Immunological Aspects of SARS-CoV-2 Infection and the Putative Beneficial Role of Vitamin-D.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is still an ongoing global health crisis. Immediately after the inhalation of SARS-CoV-2 viral particles, alveolar type II epithelial cells harbor and initiate local innate immunity. These particles can infect circulating macrophages, which then present the coronavirus antigens to T cells. Subsequently, the activation and differentiation of various types of T cells, as well as uncontrollable cytokine release (also known as cytokine storms), result in tissue destruction and amplification of the immune response. Vitamin D enhances the innate immunity required for combating COVID-19 by activating toll-like receptor 2. It also enhances antimicrobial peptide synthesis, such as through the promotion of the expression and secretion of cathelicidin and ß-defensin; promotes autophagy through autophagosome formation; and increases the synthesis of lysosomal degradation enzymes within macrophages. Regarding adaptive immunity, vitamin D enhances CD4+ T cells, suppresses T helper 17 cells, and promotes the production of virus-specific antibodies by activating T cell-dependent B cells. Moreover, vitamin D attenuates the release of pro-inflammatory cytokines by CD4+ T cells through nuclear factor κB signaling, thereby inhibiting the development of a cytokine storm. SARS-CoV-2 enters cells after its spike proteins are bound to angiotensin-converting enzyme 2 (ACE2) receptors. Vitamin D increases the bioavailability and expression of ACE2, which may be responsible for trapping and inactivating the virus. Activation of the renin-angiotensin-aldosterone system (RAS) is responsible for tissue destruction, inflammation, and organ failure related to SARS-CoV-2. Vitamin D inhibits renin expression and serves as a negative RAS regulator. In conclusion, vitamin D defends the body against SARS-CoV-2 through a novel complex mechanism that operates through interactions between the activation of both innate and adaptive immunity, ACE2 expression, and inhibition of the RAS system. Multiple observation studies have shown that serum concentrations of 25 hydroxyvitamin D are inversely correlated with the incidence or severity of COVID-19. The evidence gathered thus far, generally meets Hill's causality criteria in a biological system, although experimental verification is not sufficient. We speculated that adequate vitamin D supplementation may be essential for mitigating the progression and severity of COVID-19. Future studies are warranted to determine the dosage and effectiveness of vitamin D supplementation among different populations of individuals with COVID-19.

Differential diagnosis of atypical encephalopathy in critical care: a case report.

BACKGROUND: A lower level of consciousness is a common presentation in critical care, with many different causes and contributory factors, of which more than one may be present concurrently. CASE PRESENTATION: We described a woman with poorly controlled diabetes and steroid-dependent asthma who presented in a deep coma. She was found to have Streptococcus intermedius bacteremia and pyogenic ventriculitis that originated from right middle lobe pneumonia. Also, multiple small parenchymal lesions were observed on brain magnetic resonance imaging and increased protein concentration was noted in cerebral spinal fluid. Initially, her coma was thought to be due to diabetic ketoacidosis and septic encephalopathy. However, her lowered level of consciousness was disproportionate to either diabetic ketoacidosis or septic encephalopathy, and her clinical course was not as expected for these two conditions. Treatment with antibiotic, corticosteroid and antihelminthic drugs was administered resulting in improving consciousness. The Streptococcus intermedius pneumonia progressed to form a large cavity that needed an early surgical lobectomy and resulted in the unexpected diagnosis of chronic cavitary pulmonary aspergillosus. CONCLUSIONS: In critical care, a lowered level of consciousness may have many etiologies, and critical care clinicians should be familiar with the signs and symptoms of all possible causes to enable prompt diagnosis and appropriate treatment.

Clinical progression of asynchronous cutaneous lesions in a patient with locally acquired mpox infection.

We present one of the earliest domestic mpox cases in Taiwan, highlighting the asynchronous and atypical progression of cutaneous lesions which could pose significant diagnostic challenges for clinicians.

Antibiotic Stewardship Related to Delayed Diagnosis and Poor Prognosis of Critically Ill Patients with Vancomycin-Resistant Enterococcal Bacteremia: A Retrospective Cohort Study.

