Te-Yu Lin

Impact of vancomycin MIC creep on patients with methicillin-resistant Staphylococcus aureus bacteremia

BACKGROUND/PURPOSE To date, vancomycin is still the standard treatment for methicillin-resistant Staphylococcus aureus (MRSA) infections, but minimum inhibitory concentration (MIC) creep is becoming a major concern. The aims of this study were to investigate trends in vancomycin use and MIC values over the last decade at our institute and to evaluate the outcomes of bacteremic patients infected with MRSA isolates with reduced vancomycin susceptibility. METHODS Vancomycin use and density were evaluated using the defined daily doses (DDD) method. Patients with MRSA bacteremia were enrolled retrospectively. Patient demographic data and clinical outcomes were analyzed. The first isolate from each patient was collected for E-testing in order to determine vancomycin MIC. MIC trends were assessed as MIC(50), MIC(90), and the geometric mean. RESULTS Vancomycin use has increased over the last decade. One hundred and forty patients were enrolled and their respective isolates were retrieved, including isolates from 45 patients in 2001, 46 patients in 2005, and 49 patients in 2009. The geometric mean (± standard deviation) of the vancomycin MIC for MRSA isolates obtained in 2009 was 1.39 ± 0.30 μg/mL, which is significantly higher than the mean vancomycin MIC obtained in 2001 (1.19 ± 0.34 μg/mL, p < 0.01) and 2005 (1.99 ± 0.25 μg/mL, p < 0.001). There were no significant differences in terms of the in-hospital mortality rate between patients with MRSA isolates with MICs ≥ 1.5 μg/mL or < 1.5 μg/mL. CONCLUSION We identified a significant upward trend in the use of vancomycin and its MIC over the last decade. This study shows that patients infected with MRSA isolates with high MICs (≥1.5 μg/mL) do not have a significantly higher mortality rate compared with isolates with low MICs (<1.5 μg/mL).

Candida lipolytica candidemia as a rare infectious complication of acute pancreatitis: A case report and literature review

Candida lipolytica candidemia is a rare but an emerging pathogenic yeast infection in humans. It can gain access to the bloodstream through intravascular catheterization, especially through central venous catheters in immunocompromised or critically ill patients during hospitalization. In this report, we present a noncatheter-related C. lipolytica candidemia infection in an 84-year-old man who was admitted due to acute pancreatitis. The possible pathogenesis and management of C. lipolytica candidemia are highlighted. It was an unusual infectious complication of acute pancreatitis. Clinicians should be aware that such an opportunistic pathogen can lead to invasive candidemia infection. In clinical practice, systemic antifungal therapy and the removal of the potentially infected central venous catheter might be recommended for the treatment of C. lipolytica candidemia.

Methicillin-resistant Staphylococcus aureus bacteremia in hemodialysis and nondialysis patients

BACKGROUND/PURPOSE Increased mortality has been reported in patients treated with vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with high minimum inhibitory concentration (MIC) values within the susceptibility range. However, this finding has not been verified in hemodialysis patients, who have much higher invasive MRSA infection rates than nondialysis patients. We aimed at comparing vancomycin MICs between hemodialysis and nondialysis patients, and identifying predictors of high vancomycin MICs and infection-related mortality in hemodialysis patients with MRSA bacteremia. METHODS Patients with MRSA bacteremia from January 2008 through December 2009 were enrolled. Vancomycin MIC was determined for each first isolate using the Etest method. Clinical characteristics and vancomycin MICs were compared between hemodialysis and nondialysis patients. Factors associated with high vancomycin MIC (2 μg/mL) and infection-related mortality in hemodialysis patients were analyzed. RESULTS A total of 162 MRSA bacteremia episodes were identified. Forty-four (27.0%) isolates were obtained from hemodialysis patients and 118 (73.0%) from nondialysis patients. Diabetes (63.3% vs. 39.8%, p = 0.007) and prior vancomycin exposure in 30 days (31.8% vs. 12.7%, p = 0.005) were more prevalent in hemodialysis group than in nondialysis group. A higher prevalence of vancomycin MIC of 2 μg/mL was observed in hemodialysis group in comparison with nondialysis group (11.4% vs. 1.7%, p = 0.016). In following analyses of hemodialysis group, patients with initial presentation of septic shock had a higher risk of vancomycin MIC of 2 μg/mL than nonseptic shock patients (100.0% vs. 38.5% p = 0.014). Infection-related mortality was associated with age, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia in univariate analysis. CONCLUSION Hemodialysis patients with MRSA bacteremia are more likely to have a high vancomycin MIC (2 μg/mL) compared with nondialysis patients. Infection-related mortality is associated with the patients clinical manifestations, including age, APACHE-II score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia. Treatment selection should be tailored according to the patients clinical condition.

