different clinical conditions, APACHE II score was consistently an independent factor for 14-day mortality, and appropriate antimicrobial therapy did not affect the mortality in any group. In conclusion, severity of disease, based on the APACHE II score, was the independent risk factor for 14-day mortality for patients with monomicrobial A. nosocomialis bacteraemia, even in different clinical conditions. In contrast, appropriate antimicrobial therapy did not reduce the 14-day mortality. The result highlighted a different effect of appropriate antimicrobial therapy on infections caused by two phenotypically undifferentiated Acinetobacter.

Risk factors and clinical outcomes of patients with carbapenem-resistant Acinetobacter baumannii bacteremia.

BACKGROUND: It is still controversial whether carbapenem-resistant Acinetobacter baumannii (CRAB) is an independent risk factor for mortality. This study aimed to determine the risk factors and outcomes of patients with CRAB bacteremia, compared to those with carbapenem-susceptible A. baumannii (CSAB) bacteremia. METHODS: This retrospective cohort study was conducted in Taipei Veterans General Hospital, Taiwan. Patients with bacteremia due to A. baumannii during June 2002 and December 2007 were included. RESULTS: A total of 62 patients with CRAB and 164 with CSAB bacteremia were included. Among these patients, the independent risk factors for acquiring CRAB bacteremia were hematological malignancy [odds ratio (OR): 4.04; 95% confidence interval (CI): 1.29-12.70; p = 0.017], previous use of cefepime (OR: 2.60; 95% CI 1.11-6.08; p = 0.028) and use of total parenteral nutrition (OR: 3.06; 95% CI 1.12-8.39; p = 0.029). The patients with CRAB bacteremia had higher mortality rate than those with CSAB bacteremia. However, multivariate analysis showed that among patients with A. baumannii bacteremia, acquisition of CRAB by itself was not an independent risk factor for 14-day mortality. Instead, the independent factors predicting14-day mortality were Acute Physiology and Chronic Health Evaluation (APACHE) score > 20 (OR: 6.33; 95% CI: 2.32-17.26; p < 0.001), shock (OR: 2.68; 95% CI: 1.11-6.23; p = 0.025) and inappropriate antimicrobial therapy (OR: 2.14; 95% CI: 1.01-4.53; p = 0.046). CONCLUSION: Risk factors for CRAB bacteremia were hematological malignancies, previous use of cefepime and use of total parenteral nutrition. Acquisition of CRAB itself is not a poor prognostic factor for the patients with A. baumannii bacteremia.

Impact of appropriate antimicrobial therapy on mortality associated with Acinetobacter baumannii bacteremia: relation to severity of infection.

BACKGROUND: The efficacy of antimicrobial therapy for Acinetobacter baumannii bacteremia has been difficult to establish because of confounding by underlying diseases, severity of infection, and differences in the pathogenicity of Acinetobacter species. This retrospective study was conducted to evaluate the effect of appropriate antimicrobial therapy on 14-day mortality after adjustment for multiple risk factors. METHODS: The population consisted of 252 patients with monomicrobial A. baumannii bacteremia admitted to a large teaching hospital in Taiwan. The isolates were identified to species level using reference molecular methods. Predictors of 14-day mortality were determined by logistic regression analysis. The influence of severity of infection, determined by Acute Physiology and Chronic Health Evaluation (APACHE) II score, on the impact of appropriate use of antimicrobials on 14-day mortality was assessed by including an interaction term. RESULTS: The overall 14-day mortality rate was 29.8% (75 of 252 patients). The unadjusted mortality rate for appropriate antimicrobial therapy was 13.2% (12 of 91 patients). Appropriate therapy was independently associated with reduced mortality (odds ratio [OR], 0.22; 95% confidence interval [CI], .01-.50; P < .001), and the effect was influenced by APACHE II score (OR for interaction term, 0.90; 95% CI, .82-.98; P= .02). A subgroup analysis revealed that the benefit of appropriate therapy was limited to patients with high APACHE II scores (OR for patients with scores >25 and ≤ 35, 0.16 [95% CI, .07-.37]; OR for those with scores >35, 0.06; 95% CI, .01-.25). CONCLUSIONS: Appropriate antimicrobial therapy significantly reduced 14-day mortality for A. baumannii bacteremia in severely ill patients.

Amino acid substitutions of quinolone resistance determining regions in GyrA and ParC associated with quinolone resistance in Acinetobacter baumannii and Acinetobacter genomic species 13TU.

