Kao Pin Hwang

Combating antimicrobial resistance: Antimicrobial stewardship program in Taiwan

Multi-drug-resistant organisms are increasingly recognized as a global public health issue. Healthcare-associated infection and antimicrobial resistance are also current challenges to the treatment of infectious diseases in Taiwan. Government health policies and the health care systems play a crucial role in determining the efficacy of interventions to contain antimicrobial resistance. National commitment to understand and address the problem is prerequisite. We analyzed and reviewed the antibiotic resistance related policies in Taiwan, USA, WHO and draft antimicrobial stewardship program to control effectively antibiotic resistance and spreading in Taiwan. Antimicrobial stewardship program in Taiwan includes establishment of national inter-sectoral antimicrobial stewardship task force, implementing antimicrobial-resistance management strategies, surveillance of HAI and antimicrobial resistance, conducting hospital infection control, enforcement of appropriate regulations and audit of antimicrobial use through hospital accreditation, inspection and national health insurance payment system. No action today, no cure tomorrow. Taiwan CDC would take a multifaceted, evidence-based approach and make every effort to combat antimicrobial resistance with stakeholders to limit the spread of multi-drug resistant strains and to reduce the generation of antibiotic resistant bacteria in Taiwan.

The impact of the heptavalent pneumococcal conjugate vaccine on risk factors for Streptococcus pneumoniae carriage in children.

Background: The aim of the study was to investigate whether the 7-valent pneumococcal conjugate vaccine (PCV7) alters common risk factors of nasopharyngeal carriage by Streptococcus pneumoniae in children. Methods: From July 2005 through December 2010, we performed a cross-sectional study investigating risk factors associated with pneumococcal carriage in children. Parents of participating children completed questionnaires including whether or not the children received PCV7 vaccination. Results: Among 9705 children, 20.2% of them received at least 1 dose of the PCV7 vaccine. Multivariate logistic regression models identified older age, having 1 sibling in a family, history of acute otitis media and household exposure to smoking as independent risk factors for pneumococcal carriage in the unvaccinated group, but not associated with pneumococcal carriage in the vaccinated group. The number of siblings ≥2 in a family, history of upper respiratory tract infection and child-care attendance were strong factors associated with pneumococcal carriage in children, regardless of vaccination. In vaccinated group, breast-feeding was associated with increased nonvaccine type pneumococcal carriage, mainly in children with upper respiratory tract infection. Conclusions: PCV7 decreased the association between pneumococcal carriage and older age, 1 sibling in a family, history of acute otitis media and household exposure to smoking, but increased the association between pneumococcal carriage and breast-feeding.

Identification of porcine rotavirus-like genotype P[6] strains in Taiwanese children.

The molecular characterization of genotype P[6] rotavirus strains collected from children admitted to hospital with acute dehydrating diarrhoea during a 6-year surveillance period in Taiwan is described in this study. In total, three G4P[6] strains, one G5P[6] and one G12P[6] were characterized by sequencing and phylogenetic analysis of the VP4, VP7, VP6 and NSP4 genes. Whilst all four genes of the single Taiwanese G12P[6] strain clustered with the respective genes of globally common human rotavirus strains, the G4 and G5 strains showed remarkable similarities to porcine rotavirus strains and putative porcine-origin human P[19] strains reported previously from Taiwan. The overall proportion of porcine rotavirus-like strains in Taiwan remains around 1u200a% among hospitalized children; however, the circulation and sporadic transmission of these heterotypic strains from pigs to humans could pose a public-health concern. Therefore, continuation of strain monitoring is needed in the vaccine era to detect any possible vaccine breakthrough events associated with the introduction of such heterologous rotavirus strains.

Reporting an outbreak of Candida pelliculosa fungemia in a neonatal intensive care unit

BACKGROUNDnFungemia in preterm infants is associated with high mortality and morbidity. This study reports an outbreak of unusual fungemia in a tertiary neonatal intensive care unit (NICU).nnnMETHODSnTen Candida pelliculosa bloodstream isolates were identified from six infants hospitalized in the NICU from February to March 2009. Environmental study was performed, and genetic relatedness among the 10 clinical isolates of C pelliculosa and six control C pelliculosa strains was characterized by randomly amplified polymorphic DNA assay. Inxa0vitro susceptibility of isolates to six antifungal agents was analyzed by broth microdilution method. Amphotericin B was given to infected infants and prophylactic fluconazole was prescribed to the other noninfected extremely low birth weight infants during the outbreak.nnnRESULTSnThrombocytopenia (platelet counts <100×10(9)/L) was the early laboratory finding in four infants. One of six patients died, making overall mortality 17%. Fluconazole, voriconazole, amphotericin B, and micafungin provided good antifungal activity. Cultures from the environment and hands of caregivers were all negative. Molecular studies indicated the outbreak as caused by a single strain. The outbreak was controlled by strict hand washing, cohort infected patients, confined physicians and nurses to take care of patients, prophylactic fluconazole to uninfected neonates, and proper management of human milk.nnnCONCLUSIONnThe study demonstrated the clinical importance of emerged non-albicans Candida species in NICU. For unusual pathogen isolated from immunocompromised hosts, more attention should be paid to monitor the possibility of an outbreak.

