I-Fei Huang

Emergence of extended spectrum-β-lactamase-producing Escherichia coli O25b-ST131: a major community-acquired uropathogen in infants

Background: Escherichia coli sero-group O25b-sequence type 131 (O25b-ST131), a multidrug-resistant clonal group, is a significant pathogen in adults and children. This study investigated the genotyping and role of extended spectrum &bgr;-lactamase (ESBL)-producing E. coli O25b-ST131 and non-O25b-ST131 in urinary tract infections in infants. Methods: Clinical and laboratory data from 111 infants less than 1 year of age, who were hospitalized for urinary tract infections caused by ESBL-producing E. coli between 2009 and 2012 were collected. Polymerase chain reactions and multi-locus sequence typing were used to identify E. coli O25-ST131 clones. The gene blaCTX-M groups 1, 2 and 9, a specific polymerase chain reaction of CTX-M 14 and 15, were also determined in ESBL-producing E. coli isolates. Results: O25b-ST131 accounted for 65% of the 111 isolates, although 92 isolates belonged to the blaCTX-M group 9, of which most were CTX-M-14. Those with O25b-ST131 clones had similar risk factors, clinical features and outcomes as those with non-O25b-ST131. The E. coli O25b-ST131 isolates were more resistant to ciprofloxacin and gentamicin, but more susceptible to cefoxitin, minocycline and trimethoprim/sulfamethoxazole than the non-O25b-ST131 isolates. Most of the infants (78%) were previously healthy with no apparent risk factors. Conclusions: E. coli O25b-ST131 is a major community-acquired uropathogen in the infant population. Regardless of O25b-ST131 or non-O25b-ST131 clones, CTX-M-14 accounts for majority of the ESBL genotype. The O25b-ST131 clone is not associated with more severe clinical disease, but it may make the diagnosis and selection of antimicrobials for treatment more challenging.

Infantile hypertrophic pyloric stenosis before 3 weeks of age in infants and preterm babies

Background:  Most infantile hypertrophic pyloric stenosis (IHPS) cases are diagnosed between 3 and 12 weeks after birth. Few data exist regarding Asian infants with IHPS who are younger than 3 weeks or are preterm. The goal of this study is to identify unusual clinical manifestations, clinical course, duration of hospital stay, and complications of Asian infants with IHPS who are preterm or younger than 3 weeks of age.

Infective endocarditis in children without underlying heart disease

BACKGROUND/PURPOSE Although pre-existing heart disease is the main predisposing factor for pediatric infective endocarditis (IE), cases of IE in children without underlying heart disease have been increasingly reported. This study reviews the clinical and laboratory characteristics of pediatric IE patients with and without underlying heart disease, and presents the unique features of patients with no apparent pre-existing heart disease. METHODS Children who were admitted to our hospital from January 1991 to April 2011 and met the Modified Duke criteria for definite or possible IE were retrospectively analyzed. Clinical characteristics and laboratory data were collected by chart review. RESULTS Forty-seven patients with a total of 48 episodes of IE were enrolled. Of these patients, 31 children (64.6%) had congenital heart disease (CHD), six (12.5%) had non-CHD chronic disease, and eleven (22.9%) were previously healthy adolescents. Five patients with non-CHD chronic conditions acquired infection from central catheter: two methicillin-resistant Staphylococcus aureus (MRSA), two Candida albicans and one coagulase-negative Staphylococcus (CoNS). The microbial pathogens in 11 previously healthy individuals were Streptococcus viridans (n = 3), methicillin-sensitive S. aureus (MSSA, n = 2), Haemophilus parainfluenzae (n = 2), Staphylococcus lugdunensis (n = 1), Enterococcus (n = 1), and Diphtheroid (n = 1). In total, five of 17 non-CHD patients were infected with S. aureus (two MRSA and three MSSA) and the vegetations in these five patients were detected in the right side of the heart (tricuspid valve or right atrium). The average interval between onset of symptoms and diagnosis of IE in the CHD and previously healthy groups was 18 and 31 days, respectively. Patients in the previously healthy group were older and more often required surgical interventions for removal of vegetation. CONCLUSION Over one-third (35.4%) of cases of IE in children occurred in patients without pre-existing cardiac disease. Early identification of these patients is critical and requires a high index of suspicion. The pathogenesis of IE in previously healthy individuals is still uncertain, but previous skin infection or dental problems may contribute to potential risk.

