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BACKGROUND Burkholderia cepacia complex (BCC) represents a group of multidrug-resistant gram-negative bacteria that cause infections among immunocompromised hosts. Bacteremia occurs in patients who are chronically ill and is associated with substantial morbidity and mortality. The aim of this study was to investigate the clinical characteristics and outcomes of BCC bacteremic patients without cystic fibrosis. METHODS We conducted a retrospective study at the National Taiwan University Hospital. Adults with BCC bacteremia from January 2015 to May 2019 were enrolled. The primary outcome was 14-day mortality. Multivariable logistic regression was performed for outcome analysis. RESULTS One-hundred and ninety-five patients were analyzed and their mean age was 67 years. Over 95% of the BCC isolates were susceptible to trimethoprim/sulfomethoxazole (TMP/SXT). Levofloxacin resistance rates were high, with only 25.1% of isolates being susceptible. Pairwise comparisons were made between different definitive regimens including meropenem-monotherapy, ceftazidime-monotherapy, levofloxacin-monotherapy, TMP/SXT-monotherapy, tigecycline-monotherapy as well as combination versus monotherapy. No regimen was significantly associated with survival in our study. Multivariable logistic regression showed that the Pitt bacteremia score (adjust odds ratio [aOR],1.46; 95% confidence interval [CI],1.19-1.79; p

Acinetobacter baumannii causes healthcare-associated infections worldwide. Capsular polysaccharide (CPS) is shown an important virulence factor of A. baumannii both in vitro and in vivo. Capsule locus 2 (KL2) for CPS is the most common KL type and is associated with carbapenem resistance. It is unclear whether KL2 is related to the clinical outcome of invasive A. baumannii infection. Here we had followed patients with A. baumannii bacteraemia prospectively between 2009 and 2014. One-third of the unduplicated blood isolates were randomly selected each year for microbiological and clinical studies. The KL2 gene cluster was identified using polymerase chain reaction. A total of 148 patients were enrolled randomly. Eighteen isolates (12.2%) carried KL2, and 130 isolates (87.8%) didn't. Compared with non-KL2 isolates, KL2 isolates had significantly higher resistance to imipenem, sulbactam, and tigecycline. Compared with the non-KL group, in the KL2 group, the hospital stay before development of bacteraemia was longer (P

Background/purpose Streptococcus pneumoniae causes pneumonia and other invasive diseases, and is a leading cause of mortality in the elderly population. The present study aimed to provide current antimicrobial resistance and epidemiological profiles of S. pneumoniae infections in Taiwan. Methods A total of 252 nonduplicate S. pneumoniae isolates were collected from patients admitted to 16 hospitals in Taiwan between January 2017 and December 2019, and were analyzed. The minimum inhibitory concentration of antibiotics was determined using the Vitek 2 automated system for antimicrobial susceptibility testing. Furthermore, epidemiological profiles of S. pneumoniae infections were analyzed. Results Among the strains analyzed, 88% were recognized as invasive pneumococcal strains. According to the Clinical and Laboratory Standards Institute criteria for non-meningitis, the prevalence of penicillin-non-susceptible S. pneumoniae demonstrated a declining trend from 43.6% in 2017 to 17.2% in 2019. However, the rate of penicillin-non-susceptible S. pneumoniae was 85.7% based on the criteria for meningitis. Furthermore, the prevalence of ceftriaxone-non-susceptible S. pneumoniae was 62.7% based on the criteria for meningitis. Isolates demonstrated higher susceptibility toward doripenem and ertapenem than toward meropenem and imipenem. An increased rate of non-susceptibility toward levofloxacin was observed in southern Taiwan (15.1%) and elderly patients (≥65 years; 11.4%). Most isolates were susceptible to vancomycin and linezolid. Conclusion Empirical treatment with ceftriaxone monotherapy for pneumococcal meningitis should be carefully monitored owing to its high non-susceptibility rate. The susceptibility rates of most isolates to penicillin (used for treating non-meningitis pneumococcal diseases), carbapenems (ertapenem and doripenem), respiratory quinolones (moxifloxacin and levofloxacin), vancomycin, and linezolid suggested the potential of these antibiotics in treating pneumococcal diseases in Taiwan.

Backgroud/purpose Bloodstream infections (BSI) are common in patients with major burns, but its effect on mortality remains controversial. This study was aimed to investigate if BSI is significant risk factor of mortality? Methods This is a retrospective chart review study included 266 adult patients admitted to our burn center from 2000 to 2019. Age, sex, inhalation injuries, total burn surface area (TBSA), duration of stay in intensive care unit, BSI and mortality were variables studied. Fisher exact test, Mann-Whitney test and logistic regression was used for statistical analysis. Results There were 234 survivors and 32 non-survivors. Male was predominant. The overall incidence of BSI was 18.8%, and the overall crude mortality was 12%. Burns ≥ 30% TBSA and BSI were significant risk factors. A predictive function based on 30% TBSA and BSI within 14 days after the onset of burns (BSI-14) was derived. The function has a sensitivity of 0.97, specificity of 0.42 and achieved a maximum Youden Index at functional value ≥ 0.05727. The mortality probability of BSI-14 in burns ≥ 30% TBSA was 40.8%. Conclusions BSI and burns ≥ 30% TBSA were significant risk factors of mortality. Early detection of BSI-14 is critical in burn care as its probability of mortality can be as high as 40% in patients ≥ 30% TBSA of burns. To reduce the risk of mortality, early in ventilator withdrawal, invasive lines and tubes removal, and early grafting should be emphasized besides infection control and appropriate use of antibiotics.

Background/Purpose: Multimorbidity is a worldwide issue when aging is rapidly. The aim of this study was to evaluate the impact of demography, morbidity, disability and depression on short-term and long-term mortality for multimorbid inpatients. Methods: The participants’ information were assessed upon recruitment. Multimorbidity and disability were measured by modified Charlson comorbidities Index (CCI) and Barthel Index for Activity of Daily Living (ADL), respectively. Depression was screened over one-item self-reported perceptions of depressed mood rated as yes or no. The factors of in-hospital mortality and periodic mortality after discharge were examined by Cox proportional hazard regression and Kaplan–Meier survival analyses. Results: A total of 201 inpatients from a hospitalist's ward were recruited. The in-hospital mortality was 14.4%, while 24-month mortality was 57.8%. After adjustment, severe ADL dependence (

Objectives The aim of this study was to investigate the trends in serotypes and in vitro antimicrobial susceptibility of Streptococcus pneumoniae causing adult invasive pneumococcal disease (IPD) to dalbavancin, telavancin, tedizolid, eravacycline, omadacycline and other comparator antibiotics from 2017–2020 following implementation of the 13-valent pneumococcal conjugate vaccine (PCV-13) and during the COVID-19 (coronavirus disease 2019) pandemic. Methods During the study period, 237 S. pneumoniae isolates were collected from non-duplicate patients, covering 15.0% of IPD cases in Taiwan. Antimicrobial susceptibility testing was performed using a Sensititre® system. A latex agglutination method (ImmuLex™ Pneumotest Kit) was used to determine serotypes. Results Susceptibility rates were high for vancomycin (100%), teicoplanin (100%) and linezolid (100%), followed by ceftaroline (non-meningitis) (98.3%), moxifloxacin (94.9%) and quinupristin/dalfopristin (89.9%). MIC50 and MIC90 values of dalbavancin, telavancin, tedizolid, eravacycline and omadacycline were generally low. Non-vaccine serotype 23A was the leading cause of IPD across the adult age range. Isolates of serotype 15B were slightly fewer than those of PCV-13 serotypes in patients aged ≥65 years. The overall case fatality rate was 15.2% (36/237) but was especially high for non-PCV-13 serotype 15B (21.4%; 3/14). Vaccine coverage was 44.7% for PCV-13 and 49.4% for the 23-valent pneumococcal polysaccharide vaccine (PPSV-23), but was 57% for both PCV-13 and PPSV-23. Conclusion The incidence of IPD was stationary after PCV-13 introduction and only dramatically decreased in the COVID-19 pandemic in 2020. The MIC50 and MIC90 values of dalbavancin, telavancin, tedizolid, eravacycline, omadacycline were generally low for S. pneumoniae causing adult IPD.