BACKGROUND AND PURPOSE: Amino acid substitutions in GyrA and ParC are associated with resistance to quinolones in Acinetobacter baumannii (A baumannii), but this association is rarely elucidated in Acinetobacter genomic species (AGS) 13TU. This study aims to compare the association of amino acid substitutions in GyrA and ParC with quinolone resistance in A baumannii and AGS 13TU in Taiwan. METHODS: Eleven representative strains of A baumannii and 13 strains of AGS 13TU were selected from 402 bacteremic isolates. The sequences of quinolone resistance determining regions of gyrA and parC were determined. Minimal inhibitory concentrations (MICs) of nalidixic acid, ciprofloxacin, levofloxacin and moxifloxacin were determined by agar dilution method. RESULTS: Ser83Leu substitution in GyrA in A baumannii (one strain) was associated with resistance to all tested quinolones. This substitution plus a Ser80Leu or Ser80Tyr in ParC in A baumannii (four strains) and AGS 13TU (two strains) were associated with higher MICs of all quinolones. All but one quinolone MICs of A baumannii (one strain) and AGS 13TU (two strains) carrying a single substitution Ser56Asn in ParC remained in the susceptibility breakpoint. The Ser83Leu substitution in GyrA, even with additional Ser56Asn substitution in ParC, was associated with resistance to only nalidixic acid, but not other newer quinolones in AGS 13TU (two strains). CONCLUSION: A baumannii and AGS 13TU possessed similar quinolone resistance associated with amino acid substitutions in GyrA and ParC. Further study with more strains is needed to determine whether a single Ser83Leu substitution in GyrA was associated with a high level of quinolone MIC only in A baumannii, but not in AGS 13TU.

Emergence of carbapenem-resistant non-baumannii species of Acinetobacter harboring a blaOXA-51-like gene that is intrinsic to A. baumannii.

The bla(OXA-51)-like gene, originally intrinsic to Acinetobacter baumannii, had been detected in two clones of Acinetobacter nosocomialis and one clone of Acinetobacter genomic species "Close to 13TU." These bla(OXA-51)-like genes, all preceded by ISAba1, were located on plasmids that might have originated with A. baumannii. The plasmid-borne ISAba1--bla(OXA-51)-like confers a high level of carbapenem resistance and affects the accuracy of using bla(OXA-51)-like detection as a tool for differentiating A. baumannii from other Acinetobacter species.

Prognostic factors of candidemia among nonneutropenic adults with total parenteral nutrition.

BACKGROUND: Immediate removal of central venous catheters (CVCs) is not possible in patients with candidemia requiring total parenteral nutrition (TPN). This study analyzed the possible prognostic factors for survival time after onset of candidemia among nonneutropenic adults requiring TPN. METHODS: We conducted a retrospective analysis from September 2003 to August 2005. RESULTS: A total of 59 nonneutropenic adults with candidemia and requiring TPN were identified retrospectively. All Candida isolates were susceptible to flucytosine and amphotericin B. With the exception of one C glabrata isolate, all other isolates were susceptible to fluconazole and itraconazole. The only predictor of 30-day survival rate after onset of candidemia identified in our analysis was an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 23 points or less. Adults with higher APACHE II scores, who did not have their CVCs changed, did not receive antifungal treatment, or who had thrombocytopenia had shorter survival times after the onset of candidemia. CONCLUSIONS: APACHE II scores, thrombocytopenia, antifungal agents, and CVCs changes are associated with survival time in nonneutropenic adults requiring TPN after the onset of candidemia.

Clinical manifestations of treatment-naive patients with acquired immunodeficiency syndrome and responses to highly active antiretroviral therapy in the Taipei Veterans General Hospital: a 5-year prospective study.

BACKGROUND: Taipei Veterans General Hospital, one of the medical centers in Taiwan, has provided highly active antiretroviral therapy (HAART) to human immunodeficiency virus/AIDS patients for more than 10 years. Five years ago, we began a prospective follow-up of our patients' clinical manifestations and responses to HAART by collecting their clinical data. In this study, we analyzed the morbidity, mortality, and responses to HAART of treatment-naive AIDS patients. The purpose was to provide local data that may be valuable in Taiwan. METHODS: Study cases were enrolled from January 1, 2004, to February 28, 2009, with inclusion criteria of newly diagnosed AIDS during hospitalization and being naive to HAART. Antiretroviral therapy was initiated. To evaluate the clinical responses to HAART, we excluded patients who were pregnant, died within 1 month after confirmation of an AIDS diagnosis, failed to initiate HAART, or were lost to follow-up for more than 6 months. Plasma viral loads and CD4(+) counts were quantified by reverse-transcriptase polymerase chain reaction and flow cytometry, respectively. Statistical analysis was performed using SPSS statistical software. RESULTS: A total of 49 patients were enrolled and 45 patients fulfilled the inclusion criteria for evaluating the efficacy of HAART. At 3 months, 12 months, and 30 months after the initiation of HAART, 64.4% (29 of 45), 88.2% (30 of 34), and 93.8% (15 of 16) had undetectable plasma viral loads, respectively, and 37.8% (17 of 45), 73.5% (25 of 34), and 81.2% (13 of 16) had CD4(+) counts of more than 200 cells/µL, respectively. Median CD4(+) counts increased from baseline at Month 3 by 171 cells/µL and at Month 30 by 375 cells/µL. The overall mortality was 22.4% (11 of 49). CONCLUSION: The virologic and immunologic responses after initiating HAART in this study demonstrated our achievements in providing care and treatment for AIDS patients during this 5-year period, which provides a strong evidence of the efficacy of HAART.

