Fu Lun Chen

Clinical and epidemiological features of Chryseobacterium indologenes infections: Analysis of 215 cases *

PURPOSE This study investigates the clinical and epidemiological features of Chryseobacterium indologenes infections and antimicrobial susceptibilities of C indologenes. METHODS With 215 C indologenes isolates between January 1, 2004 and September 30, 2011, at a medical center, we analyzed the relationship between the prevalence of C indologenes infections and total prescription of colistin and tigecycline, clinical manifestation, antibiotic susceptibility, and outcomes. RESULTS Colistin and tigecycline were introduced into clinical use at this medical center since August 2006. The increasing numbers of patients with C indologenes pneumonia and bacteremia correlated to increased consumption of colistin (p = 0.018) or tigecycline (p = 0.049). Among patients with bacteremia and pneumonia, the in-hospital mortality rate was 63.6% and 35.2% (p = 0.015), respectively. Administration of appropriate antibiotics showed significant benefit in 14-day survival in patients with C indologenes bloodstream infection (p = 0.040). In bacteremic patients, old cardiovascular accident (p = 0.036) and cancer (p = 0.014) were the most common comorbidity. The most common co-infection pathogen in patients with C indologenes pneumonia was Acinetobacter baumannii (36/91, 39.6%), followed by Pseudomonas aeruginosa (23/91, 25.3%), carbapenem-resistant A baumannii (22/91, 24.2%), and Klebseilla pneumoniae (13/91, 14.3%). Antimicrobial susceptibility testing of the 215 isolates showed that trimethoprim-sulfamethoxazole was the most active agent (susceptibility rate: 87.4%), followed by cefoperazone-sulbactam (48.0%). CONCLUSION The present study showed a trend of increasing prevalence of C indologenes infection after introduction of colistin and tigecycline usage. The bacteremia group had higher mortality rate than the pneumonia group. Increasing resistance to piperacillin-tazobactam, ceftazidime, cefepime, and newer fluoroquinolone were noticed in our analysis. Trimethoprim-sulfamethoxazole was a potential antimicrobial agent in vitro for C indologenes. To avoid collateral damage, we emphasize the importance of antibiotic stewardship program.

Corynebacterium striatum bacteremia associated with central venous catheter infection

Corynebacterium striatum (C striatum) has been considered a contaminant of blood culture in past decades. Here we report the case of a patient with acute deterioration of chronic renal failure. She received hemodialysis and died from C striatum bacteremia. By using a randomly amplified polymorphic DNA (RAPD) method, we found that an association existed between C striatum from the bloodstream and that from the central venous catheter. We suggest that C striatum could be a pathogen of bloodstream infection in patients with such a catheter in place.

Comparison of pneumonia- and non-pneumonia-related Acinetobacter baumannii bacteremia: Impact on empiric therapy and antibiotic resistance

OBJECTIVE Acinetobacter baumannii (AB) bacteremia has increasingly emerged as a nosocomial pathogen in healthcare settings, associated with high patient morbidity and mortality. The objective of this study was to compare clinical features, risk factors, treatment outcome, and antibiotic resistance in patients with pneumonia- and non-pneumonia-related AB bacteremia. METHODS We conducted a retrospective study in a tertiary teaching hospital in northern Taiwan. The medical records of the 141 episodes of hospital-acquired AB bacteremia between July 1, 2006 and June 30, 2012 were reviewed, and sorted into groups of AB bacteremia with (n = 59) and without pneumonia (n = 82). RESULTS The hospital-acquired pneumonia-related AB bacteremia group were found to be significantly more frequently treated in intensive care units (49.2%, p < 0.001), but the AB bacteremia without pneumonia group were significantly more frequently treated on general wards (85.4%, p < 0.001). Patients with pneumonia tended to be older than the nonpneumonia group (72.8 years vs. 65.2 years in mean age, p < 0.01), and more likely to use mechanical ventilators (62.7% vs. 15.9 %, p < 0.001). Pneumonia patients were found to receive broad-spectrum antibiotics significantly earlier than nonpneumonia patients (p < 0.001). Compared to those without pneumonia, the patients with pneumonia had significantly higher incidence of antibiotic-resistance (p < 0.05), longer hospital stay (p < 0.01), and higher mortality rate (p < 0.001). The incidence of multidrug-resistant AB was significantly higher in patients with pneumonia (p < 0.05), and only colistin (p < 0.01) and tigecycline (p < 0.01) were significantly active against multidrug-resistant AB isolates. CONCLUSION Pneumonia-related AB bacteremia has a worse outcome, more antibiotic resistance, and more comorbidity than the nonpneumonia group.

