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INTRODUCTION This study investigated the differences in road-crossing behavior among healthy older adults and patients with Alzheimer's disease (AD). METHOD Twelve pedestrians with mild AD and 24 age-, gender-, and education-matched controls were examined with a battery of cognitive, visual, and motor tests. Using a simulated two-lane, one-way road-crossing situation, we determined the remaining time and safety margin for each participant in traffic situations involving different vehicle speeds (40 km/h vs. 60 km/h vs. 80 km/h), time gaps (5 s vs. 7 s vs. 9 s), and time of day (dusk vs. midday). RESULTS We found that patients with AD were more vulnerable to traffic crash while crossing the road than healthy older adults (Odds Ratio = 2.50, P

Summary We investigated the trends in antimicrobial resistance among species of Gram-negative bacilli isolated from patients with hepatobiliary tract infections in Taiwan during the period 2006–2010 as part of the Study for Monitoring Antimicrobial Resistance Trends (SMART). During the study period, 1032 isolates of Gram-negative bacilli that had been collected from patients with hepatobiliary infections were tested for susceptibility to 12 antimicrobial agents in accordance with the Clinical and Laboratory Standards Institute guidelines. Enterobacteriaceae accounted for the majority ( n = 874, 84.7%) of isolates and Escherichia coli was the most common pathogen ( n = 323, 31.3%). There were significantly more E. coli ( P = 0.001) and Proteus mirabilis ( P = 0.031) isolates collected from patients who had been hospitalized for less than 48 h and significantly more Serratia marcescens ( P = 0.035) and Pseudomonas aeruginosa ( P = 0.008) isolates collected from patients who had been hospitalized for 48 h or longer. The prevalence of extended–spectrum β–lactamase (ESBL)-producing pathogens was low. The decline in susceptibility rates with time was remarkable for ceftazidime ( P = 0.036), ciprofloxacin ( P = 0.029), and levofloxacin ( P = 0.018). The most effective antibiotics, i.e., those that were active against more than 90% of Enterobacteriaceae, were amikacin, cefepime, imipenem, ertapenem, and piperacillin–tazobactam. Susceptibility of P. aeruginosa to anti-pseudomonal agents was greater than 80%. In this study, we found an overall increase in resistance to antimicrobial agents among Gram-negative bacilli isolated from patients with hepatobiliary tract infections in Taiwan. Surveillance of antimicrobial susceptibility and updates of treatment guidelines are recommended to help achieve optimal therapy for patients with hepatobiliary infections.

Background Approximately two-thirds of the patients with severe sepsis or septic shock are first encountered in the emergency departments (EDs) of western countries, in which bacteremia is present in about 50% of patients with severe sepsis. The situation of bacteremia presenting to the EDs in Taiwan is not well documented. The objective of this study was to examine the epidemiology and microbiology of bacteremia in adult patients who visited the ED of a medical center in southern Taiwan. Methods A retrospective observational study of the epidemiology and microbiology of bacteremia was conducted in the ED of a medical center involving 6,137 adult patients and 13,903 blood cultures. Results A total of 831 consecutive patients with 890 episodes of bacteremia were obtained from January 1 to December 31, 2004, indicating a positive culture rate of 13.5% (1,872/13,903). Among these episodes, 525 (59%) were defined as true community–acquired infections followed by 263 (29.5%) as health care–associated infections and 102 (11.5%) as nosocomial infections. Of the 972 isolates, 289 (29.7%) were gram-positive species and 683 (70.3%) were gram-negative species. Urinary tract infections (32.2%, 287/890) were most common in these patients, with Escherichia coli (30.8%, 299/972) being the most common pathogen. Bacteremia caused by Staphylococcus aureus was more common in nosocomial than true community–acquired infections (31.3% vs . 12%) and had significantly higher possibility of resistance to methicillin in infections not purely acquired from community (odds ratio = 24.92; 95% confidence interval, 9.88–62.87). The overall crude mortality rate was 21% and nearly half of the mortalities occurred within 3 days of visiting the ED. All patients discharged inadvertently were uneventful ( n = 65, two lost at follow-up). Conclusions Categories of bacteremia acquisition was associated with different distribution of pathogens, antimicrobial resistance, and clinical outcome. Traditional classification might overestimate the problem of drug resistance in community-acquired infections. The concept of health care–associated infection should be introduced to avoid overemphasis of drug-resistant problem in true community–acquired infection.