Purpose: Patients with septicemia caused by vancomycin-resistant Enterococcus (VRE) bacteremia have higher mortality rates than patients infected by VSE. Vancomycin or teicoplanin is selected as the antibiotic stewardship intervention to cover methicillin-resistant Staphylococcus aureus infections before blood culture reveals VRE bacteremia in critically ill patients with Gram-positive cocci (GPC) bacteremia; this may require linezolid or daptomycin treatment instead. We thus evaluated antibiotic stewardship practices, such as appropriate timing of antibiotic use in GPC bacteremia, and clinical outcomes of critically ill patients with VRE infection. Patients and Methods: This retrospective study enrolled 191 critically ill patients with enterococcal bacteremia at the Taipei Tzu Chi Hospital during January 1, 2019-December 31, 2020. Demographic and clinical characteristics, as well as disease outcomes and appropriate antibiotic use after GPC bacteremia diagnosis, were compared between the VRE and VSE groups. Results: Of 191 patients, 55 had VRE bacteremia (case group) and 136 had VSE bacteremia (control group). The rate of antibiotic change after initial antibiotic use for GPC bacteremia was higher in the VRE bacteremia group (100% vs 10.3%; p<0.001). The time to appropriate antibiotic administration after GPC bacteremia diagnosis was longer in the VRE bacteremia group (3.3±2.1 vs 1.5±1.8 days; p<0.001). Patients with VRE bacteremia had higher 28-day mortality rates (relative risk, 1.997; 95% confidence interval [CI], 1.041-3.83). Multivariate Cox regression analysis showed that delayed appropriate antibiotic administration of >3 days after GPC bacteremia diagnosis increased the risks of 28-day all-cause mortality (adjusted hazard ratio, 2.045; 95% CI, 1.089-3.84; p=0.026) in patients with VRE infection. Conclusion: Patients with VRE bacteremia with delayed appropriate antibiotic administration of >3 days after GPC bacteremia diagnosis had increased 28-day mortality risks. New strategies for early VRE detection in GPC bacteremia may shorten the time to administer appropriate antibiotics and lower mortality rates.

Clinical application of 222 nm wavelength ultraviolet C irradiation on SARS CoV-2 contaminated environments.

This was a preliminary study on ultraviolet C (UVC) irradiation for SARS-CoV-2-contaminated hospital environments. Forty-eight locations were tested for SARS-CoV-2 using RT-PCR (33.3% contamination rate). After series dosages of 222-nm UVC irradiation, samples from the surfaces were negative at 15 s irradiation at 2 cm length (fluence: 81 mJ/cm2).

A case of methicillin resistant Staphylococcus aureus necrotizing pneumonia with pulmonary cryptococcosis.

A 37-year-old healthy man was transferred to the emergency department of this hospital because of fever and hemoptysis. A radiograph of the chest revealed a cavitary lesion in the right upper lobe. Computed tomography of the chest showed necrotizing cavitary pneumonia. Urgent throacoscopic lobectomy was performed. Sputum and intraoperative pleural pus grew methicillin resistant Staphylococcus aureus (MRSA). The pathological examination reportedly revealed cryptococcal infection. He had a full recovery after intravenous linezolid treatment.

Masks and closed-loop ventilators prevent environmental contamination by COVID-19 patients in negative-pressure environments.

Herein, we report that nosocomial infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be mitigated by using surgical masks and closed looped ventilation for both non-critical and critical patients. These preventive measures resulted in no viral contamination of surfaces in negative pressure environments.

Clinical Application of Ultraviolet C Inactivation of Severe Acute Respiratory Syndrome Coronavirus 2 in Contaminated Hospital Environments.

To overcome the ongoing coronavirus disease 2019 (COVID-19) pandemic, transmission routes, such as healthcare worker infection, must be effectively prevented. Ultraviolet C (UVC) (254 nm) has recently been demonstrated to prevent environmental contamination by infected patients; however, studies on its application in contaminated hospital settings are limited. Herein, we explored the clinical application of UVC and determined its optimal dose. Environmental samples (n = 267) collected in 2021 were analyzed by a reverse transcription-polymerase chain reaction and subjected to UVC irradiation for different durations (minutes). We found that washbasins had a high contamination rate (45.5%). SARS-CoV-2 was inactivated after 15 min (estimated dose: 126 mJ/cm2) of UVC irradiation, and the contamination decreased from 41.7% before irradiation to 16.7%, 8.3%, and 0% after 5, 10, and 15 min of irradiation, respectively (p = 0.005). However, SARS-CoV-2 was still detected in washbasins after irradiation for 20 min but not after 30 min (252 mJ/cm2). Thus, 15 min of 254-nm UVC irradiation was effective in cleaning plastic, steel, and wood surfaces in the isolation ward. For silicon items, such as washbasins, 30 min was suggested; however, further studies using hospital environmental samples are needed to confirm the effective UVC inactivation of SARS-CoV-2.