Characteristics of CTX-M Extended-Spectrum β-Lactamase-Producing Escherichia coli Strains Isolated from Multiple Rivers in Southern Taiwan

ABSTRACT Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli sequence type ST131 has emerged as the leading cause of community-acquired urinary tract infections and bacteremia worldwide. Whether environmental water is a potential reservoir of these strains remains unclear. River water samples were collected from 40 stations in southern Taiwan from February to August 2014. PCR assay and multilocus sequence typing (MLST) analysis were conducted to determine the CTX-M group and sequence type, respectively. In addition, we identified the seasonal frequency of ESBL-producing E. coli strains and their geographical relationship with runoffs from livestock and poultry farms between February and August 2014. ESBL-producing E. coli accounted for 30% of the 621 E. coli strains isolated from river water in southern Taiwan. ESBL-producing E. coli ST131 was not detected among the isolates. The most commonly detected strain was E. coli CTX-M group 9. Among the 92 isolates selected for MLST analysis, the most common ESBL-producing clonal complexes were ST10 and ST58. The proportion of ESBL-producing E. coli was significantly higher in areas with a lower river pollution index (P = 0.025) and regions with a large number of chickens being raised (P = 0.013). ESBL-producing E. coli strains were commonly isolated from river waters in southern Taiwan. The most commonly isolated ESBL-producing clonal complexes were ST10 and ST58, which were geographically related to chicken farms. ESBL-producing E. coli ST131, the major clone causing community-acquired infections in Taiwan and worldwide, was not detected in river waters.

Clinical Manifestations of Nontyphoid Salmonellosis in Children Younger than 2 Years Old—Experiences of a Tertiary Hospital in Southern Taiwan

BACKGROUND Few published studies have explored the clinical manifestations of nontyphoid salmonellosis in children <2 years of age. The aim of this study was to investigate the clinical manifestations, microbiological features, complications, fecal excretion time, and responses to treatment in children <2 years of age with nontyphoid salmonellosis. METHODS Between January 2005 and December 2009, pediatric patients who were admitted to Kaohsiung Veterans General Hospital with positive cultures for nontyphoid Salmonella were enrolled. The following data were recorded: demographic, clinical, and microbiological features, underlying diseases, treatment regimen, complications, responses to treatment, and fecal excretion time. The clinical manifestations were compared between patients <2 years of age and patients >2 years of age. RESULTS Of a total 279 enrolled patients, 179 were >2 years of age. Compared with the patients who were ≥2 years of age, patients <2 years of age demonstrated a significantly higher incidence of bloody stool, mixed infection, extraintestinal infection, longer course of antibiotics, longer course of diarrhea after admission, and more days spent in the hospital. The rates of insusceptibility of nontyphoid Salmonella to ampicillin, chloramphenicol, trimethoprim/sulfamethoxazole, ceftriaxone, and ciprofloxacin in patients <2 years of age were 37.87%, 29.09%, 23.73%, 3.26%, and 2.25%, respectively. Younger patients were generally more susceptible to antibiotics than patients ≥2 years of age, although this result was not statistically significant. CONCLUSION The clinical manifestations of nontyphoid salmonellosis are more severe in younger children <2 years of age than older children. Local susceptibility patterns could serve as a guide for the prescription of antibiotics by clinicians.

Urinary tract infection in infants caused by extended-spectrum beta-lactamase-producing Escherichia coli: comparison between urban and rural hospitals.

BackgroundCommunity-acquired urinary tract infection (UTI) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli is an emerging problem. Compared with urban infants, rural infants may encounter different distributions of community-acquired resistant strains and various barriers to efficient management.MethodsA retrospective survey and comparison was conducted for infants with UTI caused by ESBL-producing E. coli admitted to an urban hospital (n = 111) and a rural hospital (n = 48) in southern Taiwan from 2009 to 2012.ResultsCompared with 2009 and 2010, the total number of cases at both hospitals significantly increased in 2011 and 2012 (p < 0.001). Compared with the rural patients, the urban patients were significantly younger, and they had fewer days of fever before and after admission, fewer presentations of poor activity and poor appetite, and a lower serum creatinine level. Most of the patients had no prior history of illness, and we could not identify any significant different risk factors for acquiring ESBL-producing E. coli, such as past antimicrobial use, hospitalization, UTI, and underlying renal diseases, between the urban and rural populations.ConclusionsThe increase in community-acquired UTI in infants caused by ESBL-producing E. coli was similar between the urban and rural populations. Our preliminary data suggest that the rural–urban disparities were probably related to easy access to health care by the urban population. ESBL complicates disease management, and the increase in the prevalence of ESBL producers is a major health concern and requires further healthy carrier and environmental surveillance.