Caspofungin salvage therapy in Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii pneumonia (PJP) is a severe complication and leading cause of death among human immunodeficiency virus (HIV)-infected patients. Although trimethoprim/sulfamethoxazole (TMP/SMZ) is well known for its effectiveness as empiric and target therapy, it is also associated with various side effects (including skin rash, leukopenia, hepatitis, and diarrhea). The clinical evidence of the synergistic activity of caspofungin to TMP/SMZ or salvage treatment of PJP remains controversial to date. Here, we report an HIV-infected patient complicated with PJP who had skin rash and leukopenia after TMP/SMZ treatment for 6 days. Consequently, the treatment regimen was replaced with caspofungin. The patient was discharged from the hospital in good condition after 14 days of caspofungin salvage therapy. A 46-year-old male patient was admitted to the hospital for high fever and dyspnea, representing a fresh case of HIV infection with very low CD4 count (36/mL). His chest radiograph showed bilateral interstitial infiltration of lung fields (Figure 1A), and the computed tomography scan revealed bilateral diffuse ground-glass infiltrates (Figure 1B). A bronchoalveolar lavage specimen analyzed by Gomori methenamine silver staining revealed a cluster of P. jirovecii cysts. The patient was initially administered with TMP/SMZ (160/800 mg, q6h) intravenously. He received oral prednisolone (30 mg daily) as adjunctive therapy for PJP. The patient’s white blood cell count decreased from 5700/ mL to 3200/mL, and skin rash developed on the 7 admission day. The TMP/SMZ treatment was discontinued, and caspofungin was administered at a loading dose of 70 mg intravenously and a maintenance dosage of 50 mg daily. The patient received caspofungin therapy for a total of 14 days, and the subsequent chest X-ray (Figure 1C) demonstrated a significant improvement. The patient received HAART (highly active antiretrovirus therapy) regimen with combivir (lamivudine/zidovudine) þ stocrit (efavirenz) at the time of caspofungin therapy. His CD4 count recovered

Breakthrough disseminated cryptococcosis during micafungin therapy

Echinocandins are not active against basidiomycetous yeasts, such as Cryptococcus neoformans, Trichosporon, and Rhodotorula species, and zygomycosis. We present a patient with renal failure and candidemia, who developed a breakthrough fungal infection with cryptococcemia and cryptococcuria while receiving micafungin therapy.

Starch dust explosion and flame burn injury in a patient complicated with severe cellulites caused by non-O1 Vibrio cholerae

Invasive nonepidemic Vibrio cholerae (NEVC) infections after burns injury are rare. We read with great interest the article in the Journal of Microbiology, Immunology and Infection by Chen et al, reporting that a neutropenic immunocompromised patient who denied a history of participating in water activities and suffered from urinary tract infection caused by V. cholerae nonserogroup O1. Here, we report a burn injury patient participating color party in a dried swimming pool (fresh water) in June 2015. Unfortunately he suffered from starch dust explosion and a burn wound of left upper arm infected with V. cholerae Non O1 (Figure 1). The severe cellulites caused by this unusual pathogen were successfully treated with ciprofloxacin therapy. On the night of June 28, 2015, a tragic fire accident occurred in Formosa Water Park situated near Tan-Shui River and the coastal areas in the northern Taiwan. More than 500 young people were injured with various degrees of thermal burn in the starch dust explosion. A 19-year-old male patient was admitted to Taipei municipal Wan-Fang Hospital for second to third degree burns of the extremities involving 30% of the total body surface area. The patient was admitted to the burn unit immediately and managed under stringent infection control measures. Empirical antibiotic therapy with cefazolin 1 g intravenously (IV) q. 6 hours and gentamicin 80 mg IV q. 8 hours was administered. On the 4 admission day, the skin and soft tissue revealed swelling, redness, discoloration, and pus collection on the left arm (Figure 1). The patient received surgical debridement and culture work up. Pus and tissue culture of the burn wound both isolated V. cholera non-O1 by laboratory tests. Antibiotic testing of the isolate showed that it was susceptible to ampicillin, chloramphenicol, sulfamethoxazole/trimethoprim, and ciprofloxacin, but resistant to cefazolin and gentamicin. Because the patient

