Chan-Ping Su

SARS in Hospital Emergency Room

Thirty-one cases of severe acute respiratory syndrome (SARS) occurred after exposure in the emergency room at the National Taiwan University Hospital. The index patient was linked to an outbreak at a nearby municipal hospital. Three clusters were identified over a 3-week period. The first cluster (5 patients) and the second cluster (14 patients) occurred among patients, family members, and nursing aids. The third cluster (12 patients) occurred exclusively among healthcare workers. Six healthcare workers had close contact with SARS patients. Six others, with different working patterns, indicated that they did not have contact with a SARS patient. Environmental surveys found 9 of 119 samples of inanimate objects to be positive for SARS coronavirus RNA. These observations indicate that although transmission by direct contact with known SARS patients was responsible for most cases, environmental contamination with the SARS coronavirus may have lead to infection among healthcare workers without documented contact with known hospitalized SARS patients.

Effect of different resuscitation fluids on cytokine response in a rat model of hemorrhagic shock

This study was designed to determine the effects of different resuscitation fluids on the production of proinflammatory and anti-inflammatory cytokines in an animal model of hemorrhagic shock. Wistar male rats (n = 24; 8/group) were subjected to a volume-controlled hemorrhagic shock for 30 minutes and resuscitated as follows: (1) sham group without resuscitation, (2) lactated Ringer solution (LR), 3:1; (3) 4% hydroxyethyl starch (HES) solution, 1:1; and (4) 4% modified fluid gelatin (GEL), 1:1. Hemodynamic parameters were recorded, and blood samples were collected at 0 min and 30, 90, 150, 210, 270, and 330 min after hemorrhage for plasma levels of IL-6, IL-10, and TNFα. The circulating concentrations of IL-6 at 90, 150, 210, 270, and 330 min and TNFα levels at 150, 210, and 270 min after hemorrhage were significantly elevated in animals resuscitated with GEL compared with HES or LR (P < 0.05). At 210, 270, and 330 min, IL-10 concentration was decreased significantly in GEL-resuscitated rats compared with rats resuscitated with LR or HES (P < 0.05). Mean blood pressure and serum levels of lactate after resuscitation were not different among three kinds of fluids. LR, HES, and GEL are comparable in volume efficacy for resuscitation of hemorrhagic shock but are associated with different postresuscitation immune responses. Resuscitation with GEL may be associated with cytokine production favoring a proinflammatory response. The marked elevation of IL-6 observed in the GEL-treated animals may play a role in the relatively high frequency of anaphylactoid reaction in clinical use of GEL.

Detection of SARS-associated Coronavirus in Throat Wash and Saliva in Early Diagnosis

Early detection of SARS-CoV in throat wash and saliva suggests that these specimens are ideal for SARS diagnosis.

Diagnostic value of procalcitonin for bacterial infection in elderly patients in the emergency department.

OBJECTIVES: To evaluate the diagnostic performance of procalcitonin (PCT) in elderly patients with bacterial infection in the emergency department (ED).

Hospital-based surveillance and molecular epidemiology of rotavirus infection in Taiwan, 2005-2007.

To determine the distribution of rotavirus strains and facilitate vaccine policy decisions in Taiwan, active hospital-based gastroenteritis surveillance was conducted in three sentinel hospitals. From 1 January 2005 to 31 December 2007, a total of 3435 children less than 5 years old with gastroenteritis were enrolled. The presence of rotavirus was documented by enzyme immunoassay (EIA), and the G and P genotypes were determined by reverse transcription-polymerase chain reaction (RT-PCR) and sequencing methods. Results confirmed that 856 (25%) of these gastroenteritis admissions were EIA-positive for rotavirus and 448 (52%) of the rotavirus positive admissions were less than 2 years old. The most prevalent rotavirus genotypes were G1P[8] (40%), followed by strains G3P[8] (27%), and G9P[8] (17%). These data will help inform decisions as to whether rotavirus vaccine should be considered for inclusion into Taiwans National Immunisation Programme.