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.

Invasive Haemophilus influenzae disease in adults in Taiwan.

BACKGROUND AND PURPOSE: Haemophilus influenzae is an important cause of invasive infection in infants and children, but it has been considered an uncommon cause of invasive disease in adults. We conducted a retrospective survey of invasive H. influenzae disease in adults in order to better understand the characteristics of clinical presentation and microbiology. METHODS: Patients older than 18 years with H. influenzae isolated from normally sterile sites, between July 1999 and June 2002 in a teaching hospital for adult patients were retrospectively analyzed. Data on demographics, clinical presentation, serotype, antibiotic susceptibility, and beta-lactamase production of H. influenzae isolates were analyzed. RESULTS: Fifteen patients were enrolled. The infectious diagnosis of invasive diseases comprised: pneumonia (5 patients), empyema (2), pelvic inflammatory disease (2), peritonitis (2), periorbital cellulitis with abscess formation (2), endophthalmitis (1) and primary bacteremia (1). Most patients were elderly with underlying illness. Of ten H. influenzae isolates available for analysis, two were serotype b and eight were nontypeable. Beta-lactamase production and ampicillin resistance were found in 6 H. influenzae isolates (5 nontypeable, and 1 type b). CONCLUSION: These data show H. influenzae disease in adults to be rare in Taiwan. Our limited number of cases suggest that nontypeable strains predominate in patients with invasive infection due to H. influenzae. Most patients had respiratory tract infections. Ampicillin resistance was found in more than one-half of H. influenzae isolates, and should be taken into consideration when antibiotics are prescribed on an empirical basis.

The type-2 variant of human cytomegalovirus glycoprotein N (gN-2) is not the rarest in the Chinese population of Taiwan: influence of primer design.

Studies of the human cytomegalovirus (HCMV) glycoprotein N (gpUL73-gN) showed that genotypic variations exist in different geographic areas, with gN-2 unidentified in Chinese population. The purpose of this study was to determine the HCMV gN variants in the Chinese population of Taiwan. Primers were designed and a polymerase chain reaction (PCR) was carried out on the UL73 gene. The PCR products were subjected to restriction fragment length polymorphism (RFLP) analysis. The same PCR-RFLP assay was repeated using primers published previously to demonstrate the influence of primer design. Of the 48 clinical HCMV isolates, 33 were positive for PCR products by both primer sets. Fifteen were positive only by the "in-house" PCR. The distribution of gN-1, gN-2, gN-3, and gN-4 by RFLP analysis was 14:11:7:17, with one isolate positive for both gN-1 and gN-2. The published primers detected the four genotypes with the number of 14:0:2:17. The under-representation of gN-2 and gN-3 by the method published previously may be due to inappropriate primer design when re-examining the sequences. On the basis of the results of this study, gN-2 is not the rarest gN genotype in the Chinese population of Taiwan. The design of primers used for PCR-RFLP genotyping may have a great influence on the frequency distribution of HCMV genomic variants.

Adult candidemia at a medical center in northern Taiwan: a retrospective study.

BACKGROUND AND PURPOSE: Candidemia has been associated with a very high mortality. This study evaluated the predictors of candidemia-related mortality at a teaching hospital in northern Taiwan. METHODS: We conducted a retrospective analysis of adult patients with candidemia between September 2003 and May 2005. A stepwise logistic regression analysis was performed to determine the predictors of candidemia-associated mortality. All Candida isolates were identified to species by use of the ATB ID 32C kit and their susceptibilities to antifungal agents were tested by ATB Fungus 2 system. RESULTS: 179 episodes in 174 adult patients with candidemia were identified retrospectively. The predictors of mortality included duration of prior antibiotics >or=28 days, Acute Physiology and Chronic Health Evaluation (APACHE) II score >or=23 and retention of central venous catheters (CVCs). There was no statistically significant association between the time to the start of antifungal therapy and mortality from nosocomial candidemia. In addition, there was no significant association between the time to CVC removal and mortality after stratification by APACHE II score. CONCLUSIONS: Despite effective antifungal therapy after the onset of candidemia in more than half of the patients studied, mortality remained very high, especially in the groups with longer duration of prior antibiotic treatment, higher APACHE II score and CVC retention. Timing of CVC removal after onset of candidemia was not correlated with mortality.