Accurately differentiating tuberculous pleurisy from lung cancer is important for disease management but difficult using conventional laboratory methods. This study assessed the value of adenosine deaminase (ADA) and interferon gamma (IFN-γ) for differentiating the two conditions in a region of Taiwan with a high prevalence of tuberculosis. The study population comprised patients with lymphocytic exudative pleural effusions: tuberculous (n=24) and malignant (n=42). Mean levels of ADA and IFN-γ in pleural fluid, measured with commercial standardized kits, were significantly higher for tuberculous than for malignant pleurisy (p

Summary The traffic control bundle consists of procedures designed to help prevent epidemic nosocomial infection. We retrospectively studied the serial infection control measures to determine factors most effective in preventing nosocomial infections of healthcare workers (HCWs) during the 2003 Taiwanese severe acute respiratory syndrome (SARS) epidemic. Fever screening stations, triage of fever patients, separating SARS patients from other patients, separation of entrances and passageways between patients and HCWs, and increasing hand-washing facilities all demonstrated a protective effect for HCWs (univariate analysis; P

We conducted a multi-center, randomized, laboratory-blinded clinical trial in 185 healthy adults (60 years) and 107 elders (60 years) to examine the immunogenicity and safety of different doses of an inactivated, monovalent, non-adjuvanted, split vaccine against the 2009 pandemic influenza A (H1N1) virus. The 186 adults were assigned to three treatment groups, i.e., one 15 μg hemagglutination (HA) antigen dose, two 15 μg or 30 μg HA doses in 3 weeks apart, and the 107 elders were treated with two 15 μg or 30 μg doses in 3 weeks apart. Prior to the vaccination, 4.8% subjects had hemagglutination-inhibition (HAI) antibody titers of 1:40 or more. By day 21 post-vaccination of one dose of 15 μg HA, the seroprotective rate was 95.1% and 75.5% in subjects60 and65 years of age, respectively; by day 21 post the second 15 μg HA dose, the seroprotective rates were 93.2% and 73.1%, respectively. The seroprotective rates for recipients of 30 μg HA antigen by day 21 were 95.2% for subjects60 years and 81.1% for subjects65 years of age, that was boosted to 98.3% and 80.4%, respectively with a second dose of 30 μg HA antigen. No vaccine-related serious adverse events occurred. The data indicated a single 15 μg HA dose of the vaccine induced a protective immune response in most adults, including the elders60 years of age, and a booster dose at the third week did not render a higher level of antibody response.

We conducted a multi-center, randomized and laboratory-blinded clinical trial with subgroup analyses, involving adults aged greater than 60 years old (range 61-86 years old), to investigate the immunogenicity and the potential factors affecting the immune response of a monovalent, unadjuvanted, inactivated, split-virus vaccine. A total of 107 subjects were randomized to receive 15 and 30 microg of hemagglutinin antigen in a 1:1 ratio. The immunogenicity was detected through hemagglutination inhibition (HAI) test of serum obtained before and 3 weeks after vaccination. By 3 weeks after vaccination, HAI titer >or=1:40 was observed in 75.5% and 81.1% of participants receiving 15 and 30 microg of hemagglutinin antigen, respectively. Positive seroconversion was observed in 71.7% and 81.1% of recipients of the 15 and the 30 microg, respectively. The GMTs increased by a factor of 10.7 and 17.4 in the groups of 15 and 30 microg, respectively. This study indicated that one dose of 15 microg hemagglutinin antigen without adjuvant induced protective immune response in the majority of elderly. Multivariate logistic regression analyses showed that gender, age and diabetes were statistically significant factors affecting the seroprotection rate (p=0.04, 0.01 and 0.01, respectively) and seroconversion rate (p=0.01, 0.01 and 0.01, respectively).