Early recognition of adult-onset immunodeficiency associated with neutralizing anti-interferon gamma autoantibodies (anti-IFNγ Abs) remains difficult, and misdiagnoses have been reported. Although febrile lymphadenopathy is among the most common initial manifestations of this disorder, no comprehensive clinicopathologic analysis of lymphadenopathy in patients with anti-IFNγ Abs has been reported. Here, we describe 26 lymph node biopsy specimens from 16 patients. All patients exhibited concurrent disseminated nontuberculous mycobacterial infections, and 31% received a tentative diagnosis of lymphoma at initial presentation. We found 3 distinct histomorphologic patterns: well-formed granuloma (46%), suppurative inflammation or loose histiocytic aggregates (31%), and lymphoproliferative disorder (LPD, 23%). The latter shared some of the features of malignant T-cell lymphoma, IgG4-related disease, and multicentric Castleman disease. Half of the specimens with LPD had monoclonal T cells, and 33.3% were indistinguishable from angioimmunoblastic T-cell lymphoma as per current diagnostic criteria. All lymphadenopathy with LPD features regressed with antibiotics without administration of cytotoxic chemotherapy or immunotherapy. The median follow-up time was 4.3 years. Our study highlights the substantial challenge of distinguishing between lymphoma and other benign lymphadenopathy in the setting of neutralizing anti-IFNγ Abs. Increased vigilance and multidisciplinary discussion among clinicians and pathologists are required to achieve the most appropriate diagnosis and management.

Background/Purpose Vancomycin-resistant Enterococcus (VRE), a multidrug-resistant, difficult-to-treat pathogen of healthcare-associated infections (HAIs), is now endemic at many intensive care units (ICUs). Chlorhexidine (CHG) bathing is a simple and highly effective intervention to decrease VRE acquisition, but its effect on VRE-HAIs has not been assessed in prospective studies at ICUs. Methods This is a cluster quasi-experimental controlled study. Under active VRE surveillance and contact isolation of all identified VRE carriers, four ICUs were assigned to provide 2% CHG bathing for all patients on a daily basis (CHG group) during the intervention period, while another four ICUs were assigned to provide standard care without CHG bathing for all patients (standard care group) during the same period. Results The CHG group (n = 1501) had a 62% lower crude incidence of VRE-HAIs during the intervention period, compared with the baseline period (1.0 vs. 2.6 per thousand patient-days, P = 0.009), while VRE-HAIs incidence did not change in standard care group (n = 3299) (1.1 vs. 0.5 per thousand patient-days, P = 0.139). In multivariable analyses, CHG bathing was independently associated with a 70% lower risk of VRE-HAIs (adjusted odds ratio [OR] 0.3, 95% confidence interval [CI], 0.2 to 0.7, P = 0.006). In contrast, standard care during the same period had no effect on the risk of VRE-HAIs (adjusted OR 1.8, 95% CI: 0.7 to 4.7, P = 0.259). Conclusion CHG bathing is a highly effective approach to prevent VRE-HAIs at ICUs, in the context of active VRE surveillance with contact isolation.

Background/Purpose: To investigate the characteristics of dysosmia and dysgeusia among patients diagnosed with coronavirus disease 2019 (COVID-19) in Taiwan. Methods: Prospective data collection between January 22, 2020 to May 7, 2020 of nucleic acid confirmed COVID-19 hospitalized patients in northern Taiwan by the Taiwan Centers for Disease Control were analyzed. Results: Of 217 patients enrolled, 78 (35.9%) reported dysosmia (n = 73, 33.6%) and/or dysgeusia (n = 62, 28.6%). The median duration of COVID-19 associated symptom-onset to development of dysosmia and/or dysgeusia was

Background Development of gastrointestinal (GI) complications is adversely associated with prognosis in the critically ill. However, little is known about their impact on the outcome of non-critically ill patients. In this study, we aimed to investigate the incidence of GI complications and their influence on prognosis of hospitalized pneumonia patients. Methods Adult patients admitted with a diagnosis of pneumonia from 2012 to 2014 were included. Medical records were reviewed to obtain patients’ demographics, physical signs, comorbidities, laboratory results, clinical events, and the Confusion, Urea, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score was calculated to assess the severity of pneumonia. GI complications, including bowel distension, diarrhea, GI bleeding and ileus, were evaluated during the first 3 days of hospitalization and their association with patient outcomes, such as hospital mortality and length of stay, was analyzed. Results A total of 1001 patients were enrolled, with a mean age of 73.7 years and 598 (59%) male. Among them, 114 (11%) patients experienced at least one GI complication and diarrhea (5.2%) was the most common. The hospital mortality was 14% and was independently associated with an increase in the CURB-65 score (odds ratio [OR] 1.952 per point increase; 95% confidence interval [CI] 1.516–2.514), comorbid malignancy (OR 1.943; 95% CI 1.209–3.123), development of septic shock (OR 25.896; 95% CI 8.970–74.765), and the presence of any GI complication (OR 1.753; 95% CI 1.003–3.065). Conclusions Compared to a critical care setting, GI complications are not commonly observed in a non-critical care setting; however, they still have a negative impact on prognosis of pneumonia patients, including higher mortality and prolonged length of hospital stay.

Objectives Influenza remains a crucial transmissible disease from community. We aim to identify risk factors associated with mortality among hospitalized patients with severe influenza. Methods We retrospectively reviewed medical records of adult patients with laboratory-confirmed severe influenza at a medical center between January 2016 and December 2018. The primary outcome was 30-day all-cause mortality. Results Totally 96 patients were enrolled, with 73 patients in the influenza A group and 23 in the influenza B group. Eighteen (18.8%) deaths occurred within 30 days of hospitalization, including 8 (11%) and 10 (43.5%) of each group. In multivariable Cox regression analysis, factors associated with mortality were underlying diseases of liver cirrhosis (adjusted hazard ratio [AHR], 3.94; 95% CI, 1.07–14.45) and rheumatologic diseases (AHR, 7.45; 95% CI, 2.34–23.69) and the diagnosis of influenza B (AHR, 4.33; 95% CI, 1.68–11.13). Conclusions Clinician should early identify high-risk population and warning signs of severe influenza. Our results support the policy of quadrivalent influenza vaccination because influenza B could be associated with high mortality.

Background/purpose: This study was aimed to investigate clinical characteristics and treatment outcomes of pulmonary invasive fungal infection (IFI) among patients with hematological malignancy. Methods: All patients with hematological malignancy who were treated at a medical centre from 2008 to 2013 were evaluated. Pulmonary IFI was classified according to the European Organization for Research and Treatment of Cancer 2008 consensus. Results: During the study period, 236 (11.3%) of 2083 patients with hematological malignancy were diagnosed as pulmonary IFI, including 41 (17.4%) proven, 75 (31.8%) probable, and 120 (50.8%) possible cases. Among the 116 patients of proven and probable cases of pulmonary IFI, aspergillosis alone (n = 90, 77.6%) was predominant, followed by cryptococcosis alone (n = 9, 7.8%), and mucormycosis (n = 4, 3.4%). The overall incidence of patients with pulmonary IFI was 5.9 per 100 patient-years. The highest incidence (per 100 patient-year) was found in patients with acute myeloid leukaemia (13.7) followed by acute lymphoblastic leukaemia (11.3), and myelodysplastic syndrome/severe aplastic anaemia (6.7). Fourteen (5.9%) of the 236 patients with pulmonary IFI died within 12 weeks after diagnosis of pulmonary IFI. Univariate analysis revealed that elderly age (>65 years) (P = 0.034), lack of response to anti-fungal treatment (P

Background Inadequate hospital cleaning may contribute to cross-transmission of pathogens. It is important to implement effective cleaning for the safe hospital environment. We conducted a three-phase study using human factors engineering (HFE) approach to enhance environmental cleanliness. Methods This study was conducted using a prospective interventional trial, and 28 (33.3%) of 84 wards in a medical center were sampled. The three-phases included pre-intervention analysis (Phase 1), implementing interventions by HFE principles (Phase 2), and programmatic analysis (Phase 3). The evaluations of terminal cleaning and disinfection were performed using the fluorescent marker, the adenosine triphosphate bioluminescence assay, and the aerobic colony count method simultaneously in all phases. Effective terminal cleaning and disinfection was qualified with the aggregate outcome of the same 10 high-touch surfaces per room. A score for each high-touch surface was recorded, with 0 denoting a fail and 10 denoting a pass by the benchmark of the evaluation method, and the total terminal cleaning and disinfection score (TCD score) was a score out of 100. Results In each phase, 840 high-touch surfaces were collected from 84 rooms after terminal cleaning and disinfection. After the interventions, the TCD score by the three evaluation methods all showed significant improved. The carriage incidence of multidrug-resistant organism (MDRO) decreased significantly from 4.1 per 1000 patient-days to 3.6 per 1000 patient-days (P = .03). Conclusion The HFE approach can improve the thoroughness and the effectiveness of terminal cleaning and disinfection, and resulted in a reduction of patient carriage of MDRO at hospitals. Larger studies are necessary to establish whether such efforts of cleanliness can reduce the incidence of healthcare-associated infection.