Lemierre syndrome with cervical spondylodiscitis and epidural abscess associated with direct injection of heroin into the jugular vein

Pseudomonas aeruginosa infections rarely occur in intravenous drug users with Lemierre syndrome. We report here the case of a patient, an intravenous drug user with a history of injecting heroin directly into the jugular vein, with thrombophlebitis, P. aeruginosa bacteremia, metastatic cervical spondylodiscitis, and an epidural abscess. The patient’s condition was initially complicated by moderate quadriplegia, hyperreflexia, and hypothesia below the C5 dermatome. He recovered well after surgical debridement, treatment with antibiotic drugs, and rehabilitation. The 64-year-old male heroin addict was admitted to hospital with a history of moderate paralysis of all four limbs and fever for 1 week. His initial route of heroin administration had been inhalation, but he had changed to intravenous injection 1 year previously. Six months previously he began to inject heroin directly through the neck vessels to obtain stronger and faster euphoria. He reported neck and shoulder pain with numbness 1 month later. He was conscious on admission and, on neurological examination, had hypothesia below the C5 dermatome. He had Grade 3 (3/5) muscle power in all four extremities. Examination of his skin showed multiple needle injection wounds, local redness, tenderness, and mild swelling of his right neck. He also had a fever and leukocytosis. Magnetic resonance imaging showed spondylodiscitis, an epidural abscess with spinal cord compression at the C5eC6 level, and moderate thrombosis of the jugular vein in his right neck (Fig. 1). He received surgical decompression and combination treatment with antibiotics: ciprofloxacin 400 mg intravenously every 12 hours and amikacin 375 mg

Breakthrough fungemia caused by Rhodotorula mucilaginosa during anidulafungin therapy

Rhodotorula spp. are emerging opportunistic pathogens, particularly in patients who are critically ill and immunocompromised, and are associated with peritonitis, endocarditis, meningitis, and catheter-associated infections. Here, we report a case of breakthrough fungemia caused by Rhodotorula mucilaginosa in an elderly patient who received anidulafungin therapy for Candida tropicalis candidemia. A 96-year-old male patient, who had chronic kidney disease, chronic obstructive pulmonary disease, and history of perforated peptic ulcer post subtotal gastrectomy, visited the emergency department of the hospital owing to fever, jaundice, pain, and tenderness over the right upper quadrant of the abdomen. The results of the laboratory tests after the admission of the patient revealed a white blood cell count of 2530/mL, hemoglobin level of 10.2 g/dL, platelet count of 137,000/mL, total bilirubin value of 2.33 mg/dL, direct bilirubin level of 1.8 mg/dL, aspartate aminotransferase level of 219 U/L, alanine transaminase level of 86 U/L, C-reactive protein level of 8.6 mg/dL, gglutamyl transpeptidase level of 189 U/L, and an alkaline phosphatase value of 344 U/L. Abdominal sonography revealed the evidence of gallbladder stones with acute cholecystitis. After admission, he underwent a percutaneous transhepatic gallbladder drainage (PTGBD), and received the following antibiotics empirically: 2000 mg of cefmetazole via intravenous (IV) infusion every 8 h, and 500 mg of amikacin via IV infusion every day. The blood culture revealed Escherichia coli on the 4th day of hospitalization. This organism was susceptible to the cefmetazole and amikacin as determined by BD Phoenix 100 AST System (Becton Dickinson, Sparks, MD, USA). On the 12th day of hospitalization, the cultures from the PTGBD drainage fluids and two peripheral blood samples showed the presence of C. tropicalis. Anidulafungin (a loading dose

