Shang-Yi Lin

A Mucormycosis Case in a Cirrhotic Patient Successfully Treated with Posaconazole and Review of Published Literature

Mucormycosis is an invasive fungal infection associated with a high mortality rate, especially in immunocompromised hosts. Mucormycosis rarely occurs in cirrhotic patients. Here, we report a case of mucormycosis with underlying liver cirrhosis and diabetes mellitus. The patient suffered from maxillary sinusitis and osteomyelitis, and the infection was successfully treated with antifungal agents, surgical debridement, and hyperbaric oxygen therapy. The antifungal treatments used were liposomal amphotericin B, itraconazole, and posaconazole. Although our patient had liver cirrhosis (Child-Pugh classification B), no hepatic decompensation was developed during the treatment course of posaconazole. This is the first report of the safe and effective use of posaconazole for the treatment of mucormycosis in a cirrhotic patient.

Reversible hearing impairment: delayed complication of murine typhus or adverse reaction to azithromycin?

Delayed and reversible hearing loss occurred in a 55-year-old male patient with murine typhus infection. The patient had the initial symptoms of headache, fever and chills, followed by the occurrence of bilateral hearing loss on day 9 from fever onset. Murine typhus was diagnosed with a high IgM titre by indirect immunofluorescence assay. After treatment with azithromycin and prednisolone, the fever and other symptoms subsided gradually and bilateral hearing loss improved 3 weeks later. Though an adverse reaction to azithromycin could not be ruled out, delayed onset of hearing loss was more likely a complication of murine typhus, mainly because the hearing loss did not occur during the azithromycin usage period. Although hearing loss due to murine typhus is rare, clinicians should be alert to the existence of such a delayed complication.

Metformin is associated with a lower risk of active tuberculosis in patients with type 2 diabetes: Metformin reduces TB risk in diabetics

Metformin is an oral anti‐diabetic therapy (ADT) to manage type 2 diabetes mellitus (T2DM), and has been reported to have potential anti‐tuberculosis (TB) effects. This study investigates the risk of active TB among persons with T2DM who were treated with various ADT and insulin therapies.

Management of infections caused by extended-spectrum β–lactamase-producing Enterobacteriaceae: current evidence and future prospects

ABSTRACT Introduction: The spread of extended-spectrum β–lactamase (ESBL)-producing Enterobacteriaceae has become a major public health threat worldwide. Area covered: A thorough systematic literature review describing the current evidence and future prospects of therapeutic options for infections caused by ESBL-producing Enterobacteriaceae. Expert commentary: The methods of detecting ESBLs have been evolving. The Clinical and Laboratory Standards Institute and the European Committee on Antimicrobial Susceptibility Testing lowered the MIC breakpoints of cephalosporins against ESBL-producing Enterobacteriaceae in 2010. Phenotypic testing for ESBLs is no longer recommended. Instead, the selection of appropriate antimicrobial agents largely depends on the report of minimum inhibitory concentrations (MICs). To date, therapeutic options for these multidrug-resistant organisms remain limited. The clinical efficacy of piperacillin/tazobactam and cefepime on in vitro-susceptible ESBL-producing Enterobacteriaceae remains a concern. Many studies found an in vitro-in vivo discordance based on current breakpoints. Carbapenems are the most reliable antibiotics for severe infections caused by ESBL-producing Enterobacteriaceae. However, their overuse has led to a serious problem of increasing drug resistance. Recently, ceftolozane/tazobactam and ceftazidime/avibactam have been approved for the treatment of complicated urinary tract infections and complicated intra-abdominal infections. The introduction of these new β-lactam/β-lactamase inhibitor combinations offers new carbapenem-sparing options for the treatment of ESBL infections.

Association of bacterial genotypes and epidemiological features with treatment failure in hemodialysis patients with methicillin-resistant Staphylococcus aureus bacteremia