Infectious sacroiliitis caused by Staphylococcus aureus following acupuncture: a case report

Determination of the origin of infectious sacroiliitis (ISI), a rare form of septic arthritis, is often time consuming and clinically difficult owing to its various presentations, which include joint, skin and urinary tract infections. This report describes the diagnosis, determination of infectious origin and treatment of a case of ISI attributed to the use of acupuncture for the treatment of lower back pain. We report on a 61-year-old man who developed right hip pain and fever 3 days after undergoing acupuncture over the right buttock region for the treatment of lower back pain. Blood culture showed infection with methicillin-susceptible Staphylococcus aureus and MRI disclosed the presence of an inflamed area over the right iliac bone and the right portion of the sacrum. The patient was cured after a 4-week course of antimicrobial treatment. Clinicians should take a history of acupuncture use when evaluating patients presenting with fever of unknown origin and/or bacteraemia and consider the possibility of ISI when evaluating patients with hip pain and infectious signs after acupuncture or other possible causes of infection. This indicates the importance of performing clinically clean procedures to prevent septic complications when treating patients with acupuncture.

Evolution of hepatitis A virus seroprevalence among HIV-positive adults in Taiwan.

Objectives The study aimed to describe the seroprevalence of hepatitis A virus (HAV) in HIV-positive adult patients in Taiwan between 2012 and 2016 and to examine the evolution of HAV seroprevalence between 2004–2007 and 2012–2016. Methods Clinical information and data of anti-HAV antibody results were collected from 2,860 antiretroviral-naïve HIV-positive Taiwanese aged 18 years or older who initiated combination antiretroviral therapy at 11 hospitals around Taiwan between 2012 and 2016 (2012–2016 cohort). A multivariate logistic regression model was applied to identify independent variables associated with HAV seropositivity. Comparisons of HAV seroprevalences and associated clinical characteristics were made between this 2012–2016 cohort and a previous cohort of 1580 HIV-positive patients in 2004–2007 (2004–2007 cohort). Results Of the 2,860 HIV-positive patients between 2012 and 2016, the overall HAV seropositivity rate was 21.2% (605/2860), which was independently associated with an older age (adjusted odds ratio [AOR], per 1-year increase, 1.13; 95% confidence interval [95% CI], 1.11–1.15) and co-infection with hepatitis B virus (AOR 1.44; 95% CI, 1.08–1.93). Residence in southern Taiwan (AOR 0.49; 95% CI, 0.34–0.72) was inversely associated with HAV seropositivity. The overall HAV seroprevalence in the 2012–2016 cohort was significantly lower than that in the 2004–2007 cohort (21.2% vs 60.9%, p<0.01). The decreases of HAV seropositivity rate were observed in nearly every age-matched group, which suggested the cohort effect on HAV seroepidemiology. However, among individuals aged 25 years or younger, the HAV seropositivity rate increased from 3.8% (2/52) in the 2004–2007 cohort to 8.5% (50/587) in the 2012–2016 cohort, with 95.4% (560/587) being MSM in this age group of the latter cohort. Conclusions HAV seroprevalence has decreased with time among HIV-positive adults in Taiwan. The cohort effect has increased the number of young HIV-positive patients that are susceptible to HAV infection in a country without nationwide childhood vaccination program against HAV.

Applying ATP bioluminescence to design and evaluate a successful new intensive care unit cleaning programme

This was a two-phase prospective intervention study in the cardiology intensive care unit (CICU) and medical intensive care unit (MICU) and of a public 1800-bed medical centre in Taiwan. In phase I, cleaning efficacy was monitored by ATP bioluminescence after daily morning cleaning, and only 43.9% of 221 tested surfaces passed. The baseline data were used to define an intervention consisting of a new cleaning protocol as well as a new education/training programme. In phase II, following the intervention, 88.1% of 270 surfaces were found to be clean. The combined infection rate in the CICU and MICU showed a statistically significant decrease of 49.7%.

Acute unilateral cerebellitis, Epstein-Barr virus, and HIV

A 31-year-old man presented to the emergency depart ment with a 2-day history of severe headache, nausea, and vomiting. He reported intermittent tremors in his left hand and ataxic gait for 2 weeks. Neuro logical examinations showed dysarthria and left-sided dys metria on fi nger-tonose and heel-knee-shin tests. Brain MRI showed a poorly defi ned hetero geneous hyper intensive lesion of the left cerebellar hemisphere (fi gure, A [axial T2-weighted] and B [axial T1-weighted]) and obstructive hydrocephalus caused by a cerebellar mass-eff ect (fi gure, C [sagittal T1-weighted]). Serology investi gations for bacteria, fungi, and viruses indicated un remark able results; tests for HIV and EpsteinBarr virus (EBV) were positive. HIV viral load was 2554 copies per mL and CD4 count was 235 cells per μL. CSF analysis showed pleocytosis and increased protein concentration; bacterial and fungal cultures and examinations for syphilis, cryptococcus, toxo plasmosis, and acid-fast bacilli were negative. EBV PCR of CSF was positive. Stereotactic biopsy of the cerebellum was done, and histopathological examination indicated infl ammatory infi ltration with abundant lymphocytes and histiocytes without evidence of malignant disease. Furthermore, EBVencoded RNA was expressed in infi ltrating cells. Highly active antiretroviral therapy (tenofovir, lamivudine, efavirenz), antiviral therapy (ganciclovir), and steroids (beta methasone) were prescribed for EBV-related acute cerebellitis. Follow-up brain MRI showed regression of the cerebellar infl ammatory lesion (fi gure D–F), indicating a substantial improvement in the clinical condition. He recovered well without substantial neurological sequelae. CNS infection in patients with HIV can be associated with various pathogens including viruses, toxoplasmosis, syphilis, and cryptococcus. The clinical manifestations, specifi c area involved, and immune status of patients can assist with the diff erential diagnosis. In our patient, cerebellitis was a characteristic sign distinguishable from other causes. The possibility of an EBV infection should be considered in the diff erential diagnosis of CNS lesion in patients with HIV, and EBV-related malignant diseases should be diff erentiated, to ensure appropriate treatment.

Changing seroprevalence of hepatitis C virus infection among HIV-positive patients in Taiwan

Objective The study aimed to describe the evolution of the seroprevalence of hepatitis C virus (HCV) among human immunodeficiency virus (HIV)-positive patients included in two cohorts in Taiwan. Methods We retrospectively collected the information on demographic and clinical characteristics of 4,025 and 3,856 HIV-positive Taiwanese, who were aged 18 years or older at designated hospitals around Taiwan in 2004–2007, when an outbreak of HIV infection was occurring, and 2012–2016, when the outbreak was controlled with the implementation of harm reduction program, respectively. Comparisons of HCV seropositivity were made among different age and risk groups for HIV transmission between these two cohorts. Results The overall HCV seroprevalence of the 2004–2007 cohort and 2012–2016 cohort was 43.4% (1,288/2,974) and 18.6% (707/3,793), respectively (P<0.001). The HCV seroprevalence among injecting drug users (IDUs), though decreasing, was constantly high across the two cohorts, 96.4% and 94.0% (P = 0.02), respectively, and all age groups. In contrast, the corresponding figures among men who have sex with men (MSM) and heterosexuals in the two cohorts were 5.9% vs. 3.5% (P = 0.002) and 9.4% vs. 10.9% (P = 0.59), respectively. Among sexually transmitted HIV-positive patients, HCV seropositivity was significantly correlated with age (adjusted odds ratio [aOR], per 1-year increase, 1.03; 95% confidence interval [CI], 1.02–1.05) and a rapid plasma reagin (RPR) titer ≥1:8 (aOR, 1.58; 95% CI, 1.03–2.43) in a multivariate analysis including age, gender, route for HIV transmission, baseline CD4 count and plasma HIV RNA load, the presence of hepatitis B surface antigen, and an RPR titer ≥1:8. Compared with heterosexuals, the aOR for HCV seropositivity among MSM was 0.47 (95% CI, 0.31–0.72). Conclusions HCV seroprevalence among HIV-positive patients in Taiwan decreased with time, probably related to the inclusion of younger adults and more non-IDUs, and remained high among IDUs. HCV seropositivity was associated with age and an RPR titer ≥1:8 among patients who acquired HIV through sexual contact.

Clinical Characteristics and Outcome of Chryseobacterium indologenes Bacteremia

Background: Chryseobacterium indologenes, although widely distributed in nature, is a rare human pathogen. This study aims to analyze the clinical characteristics, risk factors, and outcome of patients with C. indologenes bacteremia. Methods: A retrospective study was conducted from January 1, 2002 to April 30, 2011 analyzing patients with C. indologenes bacteremia at a medical center in northern Taiwan. Results: Forty-eight episodes of C. indologenes bacteremia in 47 patients were identifi ed. Among all bacteremic episodes, 44 (92%) were nosocomial, three (6%) were healthcare-associated, and only one (2%) was community-acquired. Thirty-three episodes (69%) were primary bacteremia, and nine (19%) were from pneumonia. Forty-one isolates (85%) were non-susceptible to imipenem, and only 20% (3/15) were non-susceptible to fl omoxef. Patients with tunneled catheter, delayed onset of bacteremia, isolates were non-susceptible to ceftazidime or cefepime and potentially associated with higher mortality. Pneumonia (OR = 31.359; 95% CI = 1.35-729.39; p = 0.032) and non-susceptibility to ceftazidime (OR = 21.057; 95% CI = 2.28-194.57; p = 0.007) were independent risk factors for in-hospital mortality. Conclusions: The emergence of C. indologenes bacteremia has had a great clinical impact on inpatient care. It is important to identify the clinical characteristics of C. indologenes bacteremia and initial prompt antimicrobial treatments.

Tubo-ovarian Actinomycosis Complicated with Hepatic Abscess

Actinomycosis is a chronic, suppurative, granulomatous diseases characterized by extensive necrosis and abscess formation. Both hepatic and pelvic actinomycosis are rare diseases. Tubo-ovarian actinomycosis complicated with hepatic abscess is rarely reported. We present a 47 year old woman with a history of an intrauterine device (IUD) implantation for about 18 years, who presented with epigastric pain for one month. A computed tomography (CT) scan of abdomen revealed a mass (13×10×9.6 cm) over the left lobe of the liver and a right-sided tubo-ovarian lesion (6.6×5.9 cm). Exploratory laparotomy confirmed liver and tubo-ovarian abscesses. Pathology of the liver and the tubo-ovarian lesions both revealed actinomycosis infection. The patient received a 4-week intravenous ampicillin treatment, followed by oral amoxicillin for 6 months. No recurrence was noted in the follow-up. Actinomycosis should be considered in concomitant liver and ovary abscesses. Detailed history taking, such as IUD implantation, along with radiological examinations and pathological findings are important for diagnosing actinomycosis infection.