Hsin-Pai Chen

Clinical significance of Acinetobacter species isolated from cerebrospinal fluid

Medical records of 54 patients whose cerebrospinal fluid (CSF) cultures were positive for Acinetobacter were retrospectively reviewed. In 34 (63.0%) patients, the Acinetobacter isolates were clinically insignificant. In the other 20 (37.0%) patients, presence of the organism was regarded as clinically significant and specific antimicrobial therapy was administered. Patients with clinically significant Acinetobacter in CSF more frequently resided in intensive care units (p = 0.011), had intracerebral hemorrhage (p = 0.012) or previous CNS infection (p = 0.003), had prior antibiotic exposure (p = 0.011), and had undergone neurosurgical procedures (p = 0.003). Their CSF was characteristic of neutrophilic pleocytosis, an elevated protein level, and a low CSF-to-serum glucose ratio. Apart from fever, no significant statistical differences existed in individual clinical symptoms and signs between the 2 groups of patients, while a combination of symptoms efficiently differentiated clinically significant and insignificant Acinetobacter. The finding of multiple CSF specimens positive for Acinetobacter was highly suggestive of an active CNS infection (p<0.001). The high ratio of clinically insignificant Acinetobacter CSF isolates highlights the importance of careful judgment when the organism is cultured from CSF. Antimicrobial therapy must be initiated promptly in patients with identified risk factors, while unnecessary treatment should be avoided in those without them.

Acute acalculous cholecystitis: A rare presentation of typhoid fever in adults

Adult typhoidal acute acalculous cholecystitis is rare with only 2 cases having been reported in the English literature. We present the case of a previously healthy 36-y-old female who suffered fever, chills, epigastralgia and progressive jaundice for 3 d, with acute acalculous cholecystitis subsequently diagnosed. In addition to antibiotic therapy with ceftriaxone, open cholecystectomy was performed. However, bile and blood culture both showed Salmonella typhi growth unexpectedly, and ileocolitis was revealed by colonoscopy. Careful tracing of the history of the patient recalled a history of travel to Indonesia. In adults without common risk factors for acalculous cholecystitis, a detailed history including travel to endemic areas and high index of suspicion for typhoidal acute acalculous cholecystitis are important, and appropriate antimicrobial therapy for covering Salmonella typhi should be considered.

Secondary Aeromonas peritonitis is associated with polymicrobial ascites culture and absence of liver cirrhosis compared to primary Aeromonas peritonitis

Aeromonas peritonitis remains a rare condition. In this study we describe the clinical features of primary and secondary Aeromonas peritonitis, and compare the differences between these two diseases entities. Patients with Aeromonas peritonitis were identified from microbiological and medical records during the period between March 1994 and March 2003. Clinical characteristics, laboratory data, microbiological results, treatment and outcome of patients were obtained by retrospective chart review. 22 and 27 patients with primary or secondary peritonitis caused by Aeromonas species were identified. All except two of these patients were adults, with a median age of 62.4 (31–76) vs 65.8 (8–85) years, respectively. Males were predominant (82 vs 78%). Peritonitis was community acquired in 73% and 56% of patients in these two groups, respectively. Significantly higher prevalence of underlying liver cirrhosis (96 vs 7%, p<0.001), which was Child‐Pugh class C in 91% of cases, in primary peritonitis was noted. Primary peritonitis was more likely to be monomicrobial (100 vs 15%, p<0.001) and complicated by bacteremia (50 vs 7%, p=0.011). A source of intraabdominal infection should be sought when Aeromonas peritonitis occurs in a patient who has no history of liver cirrhosis or who has a polymicrobial result of ascites culture.