Enterovirus infection is associated with an increased risk of childhood type 1 diabetes in Taiwan: a nationwide population-based cohort study

Aims/hypothesisThis study compared the incidence rate of type 1 diabetes in children diagnosed with enterovirus (EV) infections with that in age- and sex-matched children without EV infection in a population-based cohort. In addition, we examined whether the direction or magnitude of the association between EV infection and type 1 diabetes differs according to atopic disease status in children.MethodsWe used insurance claims data from Taiwan’s National Health Insurance Research Database to derive type 1 diabetes incidence in children aged up to 18xa0years with or without a diagnosis of EV infection during 2000–2008. Incidence rate ratios and HRs of type 1 diabetes for EV infection were estimated by Poisson regression and Cox’s proportional hazard regression model.ResultsOverall incidence of type 1 diabetes was higher in the EV than in the non-EV infection cohort (5.73 vs 3.89 per 100,000xa0person-years; incidence rate ratio 1.48 [95% CI 1.19, 1.83]), with an adjusted HR of 1.48 (95% CI 1.19, 1.83). Among children without EV, incidence increased with age at diagnosis of EV infection, except in those aged 5–10xa0years. The HRs of type 1 diabetes in children with allergic rhinitis, bronchial asthma or either one of these atopic diseases showed more variation than in those children without these diseases.Conclusions/interpretationThis nationwide retrospective cohort study found a positive correlation between type 1 diabetes and EV infection. The results suggest that a preventive strategy, such as an effective vaccine against EV infection, may lessen the incidence of type 1 diabetes in Taiwan.

Etiology of empyema thoracis and parapneumonic pleural effusion in Taiwanese children and adolescents younger than 18 years of age.

We analyzed blood and pleural fluid samples from 89 Taiwanese children with empyema thoracis and parapneumonic pleural effusion. Streptococcus pneumoniae was the major pathogen, identified in 12 children by bacterial culture and 53 children by molecular techniques, and serotype 19A was the dominant serotype. Also noteworthy was the detection of pneumococcal serotype 1, Haemophilus influenzae and Mycoplasma pneumoniae in these children.

Clonal dissemination of invasive and colonizing clonal complex 1 of serotype VI group B Streptococcus in central Taiwan

BACKGROUND/PURPOSEnThe aim of this study was to investigate clinical presentation, serotype distribution and genetic correlation of group B streptococcus (GBS) diseases. Since serotype VI prevalence far exceeded that reported in prior studies, genetic relationship of isolates was further analyzed.nnnMETHODSnGBS isolates obtaining from patients with invasive diseases and pregnant women with colonization between June 2007 and December 2010 were analyzed. All isolates were tested for serotypes by multiplex PCR assay and pulsed-field gel electrophoresis (PFGE). Serotype VI isolates were further analyzed by multilocus sequence typing (MLST).nnnRESULTSnA total of 134 GBS isolates were recovered from blood of 126 patients with invasive disease (94.0%) and anogenital swabs of 8 pregnant women (6.0%). Most common serotype was Ib (21.6%), followed by V (20.1%), VI (18.7%), III (15.7%), II (11.9 %), Ia (11.2%), and IX (0.7%). Serotype VI was also the leading type in infants with early onset disease (EOD; 3/8, 37.5%) and colonizing pregnant women (3/8, 37.5%). PFGE distinguished 33 pulsotypes, reflecting genetic diversity among GBS isolates. Among 25 serotype VI isolates tested, 14 were ST-1, seven were ST-679, three were ST-678, one was ST-681, and distributed into four PFGE pulsotypes. ST-678, ST-679, and ST-681 were novel sequence types; ST-678 and ST-679 are single-locus variants of ST-1 that belongs to clonal complex (CC) 1.nnnCONCLUSIONnCC1 dissemination of serotype VI GBS thus emerges as an important invasive pathogen in infants and nonpregnant adults in central Taiwan. Serotype prevalence of GBS must be continuously monitored geographically to guide prevention strategy of GBS vaccines.