Background: Sepsis remains a common but fatal complication among patients with immune suppression. We aimed to investigate the performance of metagenomic next-generation sequencing (mNGS) compared with standard microbiological diagnostics in patients with hematologic malignancies. Methods: We performed a prospective study from June 2019 to December 2019. Adult patients with hematologic malignancies and a clinical diagnosis of sepsis were enrolled. Conventional diagnostic methods included blood cultures, serum galactomannan for Aspergillus, cryptococcal antigen and cytomegalovirus (CMV) viral loads. Blood samples for mNGS were collected within 24 h after hypotension developed. Results: Of 24 patients enrolled, mNGS and conventional diagnostic methods (blood cultures, serology testing and virus RT-PCR) reached comparable positive results in 9 cases. Of ten patients, mNGS was able to identify additional pathogens compared with conventional methods, most of the pathogens were virus. Conclusion: Our results show that mNGS may serve as adjunctive diagnostic tool for the identification of pathogens of hematologic patients with clinically sepsis.

Background Neutralizing anti–granulocyte-macrophage colony-stimulating factor (GM-CSF) autoantibodies (AAbs) have been increasingly recognized to predispose healthy individuals to disseminated cryptococcosis. However, studies have only considered patients with central nervous system (CNS) infection. No longitudinal study has captured the disease spectrum and clinical course. Methods We prospectively enrolled adults without human immunodeficiency virus infection who had disseminated or unusual cryptococcosis. We compared the demographics, clinical features, kinetics of serum cryptococcal antigen (CrAg) titers, anti–GM-CSF AAb concentrations, and treatment outcomes between patients with (case patients) and without (control patients) anti–GM-CSF AAbs. Additional reports from the literature were also reviewed. Results Twenty-three patients were enrolled, of whom 6 tested positive for anti–GM-CSF AAbs. All case patients with positive fungal cultures (5/5 [100%]) were infected with Cryptococcus gattii VGII. Among them, 3 had exclusively pulmonary involvement, and 1 had only musculoskeletal lesions. Patients with CNS cryptococcosis exhibited a higher serum concentration of anti–GM-CSF AAbs than those with extraneural cryptococcosis. Case patients had higher initial and peak levels of serum CrAg and longer duration of antigenemia compared with the control patients. All case patients who had completed antifungal therapy had favorable outcomes without recurrence. Conclusions Testing for anti–GM-CSF AAbs should be considered for not only previously healthy patients with disseminated cryptococcosis but also those with unexplained, localized cryptococcosis. Recurrence after completion of antifungal therapy was rare despite the persistence of anti–GM-CSF AAbs.

Background: Doripenem shows good in vitro activity against common nosocomial pathogens, such as extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii. However, the use of doripenem for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remains controversial. The aim of this study was to compare the efficacy and safety between doripenem and meropenem for patients with HAP or VAP. Methods: Adult patients diagnosed with HAP and VAP at National Taiwan University Hospital, who received doripenem or meropenem for more than 48 h between January 2015 and November 2017, were retrospectively reviewed. All-cause mortality on the 30th day was used as the primary outcome measurements. Results: Fifty-seven patients with doripenem and 252 patients with meropenem were analyzed. Compared to the meropenem group, the doripenem group was younger and had a higher Sequential Organ Failure Assessment (SOFA) score. Multivariable Cox regression analysis revealed that presence of solid organ malignancies (adjusted hazard ratio [AHR], 1.82; 95% CI, 1.04–3.19, p = 0.003) and SOFA score (AHR, 1.10; 95% CI, 1.03–1.17, p = 0.003) were independent factors associated with mortality. There was no survival difference of 30-day mortality between patients receiving doripenem and meropenem for HAP or VAP (log-rank p = 0.113). However, a poorer outcome was observed among patients with hematological disease in the doripenem group (log-rank p = 0.012). Conclusion: Our results demonstrate that doripenem has similar efficacy as meropenem in HAP or VAP patients. With an aim to enhance antibiotic diversity, doripenem could be an alternative choice for patients with HAP or VAP, except for those with hematological malignancies. Keywords: Doripenem, Hospital-associated pneumonia, Meropenem, Ventilator-associated pneumonia

Background Chlorhexidine (CHG) bathing decreases the incidence of bloodstream infections in intensive care units, but its effect has been understudied in patients with hematological malignancies in noncritical care units. Methods Adults with hematological malignancies hospitalized for cytotoxic chemotherapy in noncritical care units were offered daily 2% CHG bathing. We compared outcomes of patients who chose CHG bathing (CHG group) with outcomes of those who did not choose CHG bathing (usual-care group). The primary outcome was gram-positive cocci–related, skin flora–related, or central line–associated bloodstream infection. The negative control outcome was gut-origin bacteremia. Results The CHG group (n = 485) had a crude incidence rate of the primary outcome that was 60% lower than the rate for the usual-care group (n = 408; 3.4 vs 8.4 per 1000 patient-days, P = .02) but had a similar crude incidence rate of the negative control outcome (4.5 vs 3.2 per 1000 patient-days; P = .10). In multivariable analyses, CHG bathing was associated with a 60% decrease in the primary outcome (adjusted hazard ratio [HR], 0.4; P < .001). In contrast, CHG bathing had no effect on the negative control outcome (adjusted HR, 1.1; P = .781). CHG bathing was well tolerated by participants in the CHG group. Conclusions CHG bathing could be a highly effective approach for preventing gram-positive cocci–related, skin flora–related, or central line–associated bacteremia in patients with hematological malignancies who are hospitalized for cytotoxic chemotherapy in noncritical care units.

Background: Cardiovascular disease (CVD) is an emerging cause of morbidity and mortality among HIV-positive patients receiving successful combination antiretroviral therapy, but their CVD risk has been rarely investigated in Asia–Pacific region. We aimed to assess the CVD risk of HIV-positive Taiwanese outpatients. Methods: We did cross-sectional questionnaire interviews to collect information of HIV-positive Taiwanese patients aged 40–79 at the HIV clinics of a medical center from 1 March to 31 August, 2017. The Framingham Risk Score (FRS), Atherosclerotic Cardiovascular Disease (ASCVD) risk score and Data-Collection on Adverse effects of Anti-HIV Drugs (D:A:D) risk score were used to estimate their CVD risk. Results: Of the screened 1251 patients, 1006 (80.4%) with complete data to assess their CVD risk were included for analyses. The prevalence of patients aged 40–75 and with a high CVD risk was 30.6% by FRS, 3.7% by D:A:D (R) risk score, and 22.2% by ASCVD risk score. In multiple logistic regression, older age, current smoking, higher systolic blood pressure, and higher triglyceride and fasting glucose levels were independently associated with the ASCVD risk score ≥7.5%. If current smokers aged 55–59 had stopped smoking, the proportions of them with a 10-year CVD risk of ≥10% by FRS and ≥7.5% by ASCVD risk score would have decreased by 35.3% and 20.0%, respectively. Conclusions: Higher CVD risk estimates among HIV-positive Taiwanese aged 40–75 were associated with an older age, current smoking, higher systolic blood pressure, hypertriglyceridemia, and hyperglycemia. Smoking cessation could potentially lead to significant decreases of CVD risk. Keywords: Comorbidity, Framingham equation, Atherosclerotic cardiovascular disease (ASCVD), Data-collection on adverse effects of anti-HIV drugs (D:A:D), Antiretroviral therapy

Background/purpose: Legionella pneumophila had been recognized as an important pathogen for community-acquired pneumonia. We aimed to investigate clinical features and outcomes of patients with Legionnaires' disease at a tertiary medical center in northern Taiwan. Methods: From June 2012 to February 2017, a retrospective review of adult community-acquired. Legionnaires' disease at a medical center was conducted. All Legionella infections were confirmed by positive urinary Legionella antigen assay, sera indirect immunofluorescence assay, or sputum culture for Legionella. Literature review of Legionnaires' disease from Medline and PubMED websites was performed. Results: A total of 32 cases of Legionnaires' disease were identified. Their mean age was 64.3 years, with male predominance (27 cases, 84.3%). The underlying diseases were varied and most were attributed to chronic disorders, such as diabetes mellitus (31%) and cigarette smoking (40.6%). The most common symptoms were cough (68%) and fever (59.3%). More than half of patients (18, 56.2%) with Legionnaires' disease could initially present with extrapulmonary manifestations. Sixteen (50%) patients had delay in initiation of appropriate antibiotic therapy. Patients without adequately initiation of appropriate antibiotic therapy had higher proportion (11 of 16, 68.7%) of intensive care unit admission than patients with adequate initiation (5 of 16, 31.2%). Our results inferred that a delay in treatment might result in worsening of disease severity and the need for more intensive management. Overall mortality rate was 21.8%. Development of vasopressor requirement is an independent risk factor associated with mortality. Conclusion: Legionnaires' disease in Taiwan frequently present with extrapulmonary manifestations. Patients with hemodynamic instability that need vasopressor therapy associated with mortality. Keywords: Legionnaires' disease, Macrolide, Fluoroquinolone, Community-acquired pneumonia