Factors Contributing to Prolonged Hospitalization of Patients With Infantile Hypertrophic Pyloric Stenosis

BACKGROUND To study the influence of clinical audit on diagnosis, complications, and factors contributing to hospitalization of patients with infantile hypertrophic pyloric stenosis. STUDY DESIGN Retrospective cohort study. METHOD There were 214 patients from 1991 to 2004 from three medical centers in Kaohsiung. Data were analyzed with respect to diagnostic methods, complications, and factors requiring patient hospitalization. RESULTS The ratio of male to female was 4.8:1 (177 males and 37 females). The diagnoses before admission were as follows: 22% had milk intolerance and 14.5% had esophageal reflux. There was a significant increase in the use of sonogram diagnostic test (p=0.005) and a decrease in the incidence of diagnosis by olive mass palpation but not by barium meal test. Surgery time of 48 hours after admission was significant with barium meal examination and related to longer hospital stay (p<0.001). Weight gain less than 800 g before admission (n=125) was related to longer hospital stay (p=0.026). CONCLUSION The diagnostic method was changed from olive mass palpation to sonogram. Weight gain less than 800 g before admission and surgery time of 48 hours after admission were related to longer hospital stay.

Septicemia after Barium Reduction in a Pediatric Patient with Intussusception

A 4-year-old boy was admitted to our hospital because of sudden-onset abdominal pain that lasted 5 hours. He had no prior history or signs of fever, vomiting, diarrhea, or currant-jelly stools. A physical examination revealed no rebounding tenderness or palpable abdominal mass. A standing plain film of the abdomen revealed no signs of intraperitoneal free air or intestinal obstruction. Intussusception was highly suspected because of the target sign over the right upper quadrant of the abdomen on ultrasonography. A subsequent barium enema demonstrated a spring-coil appearance over the ascending colon, which was

The Clinical Outcomes of Antimicrobial Therapy in Pediatric Patients With Nontyphoid Salmonellosis With Different Levels of Severity

Background. To evaluate if a severity score could differentiate the severity of children with nontyphoid salmonellosis; clinical outcomes of antimicrobial therapy in nontyphoid salmonellosis children with different severities. Methods. Admitted children with nontyphoid salmonellosis from 1996 to 2009 were monitored. Enrolled patients were divided into no antibiotics, concordant, and discordant therapies. Besides, the patients were classified into mild, moderate, and severe group according to the severity score. Clinical outcomes were compared among them. Results. A total of 558 patients were enrolled. In no therapy subset, compared with mild group, patients had worse clinical outcomes and more complications in severe group. Patients receiving no therapy had better clinical outcomes in mild group. However, patients receiving concordant therapy (ceftriaxone) had better clinical outcomes in severe group. Conclusions. The severity score and local antibiotic susceptibility could serve as guides for antibiotic prescription for severe nontyphoid salmonellosis in children. Inappropriate antibiotic use would worsen clinical outcomes in children with mild nontyphoid salmonellosis.

PO-0140 Whether Antimicrobial Therapy Affect Fecal Excretion Time In Paediatric Patients Of Nontyphoid Salmonellosis With Different Severity

Objective To investigate whether the administration of antibiotics affect faecal excretion time in paediatric salmonellosis with different severity. Methods Children with nontyphoid salmonellosis admitted to Kaohsiung Veterans General Hospital, Taiwan who consented to receive consecutive stool cultures every 4–7 days till two consecutive negative results between 2005 and 2013 were enrolled. Faecal excretion time was defined as the timeframe of the first positive stool culture and the first of two consecutive negative results. The Severity Score was used to stratify the patients as the severe, moderate and mild group according to their fever days before admission, band cells in peripheral blood and C-reactive protein. Patients were classified into no antibiotics (mild disease without antibiotic), concordant (severe patients receiving antibiotics active in vitro) and inappropriate therapy group (mild patients receiving antibiotics or severe patients receiving antibiotics resistant in vitro). Results 53 patients were enrolled. Compared with no antibiotic group (n = 28), the concordant group (n = 11) had comparable faecal excretion time (12.36 vs 9.79 days), fever days after admission and hospital stay (2.45 vs 2.25; 6.45 vs 6.39 days). The inappropriate group (n = 14) had significantly longer faecal excretion time (24.50 vs 9.79 days), hospital stay (8.50 vs 6.39 days) and higher platelet count (333.43 vs 269.82 × 1,000/mm3) than no antibiotics group. With further multiple regression analysis, only inappropriate antibiotic use affected significantly (p = 0.008) on faecal excretion time. Conclusions Antibiotics used in severe children with salmonellosis didn’t prolong faecal excretion time, but inadequate use of antibiotics prolonged faecal excretion time in Salmonellosis.