Early Screening of Risk for Multidrug-Resistant Organisms in the Emergency Department in Patients With Pneumonia and Early Septic Shock: Single-Center, Retrospective Cohort Study.

OBJECTIVES: Pneumonia is the fourth leading cause of death globally, with rapid progression during sepsis. Multidrug-resistant organisms (MDROs) are becoming more common with some healthcare-associated pneumonia events. Early detection of MDRO risk improves the outcomes; however, MDROs risk in pneumonia with sepsis is unknown. This study investigated the disease outcomes of pneumonia with septic shock in patients admitted in the emergency department (ED) intensive care unit (ICU), a population with a high prevalence of MDROs, after early screening of MDROs risk. METHODS: In this retrospective cohort study, patients with pneumonia and early septic shock (n = 533) admitted to the ED at the Taipei Tzu Chi Hospital from 2013 to 2019 were selected. The study population was divided into four subgroups after the MDROs risk and screening procedure were completed within 1 or 6 h of admission. ICU mortality and multidrug antibiotic therapy were compared. RESULTS: The high-risk MDROs groups had higher percentage of P aeruginosa than the low-risk group. Furthermore, the appropriate ED first antibiotics were higher in the 1-h subgroup than in the 6-h subgroup of the high-risk MDROs group. In multivariate analysis, the 6-h high-risk MDROs group had an adjusted odds ratio of 7.191 (95% CI: 2.911-17.767, P < 0.001) and 2.917 (95% CI: 1.456-5.847, P = 0.003) for ICU mortality and multidrug therapy in the ICU, respectively, after adjusting for other confounding factors. CONCLUSIONS: MDRO screening within 1 h is recommended following admission of patients with pneumonia and early septic shock in the ED, especially in areas with a high prevalence of MDROs.

Ignorance of pre-ED healthcare setting is a factor leading to inappropriate initial antibiotic treatment of sepsis in ED and poor outcomes in ICU.

OBJECTIVES: Appropriate initial antibiotic therapy is critical for successfully treating sepsis. In the emergency department (ED), clinicians often rely on septic symptoms to guide empirical therapy. The aim of this study was to investigate whether history of contacting pre-ED healthcare setting is easy to be neglected and whether the patients received more inappropriate initial antibiotic therapy and developed poorer outcomes. METHODS: Septic patients (n = 453) admitted from ED to the intensive care unit (ICU) between 2014 and 2017 were retrospectively selected. Appropriate antibiotic treatment or not was determined by checking whether the selected antibiotics can effectively eradicate the bacteria identified. Various indexes were compared between patients with appropriate and inappropriate initial antibiotic treatments, including septic symptoms (qSOFA scores) in ED, septic-severity change in ICU (SOFA-score ratios), and septic outcomes (APACHE II scores, stay length, 30-day survival probability). These indexes were also compared between pre-ED healthcare and pre-ED community patients. RESULTS: In comparison with pre-ED community patients, pre-ED healthcare patients received more inappropriate initial antibiotic treatment in ED, showing poorer outcomes in ICU, including septic severity, stay-lengths in ICU and 30-day survival probabilities. Pre-ED settings is more significant than qSOFA scores to predict the inappropriate initial antibiotic treatment. CONCLUSIONS: Pre-ED healthcare settings, which are indexes for infection with antibiotic resistant pathogens, are easy to be neglected in the first hour in ED. We suggested that standard operating procedure for getting enough information of pre-ED settings should be incorporated to the 1 h bundle of sepsis guideline.

Impact of underlying diseases on the clinical characteristics and outcome of primary pyomyositis.