Background/Purpose Mycobacterium avium complex (MAC) is frequently considered to be a contaminant or transient colonizer. To the best of our knowledge, there have been very few reports regarding the clinical significance of MAC isolates in respiratory specimens, and the associated disease spectrum in Taiwan. The purpose of this study was to investigate the clinical significance of MAC isolates in respiratory specimens. Methods We retrospectively reviewed the medical records of patients in a medical center in Southern Taiwan from whom MAC isolates were recovered from respiratory specimens, and analyzed their clinical features, chest imaging findings, treatment and prognosis. We also performed an antibiotic susceptibility test on our MAC isolates. Results The 64 isolates used in this study were recovered from April to October 2001 from respiratory specimens in 54 patients admitted to Kaohsiung Veterans General Hospital, Taiwan. According to the 2007 criteria of the American Thoracic Society, a total of 12 patients (22.2%) had clinically significant MAC pulmonary disease. Conclusion Despite the increased frequency of recovering MAC from respiratory specimens, most cases did not meet the criteria of American Thoracic Society for clinically significant nontuberculous pulmonary disease. The minimum inhibitory concentrations of drugs against these MAC isolates might help to guide treatment, but further studies should be done.

A total of 393 isolates of A. baumannii were collected from patients treated at 19 teaching hospitals in Taiwan. Minimum inhibitory concentrations (MICs) and inhibitory zone diameters for tigecycline were determined by the broth microdilution method and the disk diffusion method, respectively. The MIC results were interpreted using the US FDA tigecycline susceptibility breakpoints for Enterobacteriaceae (susceptible [S]or=2 microg/mL; intermediate [I] 4 microg/mL; resistant [R]or=8 microg/mL). The disk diffusion results were interpreted by criteria recommended by Jones et al. (Sor=16 mm; I 13-15 mm; Ror=12 mm) and also by those recommended by the US FDA for Enterobacteriaceae (Sor=19 mm; I 15-18 mm; Ror=14 mm). The percentages of susceptible, intermediate and resistant isolates determined by the broth microdilution method were 80.9%, 12.2%, and 6.9%, respectively. The rates of susceptible, intermediate and resistant isolates by the disk diffusion method using the criteria of Jones et al. were 88.3%, 9.9% and 1.8% and using the US FDA criteria were 44.0%, 51.7% and 4.3%. Using the criteria recommended by Jones et al., the total error rate of the disk diffusion method in comparison with the broth microdilution method was 14.2% (56/393). For routine susceptibility testing of tigecycline against A. baumannii the broth microdilution method, not the disk diffusion method, should be used due to the poor correlation of results between these two methods interpreted either by the Jones et al. or US FDA criteria.

Tigecycline In-vitro Surveillance in Taiwan (TIST), initiated in 2006, is a nationwide surveillance programme designed to monitor longitudinally the in-vitro activity of tigecycline against commonly encountered resistant bacteria in Taiwan. This study, part of TIST-2006 study, aimed to compare the in-vitro activity of tigecycline against clinical isolates of Gram-positive bacteria. A total of 805 isolates of Gram-positive bacteria were collected from patients treated at 20 teaching hospitals. Minimum inhibitory concentrations (MICs) of tigecycline for these isolates were determined by the broth microdilution method according to the guidelines of the Clinical and Laboratory Standards Institute, and by the Etest as per the manufacturer's instructions. Susceptibility results were interpreted by the MIC criteria recommended by the US FDA. Agreement between the two methods was low: 80.7% for methicillin-resistant Staphylococcus aureus (MRSA), 27.2% for Streptococcus pneumoniae, 22.8% for other Streptococcus spp., and 30.8% for vancomycin-resistant E. faecium (VRE). There were no very major or major errors noted. Tigecycline exhibited excellent in-vitro activity against Gram-positive cocci, including MRSA, VRE, S. pneumoniae and other Streptococcus spp. isolates in Taiwan. Correlation between MIC values determined using the broth microdilution and Etest methods for these organisms was poor.

