Chien-Chang Yang

Influence of teicoplanin MICs on treatment outcomes among patients with teicoplanin-treated methicillin-resistant Staphylococcus aureus bacteraemia: a hospital-based retrospective study

OBJECTIVES Higher vancomycin MIC values (≥1.5 mg/L via Etest) may be associated with vancomycin treatment failure among patients with serious methicillin-resistant Staphylococcus aureus (MRSA) infections. As there were limited similar data for teicoplanin, this retrospective cohort study intended to determine the predictive value of teicoplanin MICs for treatment failure among patients with MRSA bacteraemia. PATIENTS AND METHODS All patients with at least one blood culture positive for MRSA admitted to the hospital between January 2010 and January 2011 were reviewed. Patients with an age ≥18 years and receipt of teicoplanin therapy throughout the course or receipt of <72 h of vancomycin therapy and then teicoplanin for >3 days were enrolled. Teicoplanin Etest(®) MICs and treatment outcomes for MRSA bacteraemia were reviewed to identify the breakpoint of teicoplanin MICs influencing treatment outcomes. RESULTS Of the 101 patients enrolled, 56 had a lower teicoplanin MIC (≤1.5 mg/L) for MRSA and 45 had a higher MIC (>1.5 mg/L) for MRSA. A lower teicoplanin MIC was associated with a favourable outcome [37 (66.1%) versus 13 (28.9%); P<0.001] and a lower rate of bloodstream infection-related mortality [15 (26.8%) versus 22 (48.9%); P=0.022]. Patients with chronic obstructive pulmonary disease, bacteraemic pneumonia or higher Pittsburgh bacteraemia score had an unfavourable outcome (P=0.028, 0.022 and <0.001, respectively). Multivariate analysis showed that teicoplanin MIC >1.5 mg/L, higher Pittsburgh bacteraemia score and bacteraemic pneumonia were independent risk factors for unfavourable outcome. CONCLUSIONS A higher teicoplanin MIC value (>1.5 mg/L) may predict an unfavourable outcome and higher mortality rate among teicoplanin-treated MRSA bacteraemic patients.

Risk factors and outcomes of carbapenem-nonsusceptible Escherichia coli bacteremia: A matched case–control study

BACKGROUND Infections due to carbapenem-resistant Enterobacteriaceae have been the emerging problem worldwide. This primary object of this study was to understand the risk factors and clinical outcomes of carbapenem-nonsusceptible Escherichia coli (CNSEc) bacteremia. METHODS We conducted a matched case-control study in a 3,715-bed tertiary care medical center in northern Taiwan. The controls were selected among patients with carbapenem-susceptible E coli and were matched with CNSEc for bacteremia. RESULTS Fifty-one patients were included in this study (17 cases and 34 controls). Bivariate analysis showed that prior exposure to carbapenems (p<0.001), stay in intensive care units (p=0.016), placement of central venous catheters (p=0.001), chronic liver diseases (p<0.001), uremia with regular dialysis (p=0.004), and mechanical ventilation (p=0.004) were associated with CNSEc bacteremia. Multivariate analysis revealed that prior exposure to carbapenems [odds ratio (OR), 29.17; 95% confidence interval (CI), 1.76-484.70; p=0.019], uremia with regular dialysis (OR, 98.58; 95% CI, 4.02-999; p=0.005) and chronic liver diseases (OR, 27.86; 95% CI, 2.31-335.83; p=0.009) were independent risk factors for CNSEc bacteremia. Compared with carbapenem-susceptible E coli group, CNSEc group had a longer hospital stay (68.4 days vs. 35.8 days; p=0.04) and a higher disease severity, as indicated by a Pittsburgh bacteremia score greater than or equal to 4 (5.6% vs. 2.5%; p=0.015). Patients with CNSEc bacteremia had a higher overall in-hospital mortality rate (94.12% vs. 50.00%; p=0.002), but there was no difference in the 28-day mortality between these two groups. CONCLUSIONS CNSEc bacteremia would lead to a poor outcome among patients with prior exposure to carbapenems, chronic liver disease, and uremia with regular dialysis.