BACKGROUND AND PURPOSE: Primary pyomyositis is increasingly recognized in non-tropical areas, its incidence seeming to mirror the increase in immunocompromised populations. In this study, we sought to analyze the differences in clinical characteristics, causative organisms, treatment and outcome between pyomyositis patients with and without underlying diseases. METHODS: Thirty five patients with a diagnosis of primary pyomyositis seen in our hospital between July 1989 and July 2006 were enrolled. Descriptive information concerning age, gender, clinical features, underlying comorbid diseases, results of blood tests, blood culture, muscle or pus culture, disease severity and clinical stages at the time of diagnosis, therapy, and outcome were collected by review of medical charts. RESULTS: Of the 23 cases with underlying diseases, the mean age was 47.8 years (range, 24 to 79 years). Of the 12 patients without underlying diseases, the mean age was 26.2 years (range, 2 to 72 years). The lower extremities was the most common site of involvement. Staphylococcus aureus was the most frequent causative organism. Gram-negative organisms were isolated in 30.4% of patients with underlying diseases and in none of the patients without underlying diseases (p=0.07). Positive blood culture was significantly more common in patients with underlying diseases than in patients without underlying diseases (52.2% vs 8.3%, p=0.013). The mortality rate was higher in patients with underlying diseases than in patients without underlying diseases (39.1% vs 0.0%, p=0.015). White blood cell count (p=0.017), Acute Physiology and Chronic Health Evaluation (APACHE) II score (p<0.001), recurrence (p=0.004), and presence of underlying diseases (p=0.015) were significant prognostic factors for mortality by univariate analysis. APACHE II score (odds ratio, 1.57; 95% confidence interval, 1.13 to 2.20; p=0.008) was found to be a significant independent risk factor for mortality in multivariate logistic regression analysis. For prediction of mortality, the best cut-off point in APACHE II score was 16 (sensitivity, 77.8%; specificity, 92.3%; accuracy, 88.6%). CONCLUSIONS: Patients with primary pyomyositis should be treated with appropriate broad-spectrum antibiotics and be monitored closely for complications. This study found that patients who suffered from primary pyomyositis with underlying diseases had a higher rate of Gram-negative bacterial infections, bacteremia and mortality. The APACHE II score at diagnosis was found to be an independent prognostic factor for mortality.

Vancomycin-resistant enterococcal bacteremia: comparison of clinical features and outcome between Enterococcus faecium and Enterococcus faecalis.

BACKGROUND AND PURPOSE: Vancomycin-resistant enterococci (VRE) have emerged as important nosocomial pathogens. This study was conducted to clarify the clinical features and outcome of patients with vancomycin-resistant enterococcal bacteremia. METHODS: Patients with vancomycin-resistant enterococcal bacteremia treated at a medical center in northern Taiwan between November 1998 and July 2006 were reviewed. Clinical and bacteriological characteristics of Enterococcus faecium and Enterococcus faecalis were compared. RESULTS: Twelve patients (6 males and 6 females) were included for analyses. The mean age was 69.3 years (range, 40 to 86 years), and 8 cases (66.7%) were older than 65 years. All patients had underlying disease. Two patients received total hip replacement before development of VRE bacteremia. Twelve patients had prior exposure to broad-spectrum antimicrobial therapy. Ten patients had prior intensive care unit stay and prior mechanical ventilation before VRE bacteremia. All of the patients (n = 12) had an intravascular catheter in place. Bacteremia was caused by E. faecalis in 4 patients and by E. faecium in eight. The portals of entry included urinary tract (8.3%), skin, soft tissue and bone (41.7%) and unknown sources (50.0%). E. faecium showed a higher rate of resistance to ampicillin and teicoplanin than E. faecalis (87.5% vs 0.0%, p=0.01). The 60-day mortality rate was higher in patients with E. faecium bacteremia than E. faecalis bacteremia (62.5% vs 0.0%), although statistical significance was not obtained (p=0.08). CONCLUSIONS: VRE bacteremia may have an impact on the mortality and morbidity of hospitalized patients. Patients with bacteremia caused by vancomycin-resistant E. faecium had a grave prognosis, especially immunosuppressed patients. The prudent use of antibiotics and strict enforcement of infection control may prevent further emergence and spread of VRE.