Pulmonary empyema caused by co-infections of Mycoplasma pneumoniae and Fusobacterium necrophorum: A rare case of lemierre syndrome

Lemierre syndrome, also known as post-anginal septicemia or necrobacillosis, It is characterized by bacteremia, internal jugular vein (IJT) thrombosis, and metastatic septic emboli secondary to acute pharyngeal infections. The disease is easily forgotten by modern physicians. The causative agents of Lemierre syndrome include anaerobic bacteria, Streptococcus, Staphylococcus, and Klebsiella pneumoniae. Here, we reported a rare case of Lemierre syndrome in a patient with acute pharyngitis, who was complicated by bilateral otitis media and pulmonary empyema caused by co-infections of Mycoplasma pneumoniae and Fusobacterium necrophorum. The patient was proved by imaged study and successfully treated by chest tube drainage and antibiotic combination therapy. A 19-year-old male patient was admitted to our hospital with a 3-day history of fever, sore throat and dyspnea. On admission, consciousness was clear and his temperature was 39.2 C. Physical examination showed redness, swelling of pharyngeal mucosa. White blood cell count (WBC) was 32020/mm with 89% neutrophils. Serum level of C-reactive protein was 36.2 mg/dL, GOT 65 U/L, GPT 123 U/L, LDH 423 U/L. The rapid test of influenza A & B showed negative finding. Initially, he received amoxicillin/clavulanate 1000 mg/200 mg intravenously q 6 h as empiric therapy. But on the admission Day 2, the fever persisted and bilateral ear canal had purulent discharge. On the admission Day 3, the chest X-ray and CT scan showed infiltration of right lower lobe of lung with pleural effusion (Fig. 1A and B) and left internal jugular vein thrombosis (Fig. 1C). The patient received thoracocentesis and the pleural fluid analysis showed exudate and turbid color, which revealed WBC count 760/mm with 97% neutrophils, LDH 2107 U/L, total protein 5.4 g/dL (serum 6.4 g/dL), glucose 10 mg/dL (serum

Co-occurrence of Leriche syndrome and antiphospholipid syndrome in a man with refractory ulcers of the lower limbs

Leriche syndrome is a rare variant of atherosclerotic occlusive disease characterized by total occlusion of abdominal aorta and/or common iliac arteries. The antiphospholipid syndrome is a prothrombotic disorder that can affect both venous and arterial thrombosis. Co-occurrence of antiphospholipid syndrome and Leriche syndrome is extremely rare. Here, we report a male patient with refractory ulcers of the right foot; he received antibiotic therapy and surgical debridement during hospitalization, however, the ulcer wound did not heal well. The results of image study and laboratory data finally proved the above syndromes. A 52-year-old male patient complained of chronic ulcer wound of the right foot without any trauma history. He also had claudication of the legs, body weight loss with a body mass index of 17.6 kg/m, and erectile dysfunction for many years. The physical examination revealed that his bilateral femoral pulses were absent. The extremities showed bilateral lower legs muscle atrophy, and an ulcer wound with peripheral tissue gangrene on the right foot and barely palpable pulses of bilateral dorsalis pedis arteries. He received empiric antibiotic therapy with oxacillin 2 g intravenous drip q. 6 hours and gentamicin 80 mg intravenous drip q. 12 hours for 7 days, and received local surgical debridement. The aerobic and anaerobic culture all revealed negative finding, however, the ulcer wound still did not heal. Computed tomography and angiography showed total occlusion of infrarenal abdominal aorta (Figure 1), and bilateral common iliac arteries with subsequent collateral circulation. Many small collaterals vessels were reconstituted in the bilateral lower extremities. Antiphospholipid antibodies detected by enzyme-linked immunosorbent assay showed 640 RU/mL (positive), and the anticardiolipin immunoglobulin G detected by lupus