Clinical significance and outcomes of Clostridium perfringens bacteremia—a 10-year experience at a tertiary care hospital

BACKGROUND The mortality rate of patients with Clostridium perfringens bacteremia is 27-44%. Typically, the clinical characteristics of this infection are non-specific, which leads to considerable difficulty with the diagnosis and early initiation of appropriate therapy. METHODS A retrospective cohort study of patients who were hospitalized between August 2002 and July 2011 with C. perfringens bacteremia was conducted within a 3715-bed teaching hospital in northern Taiwan. The patients identified in this search were included when they had fever or other clinical features suggestive of systemic infection. Multiple logistic regression analysis was applied to determine the independent risk factors of 30-day mortality. RESULTS A total of 93 patients were identified. Elderly patients with comorbid illnesses, especially renal insufficiency or malignancy, were at risk of developing C. perfringens bacteremia, and 23 patients (24.7%) had nosocomial bacteremia. The 30-day and attributed mortalities were 26.9% (25/93) and 8.6% (8/93), respectively. Nosocomial infection was a significant predictor for mortality within 30 days (odds ratio 19.378, 95% confidence interval 2.12-176.99; p=0.009), independent of other disease parameters. Other independent risk factors included the Charlson weighted index of comorbidity, length of hospitalization, and stay in the intensive care unit. CONCLUSIONS Early recognition of this critical infection and early initiation of appropriate antibiotic treatment by surgical intervention or drainage is essential.

Influence of Third-generation Cephalosporin Resistance on Adult In-hospital Mortality From Post-neurosurgical Bacterial Meningitis

BACKGROUND/PURPOSE To investigate the clinical features, etiology and predictors of in-hospital mortality in adults with post-neurosurgical bacterial meningitis. METHODS This retrospective analysis included 60 adult patients with culture-proven post-neurosurgical bacterial meningitis hospitalized between September 2006 and August 2008. RESULTS Of the 60 patients, 88.3% had monomicrobial infection and 11.7% had mixed infection. The mean duration from the first neurosurgical procedure to the diagnosis of meningitis was 21 days (range, 1-134 days). The median frequency of neurosurgical procedure before meningitis was 1 (range, 1-5). A total of 69 isolates were identified from the cerebrospinal fluid, the most common pathogens were Gram-negative bacilli (43, 62.3%), followed by Gram-positive bacteria (24, 34.8%). The three most common Gram-negative bacilli were Serratia marcescens (7, 10.1%), Klebsiella pneumoniae (6, 8.7%), and Enterobacter cloacae (4, 5.8%). Pseudomonas aeruginosa and Acinetobacter baumannii isolates comprised less than 3%. Notably, glucose non-fermenting Gram-negative bacilli other than Acinetobacter and Pseudomonas spp. accounted for 11.6% of the total. Of the Gram-negative bacilli, resistance rates to the third-generation cephalosporins, ceftriaxone and ceftazidime, were 58.1% and 34.9%, respectively. The two most common Gram-positive pathogens were Staphylococcus aureus (10, 14.5%) and coagulase-negative staphylococci (including S. epidermidis) (10, 14.5%). The in-hospital mortality rate was 15.0%, which was significantly related to Gram-negative bacilli resistant to third-generation cephalosporins in multivariate analysis (adjusted odds ratio = 33.65; p = 0.047). CONCLUSION These findings may portend the spread of serious resistance to third-generation cephalosporins in nosocomial Gram-negative bacilli throughout the neurosurgical units, suggestive of the need to reassess the empirical use of third-generation cephalosporins in post-neurosurgical bacterial meningitis.