Endocarditis: impact of methicillin-resistant Staphylococcus aureus in hemodialysis patients and community-acquired infection.

BACKGROUND AND PURPOSE: Staphylococcus aureus endocarditis showed an increase in the 1990s compared to the 1980s. In order to characterize the clinical and laboratory features of S. aureus endocarditis, we retrospectively reviewed the medical charts of patients diagnosed with endocarditis in the 5-year-period between 2000 and 2005. METHODS: From August 2000 to August 2005, 22 patients with a definite diagnosis of infective endocarditis (IE) caused by S. aureus were reviewed. RESULTS: Of the 22 patients reviewed, 16 cases were caused by methicillin-resistant S. aureus (MRSA) while the causative agent in the other 6 cases was methicillin-susceptible S. aureus (MSSA). Patients with MRSA infections were more likely to show hospital-acquired infections, hemodialysis and ventilator dependence, septic shock, impaired initial renal function, persistent bacteremia, and a higher 3-month mortality rate. MSSA infections in patients were more likely to be community-acquired, and show intravenous drug use and longer days of fever prior to admission. Three patients with MRSA endocarditis, however, presented community-acquired infections. The mortality rate of MRSA endocarditis in hemodialysis patients was 90% (9/10). CONCLUSIONS: MRSA IE is more common than MSSA IE and is associated with a significantly poorer prognosis, especially in patients undergoing hemodialysis. Although most cases of MRSA IE are hospital acquired, we noticed 3 cases of community-acquired MRSA IE. As MRSA IE has been noticed in the community and hemodialysis patients in recent years, and is associated with higher mortalities, strategies for its prevention and management are warranted.

Necrotizing fasciitis in a medical center in northern Taiwan: emergence of methicillin-resistant Staphylococcus aureus in the community.

BACKGROUND AND PURPOSE: Necrotizing fasciitis (NF) is a rapidly progressive life-threatening infection. It is located in the deep fascia, with secondary necrosis of the subcutaneous tissues requiring urgent surgical and medical therapy. Staphylococcus aureus is, historically, a very uncommon cause of NF, but we have recently noted an increasing number of these infections being caused by community-acquired methicillin-resistant S. aureus (CA-MRSA). METHODS: The medical records of 53 patients diagnosed with NF between January 2001 and December 2005 were reviewed. A standardized instrument was used to abstract information from the medical records of each patient. RESULTS: S. aureus monomicrobial infection accounted for 37.7% (20/53) of the causal organisms noted. Of the 20 strains of S. aureus, 8 were methicillin-sensitive S. aureus and 12 were MRSA. In the 12 patients with MRSA infection, 7 had CA-MRSA. All patients with NF caused by CA-MRSA had no serious coexisting conditions or risk factors. All CA-MRSA isolates were susceptible to ciprofloxacin, trimethoprim-sulfamethoxazole, and vancomycin in vitro. All were cured after surgical intervention and medical treatment. CONCLUSIONS: For patients with severe invasive NF caused by CA-MRSA, glycopeptides may be prescribed as an empirical treatment until susceptibility results. The prognosis of NF caused by CA-MRSA was good after adequate surgical and antimicrobial treatment.

An observational study on the empiric use of cefpirome in febrile neutropenia.

BACKGROUND AND PURPOSE: The objective of this study was to document the clinical experience of cefpirome use in the treatment of febrile neutropenia in everyday medical practice. METHODS: This was an open, non-controlled multicenter study. Patients with fever and neutropenia were started on cefpirome empirically. Response to therapy was evaluated 72 to 96 h after the beginning of treatment. The primary endpoint, clinical response, was classified as: improvement (disappearance of fever and the other signs and symptoms of infection) or failure (the patient died during the therapy or had no response to the antibiotic regimen; i.e., fever persisted and the patient's clinical condition was not improving, requiring a change in antibiotic therapy). The secondary endpoints were time to the resolution of fever and improvement of neutropenia, and microbiological response evaluated on-treatment or post-treatment. RESULTS: 140 patients were enrolled in this study; clinical response was analyzed on the clinically evaluated population after 72 to 96 h of treatment. Among the 69 evaluated patients, 58 patients (84.1%) were improved and 11 patients (15.9%) failed. Overall, among the enrolled 140 patients, 124 patients' clinical outcomes were improved after treatment and 16 patients failed. The mean time to fever resolution was 3.1 days. Mean temperature reduced from a baseline reading of 38.7 degrees C to 37.2 degrees C (p<0.0001). Moreover, the mean neutrophil count (342.7/mm(3) at baseline) increased significantly to 3664/mm(3) (p<0.0001) after 72 to 96 h of treatment. Twenty five pathogens were isolated from 20 patients (13 Gram-positive and 9 Gram-negative). The eradication rate was 72% on-treatment or post-treatment, and the mean time to eradication was 5 days. CONCLUSIONS: Cefpirome improves clinical signs and symptoms of infection and offers improved coverage against some Gram-positive and Gram-negative pathogens in patients with febrile neutropenia. Thus, cefpirome is likely to be a valuable and cost-effective extended-spectrum agent for the empiric treatment of severe infections.