Predictive model of diagnosing probable cases of severe acute respiratory syndrome in febrile patients with exposure risk

Abstract Study objective Since the World Health Organization issued a global alert about severe acute respiratory syndrome (SARS) on March 12, 2003, the illness has become a major public health challenge worldwide. The objective of this study is to identify the clinical risk factors of SARS and to develop a scoring system for early diagnosis. Methods The detailed clinical data of all patients presenting to the emergency department (ED) with a temperature higher than 38.0°C (100.3°F), documented at home or at the ED, and risks of exposure to SARS within 14 days were assessed. The diagnosis of probable SARS was made according to the definition of the Centers for Disease Control and Prevention. Items with significant differences among symptoms, signs, and laboratory tests on presentation between SARS and non-SARS groups were determined and used to develop the scoring system. Results Seventy patients were enrolled and 8 were diagnosed as probably having SARS. None of the initially discharged patients or their relatives developed SARS. Compared with the non-SARS group, the SARS group was younger (33.9±15.9 years versus 44±9.8 years; P=.02), had a higher percentage of fever prolonged more than 5 days (87.5% versus 6.5%; P<.01), myalgia (75% versus 27.4%; P=.01), and diarrhea (50% versus 9.7%; P=.02); had less occurrence of cough before or during fever (0% versus 64.5%; P=.01); and had lower absolute lymphocyte (0.9±0.3×109/L versus 1.5±1.1×109/L; P<.01) and platelet counts (144.1±36.3×109/L versus 211.6±78.8×109/L; P=.02). A 4-item symptom score based on the presence of cough before or concomitant with fever, myalgia, diarrhea, and rhinorrhea or sore throat detects SARS with 100% sensitivity and 75.9% specificity; a 6-item clinical score based on lymphopenia (<1.0×109/L), thrombocytopenia (<150×109/L) and the 4 symptom items detects SARS with 100% sensitivity and 86.3% specificity. Conclusion Certain symptoms and laboratory tests indicate higher risk of febrile probable SARS. In nonendemic areas, the febrile patients with recent contact with SARS or travel history to endemic areas could be screened for the probability of SARS by the use of clinical and symptom scores.

SARS exposure and emergency department workers.

Of 193 emergency department workers exposed to severe acute respiratory syndrome (SARS), 9 (4.7%) were infected. Pneumonia developed in six workers, and assays showed anti-SARS immunoglobulin (Ig) M and IgG. The other three workers were IgM-positive and had lower IgG titers; in two, mild illness developed, and one remained asymptomatic.

Bacteremia in Previously Hospitalized Patients: Prolonged Effect From Previous Hospitalization and Risk Factors for Antimicrobial-Resistant Bacterial Infections

STUDY OBJECTIVE Patients who came from the community but were recently discharged from the hospital have a higher risk of contracting antimicrobial-resistant bacterial infections. Our objectives are to determine the time from previous hospital discharge that affects subsequent antimicrobial susceptibility pattern and risk factors for antimicrobial-resistant infection in bacteremia in recently discharged patients. METHODS Excluding patients of hospital-acquired, patients with regular health care-associated exposure, and patients whose previous hospitalization was not at our hospital, a total of 789 nonduplicated bacteremia episodes from community adult patients were enrolled in a 1-year study period. Antimicrobial-resistant bacteria, including multidrug-resistant gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci causing bacteremia, were logistically analyzed according to different posthospitalization periods (3 to 90 days, 91 to 180 days, 181 to 360 days, and no hospitalization in the past 360 days) to identify the independent effect from previous hospitalization on subsequent antimicrobial-resistant bacteremia. RESULTS Of the 789 bacteremia patients, the proportion of antimicrobial-resistant bacteremia is 14.6% (95% confidence interval [CI] 9.8% to 19.4%) for 3 to 90 days, 9.6% (95% CI 1.6% to 17.6%) for 91 to 180 days, and 6.4% (95% CI 0% to 13.4%) for 181 to 360 days since last hospitalization and 1.0% (95% CI 0.1% to 1.9%) for no hospitalization within the last 360 days. Risk of antimicrobial-resistant bacteremia decreased monthly after discharge by an odds ratio of 0.83 (95% CI 0.76 to 0.90) (P<.01). Previous carriage of antimicrobial-resistant bacteria in the past 360 days and previous stay at ICU in the past 180 days were independent risk factors for antimicrobial-resistant bacteremia in previously hospitalized patients. CONCLUSION Previous hospitalization affects the antimicrobial susceptibility of subsequent bacteremia up to 360 days after hospital discharge. Presence of risk factors for antimicrobial-resistant bacteremia in previously hospitalized patients may help emergency physicians in selecting empirical antimicrobial agents and prompting infection control precautions.