Objectives Methicillin-resistant Staphylococcus aureus (MRSA) infections in the hemodialysis (HD) population are epidemiologically classified as healthcare-associated infections. The data about the clinical impact and bacterial characteristics of hospital-onset (HO)- and community-onset (CO)-MRSA in HD patients are scarce. The current study analyzed the difference in the clinical and molecular characteristics of HO-MRSA and CO-MRSA. Methods We performed a retrospective review and molecular analysis of clinical isolates from 106 HD patients with MRSA bacteremia from 2009 to 2014. CA genotypes were defined as isolates carrying the SCCmec type IV or V, and HA genotypes were defined as isolates harboring SCCmec type I, II, or III. Results CO-MRSA infections occurred in 76 patients, and 30 patients had HO-MRSA infections. There was no significant difference in the treatment failure rates between patients with CO-MRSA infections and those with HO-MRSA infections. CA genotypes were associated with less treatment failure (odds ratio [OR]: 0.18; 95% confidence interval [95% CI], 0.07–0.49; p = 0.001). For isolates with a vancomycin minimum inhibitory concentration (MIC) < 1.5 mg/L, the multivariate analysis revealed that HA genotypes and cuffed tunneled catheter use were associated with treatment failure. For isolates with a vancomycin MIC ≥1.5 mg/L, the only risk factor for treatment failure was a higher Pitt score (OR: 1.76; 95% CI, 1.02–3.05; p = 0.043). Conclusion CA genotypes, but not the epidemiological classification of CO-MRSA, impacted the clinical outcome of MRSA bacteremia in the HD population.

Three months of rifapentine and isoniazid for latent tuberculosis infection in hemodialysis patients: High rates of adverse events

The consequences of once-weekly rifapentine plus isoniazid for 3 months (3HP) against latent tuberculosis infections in hemodialysis patients have not been studied before. This is the first study to evaluate the safety and tolerability of 3HP in this population and revealed a completion rate of 65.4%. The therapy was not associated with hepatotoxicity, but with high rates of adverse events (69.2%).

Two fatal cases of Aeromonas dhakensis bacteremia and necrotizing fasciitis in severe dengue patients

A 75-year-old female with hypertension admitted due to persistent fever for 2 days, chills, bone pain, dizziness, nausea, mild cough and thrombocytopenia (platelet: 139,000/mL). Dengue was confirmed by NS1 antigenemia and PCR-proven viremia via CDC, Taiwan. Sudden onset of high fever again and accompanied with shortness of breath, decreased urine amount, disorientation, left leg painful swelling and ecchymosis were noted on day 7. Ceftazidime was administered immediately for the suspicious of superimposed urinary tract infection and septic shock. Hemorrhagic bullae were developing over her left leg. Necrotizing fasciitis with gas gangrene was confirmed by computed tomography (Fig. 1) and emergent fasciectomy was performed immediately. She was still passed out owing to profound shock and metabolic acidosis 2days later. Blood and pus culture yielded Aeromonas hydrophila identified by automated ID/AST system (VITEK 2, bioMérieux) and Matrix-Assisted Laser Desorption IonizationTime of Flight Mass Spectrometry (MALDI-TOF MS, Bruker) and were re-identified as A. dhakensis strain LMG 19562 (accession No. KC601656.1) by rpoD gene PCRsequencing.

An Underestimated Co-infection: Swine Influenza and Pneumonia Due to Legionella pneumophila

Complications from secondary bacterial infections or co-infections are a leading cause of morbidity and mortality associated with influenza virus infection. The influenza virus can suppress the immune response to a bacterial infection, which leads to bacterial overgrowth. Groups at high risk of developing influenzarelated complications include the elderly, young children, pregnant women, people who are morbidly obese (body mass index Z40 kg/m) and people with chronic medical diseases. Compared with bacterial pneumonia without influenza infection, morbidity and mortality are recognized to be greater in cases of influenzaassociated bacterial infection. Bacterial co-infections typically occur within a few days of influenza infection at times of high viral shedding. Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus and Streptococcus pyogenes are the most frequently isolated pathogens that commonly colonize the nasopharynx. However, co-infection due to Legionella pneumophila has been rarely reported. We reported an unusual case characterized by swine influenza and pneumonia co-infection due to Legionella pneumophila. Our case was cured with prompt identification of the etiology of pneumonia and by appropriate treatment with antiviral, antimicrobacterial agents and adjunctive steroids. To the best of our knowledge, there are only 4 detailed case reports; this is the fifth coinfection case report and the first case presented in Taiwan. A 40-year-old male room attendant at a local hotel with a history of hypertension presented at our emergency department with fever, nonproductive cough, myalgia, sore throat and nasal congestion for 5 days. Physical examination revealed a temperature of 391C, a heart rate of 120 beats per minute and a respiratory rate of 28 breaths per minute. Oxygen saturation was 88% in room air. A laboratory examination revealed a white blood cell count of 12,060/μL (84% neutrophils and 13% lymphocytes), a C-reactive protein level of 60 mg/L, a serum sodium level of 133 mEq/L, a serum phosphorus level of 3.2 mg/dL and a creatinine phosphokinase level of 453 IU/L. A nasal swab tested negative for influenza A and B antigens. Urinary antigen tests for Legionella and pneumococcus were negative. Chest radiography showed a diffuse infiltrate predominantly located in the right middle lobe and left lower lobe