Clinical and laboratory features in the early stage of severe acute respiratory syndrome.

BACKGROUND AND PURPOSE: To characterize the clinical and laboratory features of severe acute respiratory syndrome (SARS) in the early stage and to compare them with those of patients initially suspected of having SARS who were later determined to have other febrile diseases. METHODS: Between March and June 2003, 122 patients with possible SARS were admitted to the isolation ward of Tri-Service General Hospital. SARS was diagnosed according to the modified World Health Organization case definition (May 1, 2003). Among them, 43 were classified as probable SARS cases and a SARS etiology was excluded in 32 patients. RESULTS: Presenting symptoms on admission included fever (97.7% of probable cases, 84.4% of excluded cases), chills (39.5% vs 18.8%), cough with sputum production (16.3% vs 40.6%), dry cough (23.3% vs 9.4%), dyspnea (18.6% vs 9.4%), diarrhea (14.0% vs none), rhinorrhea (2.3% vs none), and myalgia (7.0% vs 6.6%). Common laboratory features included lymphopenia and elevated aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, C-reactive protein and creatine kinase values. Intubation and mechanical ventilation were required in 12 probable cases and 6 excluded cases. Five patients with probable SARS (11.6%) died. A scoring system which was developed to differentiate SARS patients from other febrile patients in the emergency room could differentiate probable cases from excluded cases with a sensitivity of 36.4% and a specificity of 70.6%. CONCLUSIONS: The clinical presentation and laboratory features at the early stage do not allow differentiation of patients with SARS-CoV infection from other febrile patients. Thus, it is mandatory for all healthcare workers to strictly follow standard isolation precautions during an outbreak to minimize disease transmission.

Rapidly progressive necrotizing fasciitis caused by Staphylococcus aureus.

Necrotizing fasciitis (NF) is a rapidly progressive life-threatening infection located in the deep fascia, with secondary necrosis of the subcutaneous tissues. Staphylococcus aureus as a single etiologic agent is rare. The pathogenicity of S. aureus infections is related to various bacterial surface components and extracellular proteins. A 56-year-old man developed fever, hypotension, impaired renal and hepatic functions, disseminated intravascular coagulation, and rapidly progressive NF affecting the 4 extremities due to methicillin-susceptible S. aureus (MSSA). The initial presenting symptoms were general weakness and muscular pain over bilateral thighs and left shoulder, and gradual onset of weakness of the limbs. On the third hospital day, multiple red-purplish discoloration spread across the right lower leg and left forearm. Fasciotomy and debridement was performed on the fifth hospital day, and the diagnosis of NF was confirmed. MSSA was the only pathogen isolated from 4 sets of blood cultures taken on admission and cultures of tissues collected during surgical debridement. The disease progressed rapidly over the 4 extremities despite appropriate antibiotic treatment. He recovered after multiple extensive surgical interventions and 8 weeks of intensive medical care. Early diagnosis, intensive surgical intervention, antibiotic treatment and intensive medical care are crucial for a successful outcome in patients with septic shock and extensive NF caused by S. aureus.

Lemierre's syndrome.