Acinetobacter baumannii (Ab) is an important cause of healthcare-associated infections. Multilocus sequence typing (MLST) provides a highly discriminative typing method. We aimed to determine the clinical impact of Ab sequence types (ST) in patients with bloodstream infection (BSI).Patients with Ab-BSI were followed prospectively from 2009 to 2014. We randomly selected one-third of non-duplicate bacteremic isolates for MLST and correlated the Ab ST with the clinical course. The primary outcome was all-cause in-hospital mortality.We enrolled 148 patients. Seventy-seven (52.0%) of the isolates were ST2. Patients with ST2-BSI were less likely to be treated with appropriate empirical antimicrobial agents (31.1% vs. 60.6%; P 0.001). They had greater mortality (66.2% vs. 40.8%; P = 0.003) than patients with non-ST2-BSI. In the multivariable analysis, ST2 independently predicted greater severity of infection (Pitt bacteremia score) (adjusted odds ratio (aOR), 3.38; 95% confidence interval (CI), 1.75-6.54; P 0.001). Mediated by a higher Pitt bacteremia score (Sobel test P 0.001), ST2 is an independent prognostic factor that predict mortality (aOR, 2.34; 95% CI, 1.07-5.11; P = 0.03).ST2 was associated with high rates of inappropriate antimicrobial therapy, severe infection and mortality. Further studies are needed to confirm our findings and explore the potential of role of the virulence.

Until now, there are no approved treatment against COVID-19. Hydroxychloroquine (HCQ) was hypothesized to be active against SARS-CoV2 via antiviral and anti-inflammatory effect; however, HCQ for COVID-19 in clinical use remained debating. In this preliminary report, we presented six patients with mild to moderate COVID-19. They were treated with HCQ for 14 days from the day of COVID-19 diagnosis. Serial viral load from respiratory specimens were performed every other day. Cytokine profile was checked before HCQ initiation and on the 14th day of HCQ treatment. All patients receiving HCQ completed 14-day course without complication. Among the six patients, the mean duration from symptom onset to last detectable viral load was 34 ± 12 days, which was similar to those without specific treatment in previous reports. Low level of interferon-gamma was noted in all patients of different stage of infection and three patients had elevation of IL-17 level. Prolonged virus shedding is still observed regardless HCQ. The impact of HCQ on cytokine kinetics remained unclear; however, IL-17 could be an inflammatory marker for disease status monitor and a potential therapeutic target.

ObjectivesTo set up a prediction model for the 7-day in-hospital mortality of patients admitted from the emergency department (ED) because it is high but no appropriate initial alarm score is available.DesignThis is a prospective cohort study for prediction model development.SettingIn a tertiary referred hospital in northern Taiwan.ParticipantsED-admitted medical patients in hospitalist care wards were enrolled during May 2010 to October 2016. Two-thirds of them were randomly assigned to a derivation cohort for development of the model and cross-validation was performed in the validation cohort.Primary outcome measured7-day in-hospital mortality.ResultsDuring the study period, 8649 patients were enrolled for analysis. The mean age was 71.05 years, and 51.91% were male. The most common admission diagnoses were pneumonia (36%) and urinary tract infection (20.05%). In the derivation cohort, multivariable Cox proportional hazard regression revealed that a low Barthel Index Score, triage level 1 at the ED, presence of cancer, metastasis and admission diagnoses of pneumonia and sepsis were independently associated with 7 days in-hospital mortality. Based on the probability developed from the multivariable model, the area under the receiver operating characteristic curve in the derivation group was 0.81 (0.79–0.85). The result in the validation cohort was comparable. The prediction score modified by the six independent factors had high sensitivity of 88.03% and a negative predictive value of 99.51% for a cut-off value of 4, whereas the specificity and positive predictive value were 89.61% and 10.55%, respectively, when the cut-off value was a score of 6.ConclusionThe 7-day in-hospital mortality in the hospitalist care ward is 2.8%. The initial alarm score could help clinicians to prioritise or exclude patients who need urgent and intensive care.

Between March and October, 2018, 1248 people living with HIV completed questionnaire interviews for cancer screening, of whom 46.9% (n = 585) completed free-of-charge cancer screening. Time constraint (50.1%) was the most common reason provided for refusal to participate in cancer screening. None of the participants were diagnosed with any of the four cancers.

The coronavirus disease of 2019 (COVID-19) has caused a global pandemic and led to nearly three million deaths globally. As of April 2021, there are still many countries that do not have COVID-19 vaccines. Before the COVID-19 vaccines were developed, some evidence suggested that an influenza vaccine may stimulate nonspecific immune responses that reduce the risk of COVID-19 infection or the severity of COVID-19 illness after infection. This study evaluated the association between influenza vaccination and the risk of COVID-19 infection. We conducted a retrospective cross-sectional study with data from July 1, 2019, to June 30, 2020 with the Claims data from Symphony Health database. The study population was adults age 65 years old or older who received influenza vaccination between September 1 and December 31 of 2019. The main outcomes and measures were odds of COVID-19 infection and severe COVID-19 illness after January 15, 2020. We found the adjusted odds ratio (aOR) of COVID-19 infection risk between the influenza-vaccination group and no-influenza-vaccination group was 0.76 (95% confidence interval (CI), 0.75–0.77). Among COVID-19 patients, the aOR of developing severe COVID-19 illness was 0.72 (95% CI, 0.68–0.76) between the influenza-vaccination group and the no-influenza-vaccination group. When the influenza-vaccination group and the other-vaccination group were compared, the aOR of COVID-19 infection was 0.95 (95% CI, 0.93–0.97), and the aOR of developing a severe COVID-19 illness was 0.95 (95% CI, 0.80–1.13). The influenza vaccine may marginally protect people from COVID-19 infection.

Background Endotoxins can induce an excessive inflammatory response and result in microcirculatory dysfunction. Polymyxin-B hemoperfusion (PMX-HP) has been recognized to effectively remove endotoxins in patients with sepsis and septic shock, and a rat sepsis model revealed that PMX-HP treatment can maintain a better microcirculation. The primary aim of this study was to investigate the effect of PMX-HP on microcirculation in patients with septic shock. Methods Patients with septic shock were enrolled and randomized to control and PMX-HP groups. In the PMX-HP group, patients received the first session of PMX-HP in addition to conventional septic shock management within 24 h after the onset of septic shock; the second session of PMX-HP was provided after another 24 h as needed. Results Overall, 28 patients finished the trial and were analyzed. The mean arterial pressure and norepinephrine infusion dose did not differ significantly between the control and PMX-HP groups after PMX-HP treatment. At 48 h after enrollment, total vessel density (TVD) and perfused vessel density (PVD) were higher in the PMX-HP group than in the control group [TVD 24.2 (22.1–24.9) vs. 21.1 (19.9–22.9) mm/mm2; p = 0.007; PVD 22.9 (20.9–24.9) vs. 20.0 (18.9–21.6) mm/mm2, p = 0.008]. Conclusions This preliminary study observed that PMX-HP treatment improved microcirculation but not clinical outcomes in patients with septic shock at a low risk of mortality. Nevertheless, larger multicenter trials are needed to confirm the effect of PMX-HP treatment on microcirculation in patients with septic shock at intermediate- and high-risk of mortality. Trial registration ClinicalTrials.gov protocol registration ID: NCT01756755. Date of registration: December 27, 2012. First enrollment: October 6, 2013. https://clinicaltrials.gov/ct2/show/NCT01756755

Background: The in-hospital mortality of patients admitted from the emergency department (ED) is high, but no appropriate initial alarm score is available. Methods: This prospective observational study enrolled ED-admitted patients in hospitalist-care wards and analyzed the predictors for seven-day in-hospital mortality from May 2010 to October 2016. Two-thirds were randomly assigned to a derivation cohort for development of the model and cross-validation was performed in the validation cohort. Results: During the study period, 8,649 patients were enrolled for analysis. The mean age was 71.05 years, and 51.91% were male. The most common admission diagnoses were pneumonia (36%) and urinary tract infection (20.05%). In the derivation cohort, multivariable Cox proportional hazard regression revealed that a low Barthel index score, triage level 1 at the ED, presence of cancer, metastasis, and admission diagnoses of pneumonia and sepsis were independently associated with seven-day in-hospital mortality. Based on the probability developed from the multivariable model, the area under the receiver operating characteristic curve in the derivation group was 0.81 [0.79–0.85]. The result in the validation cohort was comparable. The prediction score modified by the six independent factors had high sensitivity of 88.03% and a negative predictive value of 99.51% for a cutoff value of 4, whereas the specificity and positive predictive value were 89.61% and 10.55%, respectively, when the cutoff value was a score of 6. Conclusion: The seven-day in-hospital mortality in a hospitalist-care ward is 2.8%. The initial alarm score could help clinicians to prioritize or exclude patients who need urgent and intensive care.