Epidemiology of acute otitis media among young children: A multiple database study in Taiwan

BACKGROUND/PURPOSEnAcute otitis media (AOM) is a common complication of upper respiratory tract infection (URTI) among children. The purpose of this study was to evaluate the epidemiology of AOM among young children in Taiwan, including the age incidence and seasonality by combining multiple databases.nnnMETHODSnTwo country-based questionnaire survey studies had been conducted to evaluate the experience of otitis media (OM) among young children: one in 2007 and the other between 2005 and 2010. The number of OM cases (5% of population younger than 7 years) in 2005 and annual visiting rates for URTI from 2005 to 2010 obtained from the National Health Insurance Research Database of Taiwan were collected and comprised the third database. The fourth database comprised ambulatory visits of children with OM to a medical center in central Taiwan between 2005 and 2010.nnnRESULTSnData from a total of 1099 questionnaires were entered into Database I in 2007, and data from 9705 questionnaires between 2005 and 2010 comprised Database II. There were 86,702 children (younger than 7 years, representing 5% of the whole population for this age group) retrieved from Database III in 2007, and 5,904 cases of OM in children between 2005 and 2010 in a hospital. In Database I, 7.46% children experienced at least one episode of AOM compared with 9.21% in Database II for children aged 5 years and younger. In Database III, 13.2% children younger than 7 years had AOM in 2005. The peak season of AOM among children was from March to May (Databases III and IV).nnnCONCLUSIONnAOM was thought to be a very common disease among children; however, this comparative analysis showed that the overall prevalence of AOM among children younger than 5 years was only 20%, much lower than in other countries. AOM was more prevalent during the spring season, and still was similarly common after age 2 years.

Recommendations for Rotavirus Vaccine

Rotavirus infection has been the leading cause of gastroenteritis among children in Taiwan. Studies have shown that 40% of hospitalization for acute gastroenteritis can be prevented through the use of vaccines, including a live, attenuated monovalent rotavirus vaccine and a pentavalent, human-bovine reassortant rotavirus vaccine. In 2009, the World Health Organization suggested that rotavirus vaccine should be included in all national immunization programs. This review summarizes issues and recommendations discussed during an expert meeting in Taiwan. The recommendations included: (1) rotavirus vaccine should be offered to all healthy infants (including those without contraindications, such as immunodeficiency) at an appropriate age; (2) either monovalent or pentavalent vaccine can be administered concurrently with routine injected vaccines; (3) the administration of rotavirus vaccine must be administered at least 2 weeks prior to oral polio vaccination; (4) the first vaccine dose for infants should be administered between age 6 weeks and age 14 weeks 6 days and the course should be completed by age 8 months 0 day; (5) pentavalent vaccines can be administered at 2 months, 4 months, and 6 months while monovalent vaccines can be taken at 2 months and 4 months; (6) a combined use of monovalent and pentavalent vaccine is justified only when the previous dose is unavailable or unknown; and (7) rotavirus vaccines may be given to premature infants, human immunodeficiency virus infected infants and infants who have received or are going to receive blood products.

Increased risk of herpes zoster in children with cancer: A nationwide population-based cohort study.

AbstractHerpes zoster is rare in healthy children, but immunocompromised persons have an increased risk of herpes zoster and severe diseases. Considering the very limited information on herpes zoster in children with cancer, we performed a nationwide population-based cohort study to estimate the incidence of herpes zoster in children with cancer and to explore the association between the 2 diseases.Data were obtained from the National Health Research Institutes Database in Taiwan. A total of 4432 children with newly diagnosed cancer between 2000 and 2007 were identified as the cancer cohort, and 17,653 children without cancer frequency-matched by sex and age at entry were considered the noncancer cohort. The association between herpes zoster and childhood cancer was determined.Children with cancer had a higher risk of herpes zoster. The incidence rate of herpes zoster was higher in the cancer cohort than in the noncancer cohort (20.7 vs 2.4 per 10,000 person-years; IRRu200a=u200a8.6; 95% CIu200a=u200a4.8–15.6). The cumulative incidence was significantly higher in the cancer cohort (Pu200a<u200a0.0001). Leukemia, lymphoma, and solid tumor were all associated with the increased risk, and leukemia had the highest magnitude of strength of association.This nationwide population-based cohort study demonstrated that children with cancer were associated with an increased risk of herpes zoster. In addition to early antiviral treatment, vaccination with heat-treated zoster vaccine or adjuvanted subunit vaccine could be an appropriate policy to decrease the incidence in children with cancer.