Lemierre's syndrome is a rare, potentially severe disease consisting of septic emboli from an internal jugular vein thrombus after oropharyngeal infection. We report a 20-year-old man who had a tonsillitis with fever for 3 days. After a 2-day defervescence, fever relapsed as well as painful swelling over the left side of the neck. Computed tomography scan and sonography of the neck revealed thrombosis of left internal jugular vein and swelling of surrounding soft tissue. Chest radiograph demonstrated cavitary infiltrates over the left upper lobe. Septic thrombophlebitis of the internal jugular vein and metastatic pulmonary emboli was highly suspected. Intravenous ceftriaxone and metronidazole were given empirically. Fusobacterium necrophorum was isolated from the blood culture with susceptibility to metronidazole. Complete defervescence and resolution of the neck swelling and pulmonary infiltrates occurred after antibiotic administration for 21 days. Lemierre's syndrome should be considered when encountering a febrile patient with painful neck swelling.

Analysis of Erythrocyte C4d to Complement Receptor 1 Ratio: Use in Distinguishing between Infection and Flare-Up in Febrile Patients with Systemic Lupus Erythematosus.

OBJECTIVE: Fever in systemic lupus erythematosus (SLE) can be caused by infection or flare-up of the disease. This study aimed to determine whether the ratio of the level of erythrocyte-bound C4d to that of complement receptor 1 (C4d/CR1) can serve as a useful biomarker in the differentiation between infection and flare-up in febrile SLE patients. METHODS: We enrolled febrile SLE patients and determined the ratio on the day of admission. The patients were divided into 2 groups according to the subsequent clinical course. RESULTS: Among the febrile SLE patients, those with flare-up had higher ratios and lower C-reactive protein (CRP) levels than those with infection. Cut-off values of <1.2447 and >4.67 for C4d/CR1 ratio and CRP, respectively, were 40.91% sensitive and 100.0% specific for the presence of infection in febrile SLE patients; similarly, cut-off values of >1.2447 and <2.2, respectively, were 80% sensitive and 100% specific for the absence of infection in febrile SLE patients. CONCLUSION: The C4d/CR1 ratio is a simple and quickly determinable biomarker that enables the differentiation between infection and flare-up in febrile SLE patients at initial evaluation. Further, when combined with the CRP level, it is useful to evaluate disease activity in SLE patients with infection.

Resistance rates to commonly used antimicrobials among pathogens of both bacteremic and non-bacteremic community-acquired urinary tract infection.

This study examined the distribution of organisms and their antimicrobial resistance in patients admitted due to acute bacteremic and non-bacteremic community-acquired urinary tract infection (UTI). During a period of 1 year and 1 month, a total of 201 patients and 253 bacterial isolates were studied. Fever higher than 38.5 degrees C was significantly more common in the bacteremic group than the non-bacteremic group (68% vs 48%; p<0.05). Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis were the most common organisms isolated. E. coli was the leading pathogen and it was significantly more predominant in bacteremic UTI than non-bacteremic UTI (73% vs 49%; p<0.01). Bacteria other than E. coli (i.e., K. pneumoniae, P. aeruginosa, Proteus spp., Morganella morganii, Enterobacter cloacae, Citrobacter spp., Acinetobacter baumannii, Serratia marcescens, and Providencia spp.) were more common in non-bacteremic UTI than bacteremic UTI (44% vs 22%; p<0.01). E. coli isolated from both bacteremic and non-bacteremic patients had a high rate of resistance to ampicillin (80%), cephalothin (59%), gentamicin (29%), piperacillin (61%), trimethoprim-sulfamethoxazole (56%), amoxicillin-clavulanic acid (34%), and ticarcillin-clavulanic acid (36%). Isolates of P. aeruginosa, K. pneumoniae, and Proteus spp. from the non-bacteremic group showed a higher proportion of resistance to extended-spectrum cephalosporins, aminoglycosides (netilmicin and amikacin) and ciprofloxacin. The emergence of a high rate of resistance to commonly used antimicrobials (ampicillin, cephalothin, gentamicin, trimethoprim-sulfamethoxazole, piperacillin, amoxicillin-clavulanic acid and ticarcillin-clavulanic acid) may have an impact on the antibiotic treatment of patients admitted due to acute community-acquired bacteremic or non-bacteremic UTI in Taiwan. Further studies are needed to clarify the impact of antimicrobial resistance on the outcome in these conditions.