Background: Suppression of intestinal flora by broad-spectrum antimicrobial agents facilitated risk of colonization or infection with resistant pathogen. We aimed to investigate the changes in bowel carriage of target resistant microorganisms (TRO) among patients treated with three different classes of Pseudomonas-sparing broad-spectrum antimicrobial agents (ertapenem, moxifloxacin and flomoxef) with anaerobic coverage. Risk factors for developing colonization of TRO were also analyzed. Methods: We prospectively enrolled the adult hospitalized patients (>20 years old) who were indicated for at least 7-day course with either of ertapenem, moxifloxacin or flomoxef. Rectal swabs were performed for the patients who received at least 1-day course of study antibiotics during the treatment duration. The TROs included Pseudomonas aeruginosa, Enterobacteriaceae, and Acinetobacter baumannii. MacConkey agars with study antibiotics were used to isolate the TROs and evaluate the antimicrobial resistance. Results: The mean age of our study population was 61.6 years, and 58.8% were males. The rates of rectal colonization for Pseudomonas aeruginosa was similar among the study medications (ertapenem 13.2%, flomoxef 20%, moxifloxacin 14.3%, p = 0.809). Compared with ertapenem, flomoxef (odds ratio [OR], 4.30; 95% confidence interval [95% CI], 1.28–14.48, p = 0.019) and moxifloxacin (OR, 6.95; 95% CI, 1.36–35.52, p = 0.019) had higher risk for colonization of ertapenem-resistant Escherichia coli colonization. Conclusion: The patients who received treatment of ertapenem may have a lower risk of rectal colonization for ertapenem resistant Escherichia coli than those who received flomoxef or moxifloxacin. The rate of Pseudomonas colonization did not differ between the three study Pseudomonas-sparing agents. Keywords: Antimicrobial resistance, Enterobacteriaceae, Pseudomonas aeruginosa, Ertapenem, Flomoxef, Moxifloxacin

Background: Central line (CL)-associated bloodstream infection (CLABSI) poses a major threat to patient safety and is associated with additional cost. This study investigated the sustained effect of multimodal interventions focusing on CL bundle improvement in the adult intensive care units (ICUs) of a teaching hospital in Taiwan. Methods: A before–after prospective study was conducted in 17 adult ICUs of a medical center in northern Taiwan from January 2009 to December 2013. Many interventions that aimed to facilitate CL bundle implementation were initiated in January 2011. The incidence rates of CLABSI and catheter-related bloodstream infection (CRBSI) were compared between the baseline and intervention periods. Catheter utilization ratios and microbiological characteristics were also analyzed. Results: The incidence rates of both CLABSI and CRBSI decreased significantly from the baseline to the intervention periods (from 9.27 to 7.66 per 1000 CL-days and from 1.51 to 0.89 per 1000 CL-days, respectively). The yearly incidence rate decreased by up to 31% (incidence rate ratio [IRR], 0.69; 95% confidence interval [CI], 0.59–0.81) for CLABSI and 59% (IRR, 0.41; 95% CI, 0.26–0.65) for CRBSI since the initiation of the interventions. The catheter utilization ratio also decreased from 0.71 to 0.63 (p

Outbreaks of hepatitis A virus (HAV) infection have been occurring among men who have sex with men in the Asia-Pacific region, the United States, and several European countries since June 2015 and recently among persons who are homeless and use illicit drugs in the United States. We evaluated the serologic responses and effectiveness of HAV vaccination in human immunodeficiency virus (HIV)-positive individuals during the outbreak in Taiwan. From June 1, 2015, to September 30, 2016, anti-HAV immunoglobulin G was prospectively determined among all HIV-positive individuals. We prospectively observed 1,533 HAV-seronegative, HIV-positive individuals (94.1% being men who have sex with men with a median cluster of differentiation 4 (CD4) count of 550 cells/μL) who were advised to receive two doses of HAV vaccine administered 6 months apart. Of them, 1,001 individuals (65.3%) received at least one dose of HAV vaccine during the study period and 532 (34.7%) declined to receive vaccine. The primary endpoints were serologic response at weeks 28-36 and acquisition of HAV infection during follow-up. The incidence rate of acute HAV infection was 3.7 and 99.3 per 1,000 person-years of follow-up in the vaccinated and unvaccinated groups, respectively, resulting in a vaccine effectiveness of 96.3%. At weeks 28-36, the seroconversion rates were 63.8% and 93.7% in the intention-to-treat and per-protocol analyses, respectively. The factors associated with seroconversion at weeks 28-36 were younger age (per 1-year decrease, adjusted odds ratio, 1.08; 95% confidence interval, 1.02-1.12) and undetectable plasma HIV RNA load (adjusted odds ratio, 3.19; 95% confidence interval, 1.32-7.68). Conclusion During the outbreak of acute hepatitis A, two-dose HAV vaccination is effective at preventing HAV infection among HIV-positive individuals receiving combination antiretroviral therapy; our data highlight the importance of HAV serologic screening and vaccination to prevent outbreaks of acute hepatitis A in at-risk populations. (Hepatology 2018;68:22-31).

We evaluated the serologic responses to different 2-dose combinations of the inactivated hepatitis A virus (HAV) vaccines Havrix and Vaqta among human immunodeficiency virus-positive individuals during an acute hepatitis A outbreak in Taiwan. In this 16-month retrospective study, one group received 1 dose of Havrix followed by 1 dose of Vaqta, and another group received 2 doses of Vaqta. The Havrix-Vaqta and Vaqta-Vaqta groups achieved similar seroconversion rates at weeks 28-36 (82.3% and 80.9%, respectively; absolute difference, 1.3% [95% confidence interval {CI}, -6.3%-3.7%]) and week 48 (94.7% and 94.4%, respectively; absolute difference, 0.3% [95% CI, -2.6%-3.2%]), suggesting the interchangeability of different combinations of HAV vaccines. The significantly higher seroconversion rate after the first dose of Vaqta, compared with the dose of Havrix (53.0% vs 32.4%) may provide potential benefits in preventing HAV infection during the outbreak.

Background Serological responses to revaccination against hepatitis B virus (HBV) are unclear in HIV-positive adults who had undergone neonatal HBV vaccination and whose antibodies against HBV had waned in the era of combination antiretroviral therapy (cART). Methods Between 2000 and 2017, 666 HIV-positive men who have sex with men (MSM) who were born after 1986, when nationwide neonatal HBV vaccination programme was implemented in Taiwan, were included for analyses. A serological response was defined when a hepatitis B surface antibody (anti-HBs) titre ≥10 mIU/mL was measured 4-24 weeks after the third dose of HBV vaccination. Results During the study period, 295 (48.7%) HIV-positive MSM (mean age, 23.2 years) who had lost HBV seroprotection were eligible for revaccination; 171 (58.0%) received at least 1 dose (20-μg) of HBV vaccine and 116 (39.3%) completed the 3-dose schedule. The serological response rate to 3 doses of HBV revaccination was 74.0% and the rate of high-titre response (anti-HBs titre ≥100 mIU/mL) was 46.0%. The CD4 count before the first dose (per 50-cell/μL increment, adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.29) was positively associated with the serological response. The incident rate of HBV infection was 9.2 per 1000 person-years of follow-up among the patients who were non-responders after revaccination. Conclusions Despite HBV vaccination in the neonatal period, the serological response rate to HBV revaccination in HIV-positive MSM was modest and could wane rapidly. Regular testing of anti-HBs should be integrated into the HIV care despite cART containing HBV-active agents.

