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In Taiwan, injecting drug use has been the main route of human immunodeficiency virus (HIV) transmission since 2005, with hepatitis B virus (HBV) and hepatitis D virus (HDV) also having similar transmission routes. This has now become an important public health issue. The aim of this study is to explore the conditions of HDV infections between injecting drug users (IDUs) with and without HIV infection in Southern Taiwan. In this study, 87 IDUs were enrolled, including 27 anti-HDV seronegative IDUs and 60 anti-HDV seropositive IDUs, and the results of their liver function tests, CD4 cell counts, and anti-HIV and HIV RNA levels were analyzed. The prevalence of anti-HDV seropositivity among hepatitis B surface antigen (HBsAg) seropositive IDUs in this study was 68.9% (60/87). The prevalence rate of anti-HDV seropositive IDUs among anti-HIV seronegative and anti-HIV seropositive cases was 40.0% (12/30) and 84.2% (48/57), respectively. Anti-HIV seropositivity was related to anti-HDV seropositivity (odds ratio = 9.34, 95% confidence interval = 2.67–31.59, p

In Taiwan, the number of new cases of human immunodeficiency virus (HIV) infection via drug injection has been increasing since 2003. Due to HIV and hepatitis B virus (HBV) having similar transmission routes, HBV and HIV infections among injecting drug users (IDUs) has become an important public health issue. The aim of this study was explore the prevalence of HBV infection among IDUs with and without HIV infection, and examine whether HIV infection is associated with HBV infection among IDUs in Southern Taiwan. We enrolled 566 IDUs, including 87 anti-HBV positive IDUs and 479 anti-HBV negative IDUs, and also analyzed the results of liver function tests, HBV DNA, anti-HIV, HIV RNA, and CD4 cell count. The results showed that the prevalence of HBV infection among IDUs was 15.4%. The prevalence of hepatitis B surface antigen (HBsAg) was higher among individuals born before 1985 (15.9% vs. 4.0%), but this was not significant. Anti-HIV seropositivity was related to HBsAg seropositivity [odds ratio (OR) = 2.47, 95% confidence interval = 1.26–4.82, p = 0.008). Anti-HCV and anti-HIV were risk factors for abnormal alanine aminotransferase (ALT; OR = 2.11, 95% confidence interval = 1.005–4.42, p = 0.048 and OR = 1.47, 95% confidence interval = 1.02–2.10, p = 0.04, respectively), and HBsAg was not a factor related to abnormal ALT. In conclusion, the prevalence of HBV infection was similar in the general population and in IDUs, and due to anti-HIV seropositivity being significantly related to HBsAg seropositivity, HBV infection among IDUs is still important. We suggest that for IDUs, HBsAg should be monitored closely.

Although previously rare, catheter-related bloodstream infection caused by rapidly growing mycobacteria is now increasingly encountered, especially among cancer patients who have catheters implanted for chemotherapy treatments. A 73-year-old female patient with acute myeloid leukemia (AML) had Mycobacterium abscessus bacteremia with manifestations of multiple skin nodules, pneumonia, and mediastinal lymphadenopathy 4 months after the implantation of a peripherally inserted central catheter (PICC) for the delivery of chemotherapy. The catheter-related M. abscessus bacteremia was confirmed by positive blood cultures of specimens drawn from a PICC line and a peripheral vein. She defervesced with the administration of meropenem, amikacin, levofloxacin, clarithromycin, and by the removal of PICC. Her fever subsided for 3 months with the disappearance of skin and lung lesions; however, she died of AML relapse. Bacteremia and skin infection caused by M. abscessus can be detected by culture and pathological examinations and should be considered in leukemia patients with a PICC. With appropriate laboratory diagnosis, M. abscessus bacteremia with disseminated infections can improve with catheter removal and combination antimicrobial therapy.

The emergence of antifungal resistance in Candida species has raised concern in recent years, especially resistance toward triazole. Several newer triazole antifungal agents have been introduced which have a broader spectrum for fungal infections, such as voriconazole. However, cross-resistance among triazoles is a major concern with regard to their clinical application. Antifungal susceptibility was performed using E-test for 166 clinical isolates (29 blood and 137 nonblood isolates) in 2003 and 2004. We applied pulsed-field gel electrophoresis for genotyping. Ninety isolates of C. albicans, 47 isolates of C. tropicalis, 27 isolates of C. glabrata, and two isolates of C. krusei were included. All isolates were susceptible to amphotericin B. Eleven (40.7%) of the 27 C. glabrata had intermediate resistance to caspofungin. Forty-seven (28.3%) of the 166 isolates were not susceptible to fluconazole, including two C. albicans, 16 C. tropicalis, 27 C. glabrata, and two C. krusei isolates. All except seven of the C. glabrata isolates were susceptible to voriconazole. All the triazole drugs had a positive correlation among their minimum inhibitory concentrations (MICs). Fluconazole MIC was a good predictor for susceptibility to voriconazole, as determined using a receiver operating characteristic curve. Furthermore, a high diversity of pulsotypes for the 27 clinical isolates of C. glabrata was observed. Previous fluconazole exposure within 3 months was associated with reduced triazole susceptibility for C. glabrata. We demonstrated a significant positive correlation of MIC values among the four tested triazole drugs. No amphotericin B and caspofungin resistant isolates were found in this study. The cross-resistance to triazole among C. glabrata isolates was associated with previous fluconazole exposure as opposed to clonal spreading. Selection pressure due to fluconazole use may play a major role in triazole cross-resistance.