Clinical characteristics, treatment and prognostic factors of candidal meningitis in a teaching hospital in Taiwan

The prognostic factors of candidal meningitis had rarely been studied owing to the rarity of this disease. We identified 17 patients with candidal meningitis at a teaching hospital in Taiwan over a 14-y period and give details of the clinical features, treatment, outcome and prognostic factors of this disease. 10 patients were children (1 was neonate) and 7 were adults. The clinical features and cerebrospinal fluid (CSF) findings were non-specific. The disease was diagnosed >72 h after hospitalization in 14 (82%) patients. The most frequently isolated species was Candida albicans (65%). Regimens of therapy included intravenous amphotericin B deoxycholate (AmB) or fluconazole alone, or a combination of intravenous AmB with intrathecal AmB, flucytosine or fluconazole. All indwelling central nervous system devices were externalized or removed. Four adults died of the disease. Three of them had malignancy and had received <48 h of antifungal therapy. For adult patients with malignancy, early diagnosis and alternative treatment modalities with newer antifungal agents may be needed.

Clinical Characteristics, Management and Prognostic Factors in Patients with Probable Severe Acute Respiratory Syndrome (SARS) in a SARS Center in Taiwan

Background: Severe acute respiratory syndrome (SARS) is an emerging viral infectious disease. We report our experience in treating SARS patients. Methods: From April 27 to May 24, 2003, a total of 36 patients with probable SARS were admitted and treated in a hospital rearranged as a special center for the management of SARS patients. Medical records for the patients were retrospectively reviewed. Univariate and multivariate analyses were performed to determine factors associated with respiratory failure and intubation. Results: Of the 36 patients with probable SARS (median age, 37 years; range, 22‐66 years), 9 were male and 27 were female. Thirty‐two patients (88.9%) were infected in the hospital setting. All patients presented with fever, and 33 eventually developed lymphopenia during hospitalization. Chest radiography showed no unique pattern, but pleural effusion was not seen. All patients initially received empiric antibacterial therapy against common causative pathogens of atypical pneumonia. Ribavirin was given to all except 1 patient. Twenty‐two patients received immunoglobulin therapy, and 32 were given corticosteroids. A total of 20 patients (55.6%) required supplemental oxygen, and 8 (22.2%) were intubated with mechanical ventilatory support. Two of these patients died. A higher body temperature at presentation (median 39.5 vs 38.6°C), and higher peak values of lactate dehydrogenase (410 vs 282 U/L) and C‐reactive protein (10.2 vs 2.5 mg/dL), were associated with subsequent respiratory failure. Multivariate analysis showed that peak level of C‐reactive protein was the only independent predictor of respiratory failure and intubation (odds ratio for every increment of 1 mg/dL = 1.45; 95% confidence interval = 1.003, 2.097; p = 0.048). Conclusion: All patients with probable SARS who were admitted to hospital presented with fever and lymphopenia. While the efficacy of different treatments could not be evaluated from this retrospective study, a higher value of C‐reactive protein was associated with the development of respiratory failure and subsequent intubation.

Implementation and outcomes of an antimicrobial stewardship program: Effectiveness of education

Background Unnecessary use of antibiotics is a common occurrence in hospitals. Implementation of antibiotic stewardship programs (ASPs) has been shown to reduce both unnecessary antibiotic use and drug‐resistant bacteria. Education is a fundamental component of an ASP. However, the effectiveness of proper uses of antibiotics education has not been clearly analyzed. Methods In a 520‐bed university hospital located in northeastern Taiwan, a significantly increasing prescription of carbapenems, specifically imipenem and meropenem, was observed. An educational program highlighting the judicious use of carbapenems was started, beginning in October 2013. A multidisciplinary ASP was implemented starting in January 2014. The consumption of antibiotics, measured by defined daily dose per 1000 occupied bed‐days, was compared among the pre‐educational, posteducational, and post‐ASP periods. Results Compared with the pre‐educational period, there was a significant reduction in antibiotics consumption of 13% total inpatient antibiotics (p = 0.008), 29.8% carbapenems (p = 0.001), 34.9% imipenem and meropenem (p < 0.001), and 27% glycopeptides (p = 0.015), in the posteducational and post‐ASP periods. The major reduction emerged during the posteducational period and was sustained after the ASP. The percentage of inpatients prescribed with antibiotics was significantly decreased (16.2%; p < 0.001). The rate of carbapenem‐resistant Acinetobacter baumannii decreased from 70.8% to 29.6% within 7 months. Conclusion A focused educational program is effective in controlling the prescription of specific antibiotic classes in the early phase of a multidisciplinary ASP.