Clinical experience and microbiologic characteristics of invasive Staphylococcus lugdunensis infection in a tertiary center in northern Taiwan

BACKGROUND/PURPOSE Staphylococcus lugdunensis is a coagulase-negative staphylococcus that cannot be ignored. This study is a comprehensive analysis of the clinical and microbiological characteristics of S. lugdunensis bacteremia and sterile site infection during hospitalization. METHODS This retrospective study included 48 patients with invasive S. lugdunensis infection. During the period of March 2002 to July 2012, they had been hospitalized in a tertiary center of northern Taiwan. Demographics, clinical characteristics, and risk factors of mortality were analyzed. All isolates were tested for antimicrobial susceptibility. We identified the staphylococcal cassette chromosome mec (SCCmec) gene for oxacillin nonsusceptible isolates. RESULTS The incidence of S. lugdunensis in coagulase-negative staphylococci bacteremia was 0.87%. Forty-eight patients were enrolled: S. lugdunensis was present in 41 patients with bacteremia, in the ascites of three patients, in the synovial fluid of two patients, in the pleural effusion of one patient, and in the amniotic fluid of one patient. The three most common sources of infection were primary bacteremia (43.8%), catheter-related infection (18.8%), and vascular graft infection (12.5%). All-cause mortality during hospitalization was 20.8% (10/48). All deceased patients were bacteremic. Risk factors associated with in-hospital mortality included a Pittsburgh bacteremia score of 2 or greater, infective endocarditis, and end-stage renal disease. Ten (20.8%) isolates were resistant to oxacillin, and 8 isolates were classified as SCCmec type V. CONCLUSION The clinical significance of S. lugdunensis should not be ignored, especially in patients with severe comorbidities. An aggressive search for endocarditis is strongly suggested in S. lugdunensis bacteremic cases.

Characteristics and outcomes of Fusobacterium nucleatum bacteremia—a 6-year experience at a tertiary care hospital in northern Taiwan

Fusobacterium nucleatum bacteremia is critical and not well defined. To identify the clinical characteristics and outcomes, we conducted a retrospective review of hospitalized patients from January 2004 to December 2009 at a tertiary center in northern Taiwan. Fifty-seven patients were enrolled. The mean age was 58.1 years, and the mean Pitt bacteremia score was 4.7. Males predominated (59.6%), and the overall 30-day mortality rate was up to 47.4%. Malignancy was the major comorbidity (26/57, 45.6%), especially oropharyngeal and gastrointestinal cancers (19/26, 73.1%). Pneumonia (17/57, 29.8%) was the most common presentation with high rates of respiratory failure (15/17, 88.2%) and mortality (11/17, 64.7%), followed by intra-abdominal infections (7/57, 12.3%). In multivariate analysis, higher Pitt bacteremia score, nosocomial infection, anemia, and intensive care unit stay were the independent factors for 30-day mortality. Nosocomial F. nucleatum bacteremia was a significant mortality predictor independent to other parameters of disease severities.

Coexistence of fatal disseminated invasive aspergillosis and pyoderma gangrenosum: a case report.

Objective: To report an unusual case of disseminated aspergillosis involving the lymph nodes, lungs, and skin in a patient with pyoderma gangrenosum (PG) and myelodysplastic syndrome (MDS). Case Presentation and Intervention: A 46-year-old man presented with productive cough of 2 weeks’ duration. Besides, several painless, fixed lymph nodes were palpated at his left neck. He had PG and MDS diagnosed in June 2004 with regular use of oral dapsone and prednisolone. His skin lesions healed with scar formation and no purulent discharge. A computed tomography scan of the head, neck and chest showed bilateral lung consolidation and abscesses at the left neck, right upper lung and right pleura. The neck abscess culture grew Aspergillus species. Dark reddish macules developed over the right arm, chest and abdominal wall, and the left lower limb 2 weeks after initiation of amphotericin B. The histology of the right arm skin biopsy showed invasive aspergillosis. Caspofungin was started then for suspicion of poor response to amphotericin B. He expired despite 35 days of antifungal therapy. Conclusion: This report highlights the rarity of coexistence of disseminated aspergillosis and PG, and should alert physicians to the possibility of invasive fungal infection superimposed on a chronic skin lesion.