Scrub typhus is widely distributed across the Asia-Pacific region, Taiwan included. The clinical manifestations and complications of scrub typhus vary and the illness ranges in severity from mild to fatal. The etiology of facial nerve palsy varies and infectious agents have been associated with this condition. Rickettsiae species have, however, rarely been reported as the causative agents. We report the case of a 49-year-old man who had fever, malaise, headache, oligouria and tea-colored urine. Bilateral pneumonitis, acute renal failure, acalculous cholecystitis and aseptic meningitis were diagnosed after a series of examinations. The patient recovered after doxycycline treatment but he developed bilateral facial palsy during the convalescent phase, which improved after the administration of a steroid. The diagnosis of infection with Orientia tsutsugamushi was confirmed by the Taiwan Center of Disease Control and the tests for Leptospira, Rickettsia typhi and Coxiella burnetii were all negative. This case indicates that scrub typhus needs to be included in the differential diagnoses of cases of bilateral and simultaneous facial nerve palsy, particularly in areas where the disease is endemic.

Extensively drug-resistant Acinetobacter baumannii (XDRAb) emerges as an important pathogen of health care–associated infections and outbreaks worldwide. During January and February 2006, there was a hospital-wide outbreak of XDRAb at a medical center in Taiwan. Without limiting the usage of carbapenems or the closure of any ward, this outbreak was effectively controlled. We investigated the molecular epidemiology and reported the infection control experiences. XDRAb is defined as A baumannii that is resistant to multiple antibiotics but susceptible to tigecycline and polymyxin B. During the outbreak, the clinical and environmental XDRAb isolates were collected and studied by antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and polymerase chain reaction for Verona integron-encoded metallo-beta-lactamases, imipenemases, and oxacillinases (OXA). Our measures to control the outbreak included private room isolation of patients until there were three successive negative cultures, reinforcement of contact precautions, daily environmental cleansing with room-dedicated cleaning tools and sodium hypochlorite, and careful auditing of adherence. During the outbreak, 32 clinical XDRAb isolates came from 13 patients who were hospitalized in four intensive care units and three wards. Most (7 of 13, 53.8%) cases were associated with a surgical intensive care unit. The results from pulsed-field gel electrophoresis study indicated that all isolates were of one genotype. All 32 isolates harbored ISAba1-blaOxA-51-like and blaOxA-72 genes. After this outbreak till August 2010, further incidences of XDRAb were sporadic cases of XDRAb with different clones and did not reach the level of outbreak. To our knowledge, this is the first reported hospital-wide outbreak caused by OXA-72 carbapenemase–producing A baumannii in the Asia-Pacific region, with successful and sustained control. Although the source or vehicle of the outbreak was not identified, our results suggest that a hospital-wide outbreak can be successfully managed with strict infection control measures, and that the limitation of the use of carbapenems and closure of wards may not be necessary.

Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3–4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c) levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: −2.5 ± 1.8% vs. −1.1 ± 1.7%, p < 0.01). The maximal HbA1c decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05). Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.

The genetic relationships among dengue virus serotype 2 (DEN-2) isolates from the Taiwan 2002 epidemic were studied by sequence analysis of the envelope (E) and nonstructural protein 1 (NS1) genes. A 0–0.4% divergence among 10 isolates revealed an epidemic strain in the outbreak. Phylogenetic study demonstrated that the 2002 Taiwan isolates were of the Cosmopolitan genotype, which is different from the Asian 1 and Asian 2 genotypes of Taiwan DEN-2 isolates from 1981 to 1998 and the American/Asian genotype of 2005 Taiwan isolates. Although grouping results from both E and NS1 gene sequence analyses were the same, the usage of the NS1 gene as a sequence analysis target has not been validated for the lower bootstrap support values of branches in the phylogenetic tree. Our result showing the same genotype changes in Taiwan and Philippines isolates suggests strain transfer of DEN-2 to nearby countries resulting in the same trend of genotype change.

Splenic abscesses caused by Burkholderia pseudomallei are rarely reported in Taiwan. Here we report a middle-aged man who presented with fever, chills, and general malaise for several days. Abdominal echo revealed isolated splenic abscesses and he received antibiotics treatment according to the initial blood culture result, Serratia marcescens. However, fever did not subside. Then he was referred to our hospital and meropenem was prescribed. Fever subsided 5 days after the beginning of meropenem administration. Repeated fine-needle aspiration of splenic abscesses drained out the pus, which was cultured as B. pseudomallei. He was finally diagnosed as a case of melioidosis based on microbiological evidence. Physicians must take melioidosis into consideration when splenic abscesses are encountered clinically.

A 33-year-old man had dengue hemorrhagic fever with initial presentation of fever, leukocytosis, and thrombocytopenia. The cause of the subsequent rapid decline in red cell counts without evidence of intravascular hemolysis or massive bleeding was confirmed as hemophagocytosis and dyserythropoiesis by bone marrow study. The patient recovered with supportive care and the bone marrow pattern was normal on repeated bone marrow study. To our knowledge, this is the first reported case of dengue virus-associated hemophagocytosis and dyserythropoiesis in Taiwan. Clinicians should consider that the occurrence of hemophagocytosis and dyserythropoiesis could be due to dengue virus infection. That this dengue virus infection was confirmed by a positive serology result at the convalescent stage but not at the acute symptomatic stage underlines the need for a second dengue serology study, as dengue infection can be missed due to an initial negative serology result.