BACKGROUND Among HIV-positive individuals, seroprotection for hepatitis A virus (HAV) following primary vaccination may wane with time. However, seroresponses to HAV revaccination are rarely investigated among HIV-positive patients who have lost protective antibodies after primary vaccination. METHODS During the outbreak of acute hepatitis A in Taiwan after June 2015, HAV-seronegative, HIV-positive individuals were advised to receive two doses of HAV vaccines at 24 weeks apart. A retrospective 1:2 matched case-control study was conducted to compare the seroresponses at weeks 4, 24, 28 and 48 of HAV vaccination between those who underwent revaccination after having lost protective antibodies (case patients) and those who underwent primary vaccination (controls). RESULTS Seventy-five case patients and 150 matched controls were included. The serological response rates were consistently higher among the case patients than controls: 88.1% vs 10.5% at week 4 following the first dose of HAV vaccination (P

We investigated 401 geriatric patients and 453 middle-aged patients with health care-associated bloodstream infection (HABSI) at a medical center during January-December 2014. Compared with middle-aged patients, the geriatric group had higher 30-day mortality (31.2% vs 23.4%, P = .01). Body mass index, serum albumin concentration, Charlson comorbidity index score, vancomycin-resistant Enterococcus bacteremia, and high C-reactive protein levels predict poor outcomes for HABSI among adult patients.

ObjectivesThere is minimal literature examining the association of sepsis with out-of-hospital cardiac arrest (OHCA). Using a large national database, we aimed to quantify the risk of OHCA among sepsis patients after hospital discharge.DesignPopulation-based cohort study.SettingNationwide sepsis cohort retrieved from the National Health Insurance Research Database of Taiwan between 2000 and 2013.ParticipantsWe included 17 304 patients with sepsis. After hospital discharge, 144 patients developed OHCA within 30 days and 640 between days 31 and 365.Primary and secondary outcome measuresThe main outcomes were OHCA events following hospital discharge for sepsis. To evaluate the independent association between sepsis and OHCA after a sepsis hospitalisation, we constructed two non-sepsis comparison cohorts using risk set sampling and propensity score matching techniques (non-infection cohort, non-sepsis infection cohort). We plotted the daily number and daily risk of OHCA within 1 year of hospital discharge between sepsis and matched non-sepsis cohorts. We used Cox regression to evaluate the risk of early and late OHCA, comparing sepsis to non-sepsis patients.ResultsCompared with non-infected patients, sepsis patients had a higher rate of early (HR 1.66, 95% CI: 1.27 to 2.16) and late (HR 1.19, 95% CI: 1.06 to 1.33) OHCA events. This association was independent of age, sex or cardiovascular history. Compared with non-sepsis patients with infections, sepsis patients had a higher rate of both early (HR 1.28, 95% CI: 1.00 to 1.63) and late (HR 1.13, 95% CI: 1.01 to 1.27) OHCA events, especially among patients with cardiovascular disease (OR 1.35, 95% CI: 1.01 to 1.81).ConclusionsSepsis patients had increased risk of OHCA compared with matched non-sepsis controls, which lasted up to 1 year after hospital discharge.

Background An unprecedented outbreak of acute hepatitis A has occurred among MSM in Taiwan since June 2015. We aimed to describe the seroepidemiology of HAV infection and to investigate the relationship between HAV vaccination and the incidence of acute hepatitis A among HIV-positive patients at the largest designated hospital for HIV care during the outbreak. Methods Between 2012 and 2016, the HAV serostatus, vaccination history, and clinical characteristics of HIV-positive patients were retrospectively reviewed. A case-control study was performed to identify the factors associated with acute hepatitis A. The trends of HAV vaccination rate and incidence of acute hepatitis A among HAV-seronegative patients were examined during the outbreak. Results During the 4.5-year period, 2088 HIV-positive patients with a mean age of 37.7 years and 90.2% being MSM were included. The overall HAV seroprevalence was 34.3%, which was significantly higher in older and non-MSM patients. The estimated incidence rate of acute hepatitis A was 52.6 cases per 1000 person-years of follow-up during the outbreak. The associated factors with acquiring acute hepatitis A were recent syphilis and having not received HAV vaccines. The HAV vaccination rate during the outbreak increased from 4.7% to 70.6% and the incidence rate of acute hepatitis A declined when up to 65% of the patients were immunized or tested positive for HAV. Conclusions The seroprevalence of HAV infection was low in the younger HIV-positive individuals. Prevention of acute hepatitis A was achieved among HIV-positive, HAV-seronegative patients through HAV vaccination and increased herd immunity during the ongoing outbreak. This article is protected by copyright. All rights reserved.

This study aimed to investigate the epidemiology and microbiology of bloodstream infections (BSIs) in patients with haematological malignancies. Clinical characteristics and microbiology of 2083 patients with haematological malignancy who were treated for BSI from 2008 to 2013 at a medical centre in Taiwan were retrospectively reviewed. Lymphoma (38.1%) was the most common, followed by acute myeloid leukaemia (30.9%). Of the 2090 non-duplicate BSI isolates, 1310 (62.7%) were recovered from patients with neutropenia. Of the Gram-negatives (53.7%), Escherichia coli was predominant (13.8%), followed by Klebsiella pneumoniae (9.5%), Acinetobacter calcoaceticus–baumannii (ACB) complex (5.7%) and Pseudomonas aeruginosa (4.0%). Of the Gram-positives (40.2%), coagulase-negative staphylococci were the most common (20.5%), followed by Enterococcus faecium (5.6%). Candida tropicalis (2.0%) was the most commonly encountered yeast (5.0%). Multidrug resistance (MDR) was identified in 21.8% of ACB complex isolates. Among the 57 Staphylococcus aureus isolates, 24 (42.1%) were resistant to oxacillin (MRSA), and among the 118 E. faecium isolates, 55 (46.6%) were resistant to vancomycin (VRE). The overall 14-day mortality rate was 12.9% ( n = 269). There was no significant difference in 14-day mortality among patients with (13.4%) and without (11.9%) neutropenia ( P = 0.315). Multivariate analysis revealed that age ≥60 years, prior allogeneic transplantation, BSI due to VRE ( E. faecium ) and shock were independent predictors of 14-day mortality. Gram-negative organisms continued to be the most common cause of BSI in patients with haematological malignancies during the period 2008–2013. There was a significant increase in the prevalence of VRE ( E. faecium ) and MDR-ACB complex isolates.

Background Little is known about risk factors for subsequent infections among vancomycin resistant Enterococcus faecium (VREfm) colonizers, especially characterized by concordant pulsotypes (CP) of paired colonization and infection-related isolates. Methods This case-control study was conducted at a teaching hospital between 2011 and 2014. Targeted patients received active surveillance culture for VREfm by anal swabs at admission. Cases were those who developed VREfm infection within 180 days after colonization of VREfm. Controls were those colonized with VREfm without subsequent VREfm infection. CP were defined by similarities ≥86.7% using pulsed-field gel electrophoresis between paired colonization and infection-related isolates. Results Ninety-seven cases and 194 controls were enrolled. By conditional multivariable logistic regression analysis, the risk factors for subsequent infection among VREfm colonizers were intensive care unit (ICU) admission (adjusted odds ratio [aOR], 9.32; 95% CI, 3.61–24.02), receipt of central venous catheters (CVC) (aOR, 3.38; 95% CI, 1.30–8.82), and utilization of third- and fourth-generation cephalosporins (aOR, 4.06; 95% CI, 1.79–9.20, and aOR, 5.32; 95% CI, 1.85– 10.29, respectively) (all P ≤ 0.01). Fifty-six (57.7%) of case patients belonged to the CP group, which were associated with ICU admission (aOR, 3.74; 95% CI, 1.38–10.13), and infection developing within 30 days after colonization (aOR, 3.34; 95% CI, 1.25–8.91). Conclusions Among VREfm colonizers, being admitted to ICU and receiving CVC or broad spectrum cephalosporins, were the risk factors for subsequent infections. These findings highlight the importance of conducting more strict infection control measures on specific groups of VREfm colonizers.