Validation of a novel severe acute respiratory syndrome scoring system

Abstract Study objective In a pilot study conducted during March 14 to April 2, 2003, 2 severe acute respiratory syndrome (SARS) screening scores were developed for predicting SARS among febrile patients presenting to the emergency department (ED). The objective of this study is to validate these scoring systems with a different set of patients. Methods All adult patients with documented fever, measured at home or at the hospital, and presenting to the ED of National Taiwan University Hospital, a 2,400-bed tertiary care teaching hospital in northern Taiwan, were prospectively enrolled. Two previously developed SARS screening scores were applied to all patients. The final diagnosis of SARS was made by the Expert Committee of the Center for Disease Control Taiwan, Republic of China, according to the criteria of Centers for Disease Control and Prevention, Atlanta, GA. Results A total of 239 adult patients, including 117 men and 122 women, were enrolled. Eighty-two patients were finally diagnosed with SARS. Compared with the SARS patients in the derivation cohort, those in the validation cohort were older (44.5±15.9 versus 33.9±15.9 years), more likely to acquire the disease locally (76.8% versus 37.5%), and more likely to have cough before or during fever. For the non-SARS patients, cases in the validation cohort presented with less cough and coryza but more diarrhea. For the 4-item symptom score, the sensitivity reached 96.3% (95% confidence interval [CI] 89.7% to 98.7%) and the specificity 51.6% (95% CI 43.8% to 59.3%). For the 6-item clinical score, the sensitivity reached 92.6% (95% CI 84.8% to 96.6%) and the specificity 71.2% (95% CI 63.6% to 77.7%). When the clinical score was applied to patients with a positive symptom score, the combined sensitivity reached 90.2% (95% CI 82.0% to 95.0%), and the combined specificity reached 80.1% (95% CI 73.2% to 85.6%). Conclusion This prospective study validated the scoring system previously developed by using a different cohort. The scoring systems could be applied to settings where mass screening of SARS is needed during future outbreaks.

Septic cavernous sinus thrombosis: an unusual and fatal disease.

BACKGROUND Septic cavernous sinus thrombosis (CST) is a rare and fatal disease. Clinical presentations in the early stage are nonspecific, and the sensitivity of cranial axial computed tomography (CT) with thick section is low. This study analyzed the clinical manifestation and neuroimaging findings in patients with septic CST in a medical center in Taiwan. METHODS This retrospective case series included nine patients with septic CST who had typical symptoms and clinical course, evidence of infection, and imaging studies which demonstrated cavernous sinus lesion, and who were treated between 1995 and 2003 at National Taiwan University Hospital. RESULTS Seven (77.8 %) patients were more than 50 years old. Five (55.6%) had diabetes, and three (33.3%) had hematologic diseases. All cases were associated with paranasal sinusitis. The most frequent initial symptom was headache (66.7%), followed by ophthalmic complaints (diplopia or ophthalmoplegia, 55.6%; blurred vision or blindness, 55.6%), and ptosis (44.4%). Initial cranial images failed to identify CTS in all patients. Subsequent magnetic resonance imaging (MRI) or coronal contrast-enhanced CT (CECT) with thin section confirmed the diagnosis. Fungi were the most common pathogens (55.6%). The inhospital case-fatality rate was high (44.4%). CONCLUSION Due to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition.