Tsong Yih Ou

Clinical and epidemiological features of Chryseobacterium indologenes infections: Analysis of 215 cases *

PURPOSE This study investigates the clinical and epidemiological features of Chryseobacterium indologenes infections and antimicrobial susceptibilities of C indologenes. METHODS With 215 C indologenes isolates between January 1, 2004 and September 30, 2011, at a medical center, we analyzed the relationship between the prevalence of C indologenes infections and total prescription of colistin and tigecycline, clinical manifestation, antibiotic susceptibility, and outcomes. RESULTS Colistin and tigecycline were introduced into clinical use at this medical center since August 2006. The increasing numbers of patients with C indologenes pneumonia and bacteremia correlated to increased consumption of colistin (p = 0.018) or tigecycline (p = 0.049). Among patients with bacteremia and pneumonia, the in-hospital mortality rate was 63.6% and 35.2% (p = 0.015), respectively. Administration of appropriate antibiotics showed significant benefit in 14-day survival in patients with C indologenes bloodstream infection (p = 0.040). In bacteremic patients, old cardiovascular accident (p = 0.036) and cancer (p = 0.014) were the most common comorbidity. The most common co-infection pathogen in patients with C indologenes pneumonia was Acinetobacter baumannii (36/91, 39.6%), followed by Pseudomonas aeruginosa (23/91, 25.3%), carbapenem-resistant A baumannii (22/91, 24.2%), and Klebseilla pneumoniae (13/91, 14.3%). Antimicrobial susceptibility testing of the 215 isolates showed that trimethoprim-sulfamethoxazole was the most active agent (susceptibility rate: 87.4%), followed by cefoperazone-sulbactam (48.0%). CONCLUSION The present study showed a trend of increasing prevalence of C indologenes infection after introduction of colistin and tigecycline usage. The bacteremia group had higher mortality rate than the pneumonia group. Increasing resistance to piperacillin-tazobactam, ceftazidime, cefepime, and newer fluoroquinolone were noticed in our analysis. Trimethoprim-sulfamethoxazole was a potential antimicrobial agent in vitro for C indologenes. To avoid collateral damage, we emphasize the importance of antibiotic stewardship program.

Corynebacterium striatum bacteremia associated with central venous catheter infection

Corynebacterium striatum (C striatum) has been considered a contaminant of blood culture in past decades. Here we report the case of a patient with acute deterioration of chronic renal failure. She received hemodialysis and died from C striatum bacteremia. By using a randomly amplified polymorphic DNA (RAPD) method, we found that an association existed between C striatum from the bloodstream and that from the central venous catheter. We suggest that C striatum could be a pathogen of bloodstream infection in patients with such a catheter in place.

Lemierre syndrome complicating multiple brain abscesses caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae cured by fosfomycin and meropenem combination therapy

A woman aged 56 years of age had a community-acquired left neck abscess and internal jugular vein thrombosis with septicemia due to extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae. Even though she was treated with intravenous meropenem, the bacteremia persisted. She was complicated with multiple brain abscesses, seizure, and leucopenia. After a combination of intravenous fosfomycin and meropenem, her clinical condition became stable. Combination treatment was continued for 2 months and she recovered. In individual cases of Lemierre syndrome with brain abscess caused by ESBL-producing Enterobacteriaceae, fosfomycin combination therapy may be the alternative choice.

Emphysematous cholecystitis complicating liver abscess due to Clostridium baratii infection

Clostridium baratii bacteremia is a rare but severe anaerobic infection. Its major clinical features are neurological presentation, and significant risk factors include hemodialysis, intestinal disease or malignancy. We describe a case of emphysematous cholecystitis complicated by a liver abscess due to C baratii infection in a healthy adult without neurological manifestation.

Safety and immunogenicity of an inactivated cell culture-derived H7N9 influenza vaccine in healthy adults: A phase I/II, prospective, randomized, open-label trial

BACKGROUND We conducted a phase I/II clinical trial to evaluate the safety and immunogenicity of a Madin-Darby canine kidney (MDCK) cell-grown inactivated H7N9 influenza vaccine for pandemic preparedness purposes. METHODS Between April 7, 2015 and May 27, 2016, healthy adults aged 20-60years were enrolled sequentially in phase I (n=40) and phase II (n=160) from three hospitals in Taiwan and randomized to receive 2 doses of whole-virus H7N9 vaccine (15 or 30μg hemagglutinin antigen (HA) with or without an aluminum hydroxide adjuvant) at 21-day intervals. Safety up to 180days and changes in hemagglutinin inhibition (HI) titers at 21days after each vaccination were determined. RESULTS Of the 200 randomized subjects, 193 (96.5%) received 2 doses of the study vaccine and were included in the intention-to-treat analysis for safety, and 190 (95%) were included in the per-protocol analysis for immunogenicity. Most adverse events were mild and transient; no death or vaccine-related serious adverse events were reported. Overall, higher immune responses were observed in the groups administered with 30μgHA formulation than in the other two groups administered with 15μgHA formulation. The highest immune response was observed in subjects who received 2 doses of the adjuvanted vaccine containing 30μgHA with HI titer, seroprotection rate, seroconversion rate, and seroconversion factor of 36.2, 64.6%, 64.6% and 5.7, respectively. CONCLUSIONS Our study demonstrated that the H7N9 influenza vaccine containing 30µgHA with aluminum hydroxide adjuvant was immunogenic and safe in adults aged 20-60years. CLINICALTRIALS.GOV identifier: NCT02436928.

Comparison of pneumonia- and non-pneumonia-related Acinetobacter baumannii bacteremia: Impact on empiric therapy and antibiotic resistance

OBJECTIVE Acinetobacter baumannii (AB) bacteremia has increasingly emerged as a nosocomial pathogen in healthcare settings, associated with high patient morbidity and mortality. The objective of this study was to compare clinical features, risk factors, treatment outcome, and antibiotic resistance in patients with pneumonia- and non-pneumonia-related AB bacteremia. METHODS We conducted a retrospective study in a tertiary teaching hospital in northern Taiwan. The medical records of the 141 episodes of hospital-acquired AB bacteremia between July 1, 2006 and June 30, 2012 were reviewed, and sorted into groups of AB bacteremia with (n = 59) and without pneumonia (n = 82). RESULTS The hospital-acquired pneumonia-related AB bacteremia group were found to be significantly more frequently treated in intensive care units (49.2%, p < 0.001), but the AB bacteremia without pneumonia group were significantly more frequently treated on general wards (85.4%, p < 0.001). Patients with pneumonia tended to be older than the nonpneumonia group (72.8 years vs. 65.2 years in mean age, p < 0.01), and more likely to use mechanical ventilators (62.7% vs. 15.9 %, p < 0.001). Pneumonia patients were found to receive broad-spectrum antibiotics significantly earlier than nonpneumonia patients (p < 0.001). Compared to those without pneumonia, the patients with pneumonia had significantly higher incidence of antibiotic-resistance (p < 0.05), longer hospital stay (p < 0.01), and higher mortality rate (p < 0.001). The incidence of multidrug-resistant AB was significantly higher in patients with pneumonia (p < 0.05), and only colistin (p < 0.01) and tigecycline (p < 0.01) were significantly active against multidrug-resistant AB isolates. CONCLUSION Pneumonia-related AB bacteremia has a worse outcome, more antibiotic resistance, and more comorbidity than the nonpneumonia group.

Caspofungin salvage therapy in Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii pneumonia (PJP) is a severe complication and leading cause of death among human immunodeficiency virus (HIV)-infected patients. Although trimethoprim/sulfamethoxazole (TMP/SMZ) is well known for its effectiveness as empiric and target therapy, it is also associated with various side effects (including skin rash, leukopenia, hepatitis, and diarrhea). The clinical evidence of the synergistic activity of caspofungin to TMP/SMZ or salvage treatment of PJP remains controversial to date. Here, we report an HIV-infected patient complicated with PJP who had skin rash and leukopenia after TMP/SMZ treatment for 6 days. Consequently, the treatment regimen was replaced with caspofungin. The patient was discharged from the hospital in good condition after 14 days of caspofungin salvage therapy. A 46-year-old male patient was admitted to the hospital for high fever and dyspnea, representing a fresh case of HIV infection with very low CD4 count (36/mL). His chest radiograph showed bilateral interstitial infiltration of lung fields (Figure 1A), and the computed tomography scan revealed bilateral diffuse ground-glass infiltrates (Figure 1B). A bronchoalveolar lavage specimen analyzed by Gomori methenamine silver staining revealed a cluster of P. jirovecii cysts. The patient was initially administered with TMP/SMZ (160/800 mg, q6h) intravenously. He received oral prednisolone (30 mg daily) as adjunctive therapy for PJP. The patient’s white blood cell count decreased from 5700/ mL to 3200/mL, and skin rash developed on the 7 admission day. The TMP/SMZ treatment was discontinued, and caspofungin was administered at a loading dose of 70 mg intravenously and a maintenance dosage of 50 mg daily. The patient received caspofungin therapy for a total of 14 days, and the subsequent chest X-ray (Figure 1C) demonstrated a significant improvement. The patient received HAART (highly active antiretrovirus therapy) regimen with combivir (lamivudine/zidovudine) þ stocrit (efavirenz) at the time of caspofungin therapy. His CD4 count recovered

Breakthrough disseminated cryptococcosis during micafungin therapy

Echinocandins are not active against basidiomycetous yeasts, such as Cryptococcus neoformans, Trichosporon, and Rhodotorula species, and zygomycosis. We present a patient with renal failure and candidemia, who developed a breakthrough fungal infection with cryptococcemia and cryptococcuria while receiving micafungin therapy.

Lemierre syndrome with cervical spondylodiscitis and epidural abscess associated with direct injection of heroin into the jugular vein

Pseudomonas aeruginosa infections rarely occur in intravenous drug users with Lemierre syndrome. We report here the case of a patient, an intravenous drug user with a history of injecting heroin directly into the jugular vein, with thrombophlebitis, P. aeruginosa bacteremia, metastatic cervical spondylodiscitis, and an epidural abscess. The patient’s condition was initially complicated by moderate quadriplegia, hyperreflexia, and hypothesia below the C5 dermatome. He recovered well after surgical debridement, treatment with antibiotic drugs, and rehabilitation. The 64-year-old male heroin addict was admitted to hospital with a history of moderate paralysis of all four limbs and fever for 1 week. His initial route of heroin administration had been inhalation, but he had changed to intravenous injection 1 year previously. Six months previously he began to inject heroin directly through the neck vessels to obtain stronger and faster euphoria. He reported neck and shoulder pain with numbness 1 month later. He was conscious on admission and, on neurological examination, had hypothesia below the C5 dermatome. He had Grade 3 (3/5) muscle power in all four extremities. Examination of his skin showed multiple needle injection wounds, local redness, tenderness, and mild swelling of his right neck. He also had a fever and leukocytosis. Magnetic resonance imaging showed spondylodiscitis, an epidural abscess with spinal cord compression at the C5eC6 level, and moderate thrombosis of the jugular vein in his right neck (Fig. 1). He received surgical decompression and combination treatment with antibiotics: ciprofloxacin 400 mg intravenously every 12 hours and amikacin 375 mg

Pulmonary empyema caused by co-infections of Mycoplasma pneumoniae and Fusobacterium necrophorum: A rare case of lemierre syndrome

Lemierre syndrome, also known as post-anginal septicemia or necrobacillosis, It is characterized by bacteremia, internal jugular vein (IJT) thrombosis, and metastatic septic emboli secondary to acute pharyngeal infections. The disease is easily forgotten by modern physicians. The causative agents of Lemierre syndrome include anaerobic bacteria, Streptococcus, Staphylococcus, and Klebsiella pneumoniae. Here, we reported a rare case of Lemierre syndrome in a patient with acute pharyngitis, who was complicated by bilateral otitis media and pulmonary empyema caused by co-infections of Mycoplasma pneumoniae and Fusobacterium necrophorum. The patient was proved by imaged study and successfully treated by chest tube drainage and antibiotic combination therapy. A 19-year-old male patient was admitted to our hospital with a 3-day history of fever, sore throat and dyspnea. On admission, consciousness was clear and his temperature was 39.2 C. Physical examination showed redness, swelling of pharyngeal mucosa. White blood cell count (WBC) was 32020/mm with 89% neutrophils. Serum level of C-reactive protein was 36.2 mg/dL, GOT 65 U/L, GPT 123 U/L, LDH 423 U/L. The rapid test of influenza A & B showed negative finding. Initially, he received amoxicillin/clavulanate 1000 mg/200 mg intravenously q 6 h as empiric therapy. But on the admission Day 2, the fever persisted and bilateral ear canal had purulent discharge. On the admission Day 3, the chest X-ray and CT scan showed infiltration of right lower lobe of lung with pleural effusion (Fig. 1A and B) and left internal jugular vein thrombosis (Fig. 1C). The patient received thoracocentesis and the pleural fluid analysis showed exudate and turbid color, which revealed WBC count 760/mm with 97% neutrophils, LDH 2107 U/L, total protein 5.4 g/dL (serum 6.4 g/dL), glucose 10 mg/dL (serum