Objectives Early diagnosis of adult-onset immunodeficiency associated with neutralizing anti-interferon-gamma autoantibodies (anti-IFNγ Abs) remains difficult given the lack of a distinctive phenotype and a routine test. This study aimed to investigate the determinants of incorrect tentative diagnoses and useful clues for early disease recognition. Methods This study enrolled adult patients who had unexplained opportunistic infections diagnosed at six hospitals and identified those having neutralizing anti-IFNγ Abs (cases). Demographics, medical history, initial presentations and laboratory data, causative pathogens, tentative diagnoses, and treatment were analysed and compared among individuals having neutralizing anti-IFNγ Abs (cases) and those without (controls). Results Among the 154 patients enrolled, neutralizing anti-IFN-γ Abs were detected in 50 (71%) of 70 patients with disseminated non-tuberculous mycobacterial infection (dNTM) but not in 84 patients without dNTM. The median time from disease onset to the recognition of dNTM associated with neutralizing anti-IFNγ Abs was 1.6 years (range, 0.25–19 years). Incorrect tentative diagnoses resulted in the administration of anti-tuberculosis regimens (60%, 30/50), immunosuppressants (48%, 24/50), and systemic chemotherapy (2%, 10/50) to the 50 cases. Multivariate analysis revealed that case patients were more likely than controls to present with multiple bone lesions (adjusted odds ratio (OR), 27.16; 95% confidence interval (CI), 1.21–609.59) and leukocytosis (adjusted OR, 1.48; 95% CI, 1.12–1.95); however, the controls had a higher rate of mycobacterial bloodstream infection (adjusted OR, 0.05; 95% CI 0.00–0.66). Conclusions The high rate of incorrect tentative diagnoses led to frequent inappropriate management in patients with neutralizing anti-IFNγ Abs, and highlighted the need for increased awareness among clinicians.

Background The outcomes of deep-seated abscesses attributed to chronic disseminated candidiasis (CDC) in patients with hematological malignancies have rarely been reported in recent years. Methods We retrospectively reviewed and analyzed the data of patients with hematological malignancies who received a diagnosis of CDC at a medical center in Taiwan between 2008 and 2013. Results Sixty-one patients (32 men and 29 women) were diagnosed with CDC. The median age was 51 years (range: 18–83). The overall incidence of CDC was 1.53 per 100 patient-years in patients with hematological malignancies between 2008 and 2013. The highest incidence of CDC was 4.3 per 100 patient-years for acute lymphoblastic leukemia, followed by 3.6 for acute myeloid leukemia. We detected 3 (4.9%) proven, 13 (21.3%) probable, and 45 (73.8%) possible cases of CDC. A total of 13 patients had positive blood cultures for Candida species: C. tropicalis (8), C. albicans (2), C. glabrata (2), and C. famata (1). The median duration of antifungal treatment was 96 days (range: 7–796 days). Serial imaging studies revealed that the resolution rate of CDC was 30.0% at 3 months and 54.3% at 6 months. Five patients (8.2%) had residual lesions that persisted beyond one year. A multivariate analysis of the 90-day outcome revealed that shock was the only independent prognostic factor of 90-day survival in patients with CDC. Conclusion The incidence of CDC did not decrease between 2008 and 2013. Patients with acute leukemia had a higher risk of CDC than those with other hematological malignancies. Imaging studies conducted at 6 months after diagnosis revealed that only half of the patients showed complete resolution. CDC requires prolonged treatment, and serial imaging at 6 months interval is suggested. Shock is the only independent prognostic factor of 90-day survival in patients with CDC.

Background: Differential roles of comorbidity burden, functional status and severity of illness in elderly and non-elderly patients admitted to general wards with infections in terms of short-term and long-term mortality remain poorly understood and worth further investigation. Methods: From 2011 to 2013, patients admitted to general wards with a main diagnosis of infections were included and their Barthel index, Charlson comorbidity index and Pitt bacteremia score were collected to evaluate their association with in-hospital and 1-year outcomes of the study cohort. Age stratification was applied for all outcome analysis. Results: A total of 2481 patients were identified, with main diagnoses of pneumonia (57%), urinary tract infection (28%) and intra-abdominal infection (18%). In-hospital mortality occurred in 291 (12%) of the population and was independently predicted by Barthel index ≤50 (odds ratio [OR] 5.67 and 2.73, respectively) and Charlson comorbidity index >2 (OR 1.49 and 2.87, respectively) in both elderly and non-elderly patients. Among 2190 hospital survivors, Barthel index ≤50 (hazard ratio [HR] 1.38) and Charlson comorbidity index >2 (HR 1.96) were associated with a higher hazard of 1-year mortality in elderly patients. However, only Charlson comorbidity index >2 (HR 2.87) was a significant characteristic of non-elderly patients to be correlated with higher 1-year mortality. Conclusion: This study found that functional status on admission was predictive of in-hospital mortality of general patients with infections irrespective of age groups; however, it played a differential role in 1-year mortality in between elderly and non-elderly patients, emphasizing the importance of functional assessment among the elderly. Keywords: Age, Comorbidity, Functional status, Infection, Outcome

Background Although the worldwide incidence of tuberculosis (TB) has been slowly decreasing, the migrant workers remains an important gap for regional TB control. In Taiwan, the numbers of the migrant workers from countries with high TB incidence increase significantly in past decades and the impact on public health remains unknown. This study aimed to explore the difference of TB incidence between Taiwanese and the migrant workers. Methods The migrant workers are obligated to receive pre-arrival, post-arrival and regular chest X-ray screening during their stay in Taiwan. We retrospectively collected these data extracted from the Alien Workers Health Database in Centers for Disease Control, Taiwan from Jan. 1, 2004 to Dec. 31, 2013. Poisson regression models were used to compare the hazard ratios of TB between Taiwanese and the migrant workers after adjusting gender and age groups. Results The total migrant workers in Taiwan reached 314,034 persons in 2004 and 489,134 persons in 2013, accounting for 2% of Taiwan population. The TB incidence of migrant workers was similar to Taiwanese (53–73.7 per 105 vs 45.5–76.8 per 105). Comparing with Taiwanese, the TB risk was significantly lower in male migrant workers (HR: 0.76; 95% CI: 0.70–0.83, P

BackgroundThe indications for lumbar puncture in non-HIV-infected, non-transplant (NHNT) patients with cryptococcosis without meningeal signs need to be more fully defined.ObjectivesThis study was designed to determine the optimal predictors of central nervous system (CNS) involvement in adult NHNT patients with cryptococcosis.MethodsThe study population consisted of adult NHNT patients with culture-confirmed cryptococcosis who sought care at a university hospital in Taiwan from 2002 to 2016. We used a case-control method to identify the clinical characteristics and laboratory findings associated with CNS involvement in patients who underwent a diagnostic lumbar puncture. In the sensitivity analysis, we included additional control patients who did not undergo lumbar puncture, but were followed beyond 12 months without the development of CNS involvement in the absence of exposure to any fungicidal agents.ResultsWe entered 270 NHNT adult patients into the study during the 15-year period. CNS involvement was confirmed in 66 (71.0%) of 93 patients who underwent lumbar puncture. A multivariable analysis revealed that presence of neurological manifestations and elevated serum CRAG titers were independently associated with a 23.97-fold (95% confidence interval [CI], 4.37-182.23) and 1.53-fold (per 2-fold increment, 95% CI 1.26-1.92) increased odds ratio for CNS involvement, respectively. Headache and focal neurologic signs were independently associated with CNS involvement. A cut-off serum CRAG titer of ≥1:64 provided the highest diagnostic performance by Youden index (sensitivity 83% and specificity 65%). Similar findings were noted in the sensitivity analysis including 198 (73%) patients.ConclusionLumbar puncture is indicated for NHNT patients with cryptococcosis who have neurologic manifestations or a serum CRAG titer of ≥1:64.

Background/Purpose Nontyphoid Salmonella (NTS) bacteremia causes high mortality and recurrence rates in human immunodeficiency virus (HIV)-infected patients. This study aimed to investigate the risk of recurrent NTS bacteremia in the era of combination antiretroviral therapy (cART). Methods The medical records of consecutive HIV-infected patients with NTS bacteremia from January 2006 to June 2014 were reviewed. The patients were divided into two groups: patients who achieved a decline of plasma HIV RNA load by ≥ 2 log 10 after 4 weeks of cART (good short-term virological response) and those who failed to achieve the goal (poor short-term virological response). Clinical information was collected on the demographics, immunological and virological responses, prophylactic antibiotics used, episodes of recurrent NTS bacteremia, and mortality. Results During the study period, 49 patients with 52 episodes of NTS bacteremia were included: 29 patients in the good virological response group, in which 16 received secondary prophylaxis; and 20 patients in the poor response group, in which 15 received secondary prophylaxis. There were no recurrent episodes of NTS bacteremia in the good-response group, whereas the incidence rate of recurrent NTS bacteremia was 5.21 per 100 person-years and 56.42 per 100 person-years of follow-up in patients receiving and not receiving prophylaxis, respectively, in the poor-response group. No patients died in the good-response group, whereas five patients (25%) in the poor-response group died. The resistance rate of 52 NTS isolates tested to ciprofloxacin was 7.7%. Conclusion The risk of recurrent NTS bacteremia is low in HIV-infected patients who achieve short-term virological response to cART, regardless of secondary prophylaxis.

To evaluate wound infection rates, pain scores, satisfaction with wound care, and wound care costs starting 48 hours after surgery.Showering after surgery is a controversial issue for wound care providers and patients. We investigated the benefits and detriments of showering for postoperative wound care.Patients undergoing thyroid, lung, inguinal hernia, and face and extremity surgeries with clean or clean-contaminated wounds were included. The patients were randomized to allow showering (shower group) or to keep the wound dry (nonshower group) for postoperative wound care starting 48 hours after surgery. The primary endpoint was the rate of surgical wound infection. The secondary endpoints included the wound pain score, satisfaction with wound care, and cost of wound care.Between May 2013 and March 2014, there were 222 patients randomized to the shower group and 222 to the nonshower group. Two patients in each group were lost to follow-up. There were 4 superficial surgical site infections in the shower group and 6 in the nonshower group (4/220, 1.8% vs 6/220, 2.7%, P = 0.751). Postoperative pain scores were comparable between the 2 groups. Patients in the shower group were more satisfied with their method of wound care, and their wound care costs were lower when compared with the nonshower group.Clean and clean-contaminated wounds can be safely showered 48 hours after surgery. Postoperative showering does not increase the risk of surgical site complications. It may increase patients' satisfaction and lower the cost of wound care.

Background/purpose Early initiation of antiretroviral therapy (ART) reduces the risks for serious infections and mortality. We aimed to assess the outcomes of initiating ART among HIV-positive Taiwanese according to the CD4 cut-off values by the WHO recommendations. Methods We reviewed medical records of patients with newly diagnosed HIV infection between 2004 and 2015 and 3 groups of patients were defined according to the timing of ART initiation based on CD4 count recommended by WHO: Group 1 between 2004 and 2009; Group 2 between 2010 and 2012; and Group 3 between 2013 and 2015. The primary outcome was all-cause mortality. All patients were followed until 2 years after the last patient was included in each group. Results Of 2022 patients included, the mortality rate was 18.28, 14.01, and 9.10 deaths per 1000 person-years of follow-up (PYFU) in Groups 1, 2, and 3, respectively. In multivariable Cox regression analysis, factors associated with mortality were age (per 1-year increase, adjusted hazard ratio [AHR], 1.06; 95% CI, 1.05–1.08), presence of AIDS-defining disease at HIV diagnosis (AHR, 4.81; 95% CI, 2.99–7.74), solid-organ malignancy (AHR, 3.10; 95% CI, 1.86–5.18), and initiation of ART (AHR, 0.09; 95% CI, 0.05–0.16). By competing risk regression model for non-AIDS-related death, the AHR for Group 3 versus Group 1 was 0.27 (95% CI, 0.09–0.80). Conclusions While continued efforts are needed to improve early diagnosis and linkage to care, initiation of cART improved survival among HIV-positive patients in Taiwan according to the increasing CD4 cut-off values that were recommended by the WHO.

Background Tenofovir disoproxil fumarate (TDF) is active against both HBV and HIV. Whether the introduction of TDF-containing combination antiretroviral therapy (cART) has improved the outcome of HIV/HBV-coinfected patients remains unclear in areas of higher HBV endemicity. Methods We retrospectively reviewed medical records of newly diagnosed antiretroviral-naive HIV-infected patients between 2007 and 2015. Four groups of patients were defined, according to the HBV status and availability of TDF for HIV treatment in Taiwan in 2011. The primary outcome was all-cause mortality. Results During the 9-year study period, 1,723 HIV-infected patients were included, with a median age of 31 years and baseline CD4 count of 273 cells per μL. The HBV seroprevalence had declined from 18.1% (125/692) in the pre-TDF era to 10.1% (104/1031) in the post-TDF era. The respective mortality rate for HIV/HBV-coinfected and HIV-monoinfected patients in the pre-TDF era was 23.2 (95% CI, 12.5-43.1) and 9.6 (95% CI, 6.1-15.0) deaths per 1000 person-years of follow-up [PYFU], and the respective mortality rate in the post-TDF era was 15.7 (95% CI, 7.0-34.8) and 8.0 (95% CI, 5.5-11.6) deaths per 1000 PYFU. The adjusted hazard ratio for mortality in multivariate Cox proportional-hazards regression analysis among HIV/HBV-coinfected patients compared to HIV-monoinfected patients was 2.79 (95% CI, 1.25-6.22) in pre-TDF era and 1.11 (95% CI, 0.45-2.72) in post-TDF era. Conclusions In this country of high HBV endemicity, the adverse impact of chronic HBV infection on the survival observed in the pre-TDF era has significantly diminished among HIV/HBV-coinfected patients compared to HIV-monoinfected patients in the era of TDF-containing cART.

Background: During one week in September, one index case, followed by two cases of rotavirus gastroenteritis infection, was identified in a neonate intermediate care unit of a tertiary teaching children's hospital. An outbreak investigation was launched to clarify the possible infection source and to stop the spread of infection. Methods: Cohort care and environmental disinfection were immediately implemented. We screened rotavirus in all the unit neonates' stool samples as well as environmental swab samples. The precautionary measures with regard to hand hygiene and contact isolation taken by healthcare providers and family members were re-examined. Results: The fourth case was identified 5 days after commencement of the outbreak investigation. There were total 39 contacts, including 6 neonates, 8 family members, and 25 healthcare providers. Nineteen stool samples collected from other neonates in the units revealed one positive case (the fourth case). However, one sample taken from the computer keyboard and mouse in the ward was also positive. The observation of hygiene precautions and the use of isolation gowns by healthcare workers were found to be inadequate. Following the intensification of infection control measures, no further cases of infection were reported. Conclusions: Hand hygiene and an intensive isolation strategy remained the most critical precautions for preventing an outbreak of healthcare-associated viral gastroenteritis in the neonate care unit. Keywords: Rotavirus, Outbreak, Neonatal care unit, Infection control

Background Sustainable systematic interventions are important for infection prevention and control (IPC). Data from surveillance of healthcare-associated infections (HAI) provides feedback for implementation of IPC programs. To address the paucity of such data in Asia, we searched for national HAI surveillance and IPC programs in this region. Methods Data were analysed from open access national surveillance reports of three Asian countries: Taiwan, South Korea and Japan from 2008 to 2015. National IPC programs were identified. Results There were differences among the countries in surveillance protocols, hospital coverage rates, and national IPC policies and programs. Nevertheless, there was a 53.0% reduction in overall HAI over the 8-year period. This consisted of a decrease from 9.34 to 5.03 infections per 1000 patient-days in Taiwan, from 7.56 to 2.76 in Korea, and from 4.41 to 2.74 in Japan (Poisson regression, all p

Aims This study examined the changes and the predictors of suicide ideation/suicide attempt and the moderating effects of psychosocial factors on the suicide ideation/suicide attempts among human immunodeficiency virus (HIV)-positive patients at 6-12 months post-diagnosis. Background Suicide behaviours are prevalent among newly diagnosed HIV-positive patients, but the changes in suicide behaviours after diagnosis and the role of psychosocial factors in these behaviours are not well studied. Design This study used a prospective longitudinal design. Methods A total of 113 participants diagnosed as HIV-positive for 6-12 months were recruited from the outpatient department. Data were collected from June 2015 - October 2016. They were asked to complete Beck's Scale for Suicide Ideation, the Beck Depression Inventory-II, the Body Image Scale, the Meaning in Life Questionnaire and the Multidimensional Scale of Perceived Social Support at baseline, the third month and the sixth month. Results The results showed the high occurrence rates for suicide ideation ranging from 27.2%, 21.6%, and 25.8% and suicide attempt ranging from 14.7%, 8.6%, and 13.3% at the baseline, the third month and the sixth month, respectively. The education level, social support from family and depressive symptoms were the predictors of suicide ideation. The history of depression disorders, depressive symptoms and social support from friends significantly predicted suicide attempt. Meaning in life-presence moderated the relationship between depressive symptoms and suicide ideation. Conclusions After diagnosed for 6-12 months, HIV-positive patients remain the high-risk group for suicide ideation and attempt. Suicide intervention targeting the risk and protective factors are required for HIV-positive patients.