SummaryBackgroundThe major sources of Legionnaires’ disease (LD) are the potable water systems of large buildings including hospitals, nursing homes, and hotels. Culturing the hospital water system for Legionella allows a preventive approach for hospital-acquired LD. However, hospital-acquired LD is rarely reported in Taiwan, and environmental cultures of Legionella in hospital water systems in Taiwan have never been systematically performed.ObjectiveThe objective of this study was to determine if Legionella is present in hospital water systems in Taiwan. Water quality analysis was also performed to determine if geographic differences in water quality result in different Legionella positivity rates.MethodThe water systems of 16 hospitals throughout Taiwan were tested for Legionella by culture. Standardized culture procedures were followed.ResultsLegionella pneumophila was isolated from 63% (10/16) of the hospital water systems; 19% (3/16) of the hospitals had an L. pneumophila positive rate greater than 30%. L. pneumophila serogroups 1 and 6 (strains that are most responsible for Legionella infections) were isolated from 80% (8/10) and 60% (6/10), respectively, of the hospitals that yielded L. pneumophila in their water distribution systems.ConclusionAs was shown in epidemiological studies in the USA and Spain, hospital-acquired legionellosis may be prevalent but underdiagnosed in Taiwan.

Objective.Use of active surveillance cultures for methicillin-resistant Staphylococcus aureus (MRSA) for all patients admitted to the intensive care unit has been shown to reduce nosocomial transmission. However, the cost-effectiveness and the utility of implementing use of active surveillance cultures nationwide remain controversial. We sought to develop an artificial neural network (ANN) model that would predict the likelihood of MRSA colonization.Setting.Two acute care hospitals, one in Pittsburgh (hospital A) and one in Kaohsiung, Taiwan (hospital B).Methods.Nasal cultures were performed for all patients admitted to the hospitals. A total of 46 potential risk factors in hospital A and 86 potential risk factors in hospital B associated with MRSA colonization were assessed. Culture results were obtained; 75% of the data were used for training our ANN model, and the remaining 25% were used for validating our ANN model. The culture results were the “gold standard” for determining the accuracy of the model predictions.Results.The ANN model predictions were accurate 95.2% of the time for hospital A (sensitivity, 94.3%; specificity, 96.0%) and 94.2% of the time for hospital B (sensitivity, 96.6%; specificity, 91.8%), integrating all potential risk factors into the model. Only 17 potential risk factors were needed for the hospital A ANN model (accuracy, 90.9%; sensitivity, 98.5%; specificity, 83.4%), and only 20 potential risk factors were needed for the hospital B ANN model (accuracy, 90.5%; sensitivity, 96.6%; specificity, 84.3%), if the minimal risk factor method was used. Cross-validation analysis showed an average accuracy of 85.6% (sensitivity, 91.3%; specificity, 80.0%).Conclusion.Our ANN model can be used to predict with an accuracy of more than 90% which patients carry MRSA. The false-negative rates were significantly lower than the false-positive rates in the ANN predictions, which can serve as a safety buffer in case of patient misclassification.

We describe a patient with Mycobacterium marinum tenosynovitis associated with a fish spine injury acquired at a gambling fishing pond in southern Taiwan and identify the source of the infection. M. marinum was isolated from fishing ponds and underground water and wastewater at the site. The isolates shared the same pulsed-field gel electrophoresis pattern as the patient. M. marinum was not detected in 54 samples obtained from 27 fish. Mycobacterium gordonae was isolated from 24 samples collected from the fish. Mycobacterium abscessus was isolated from 3 fish samples (Lateolabrax japonicus 1 and Sciaenops ocellatus 2). M. abscessus and M. gordonae were isolated from all water samples. This investigation provides strong evidence that the predisposing factor for the M. marinum infection was with a fish spine injury acquired at a gambling fishing pond. The source of the infection was the contaminated pond water.

This study examines the changes in driving behavior and cognitive performance of drivers with different breath alcohol concentration (BrAC) levels.Eight licensed drivers, aged between 20 and 30 years, with BrAC levels of 0.00, 0.25, 0.4 and 0.5 mg/l performed simulated driving tests under high- and low-load conditions. Subjects were asked to assess their subjective psychological load at specified intervals and perform various tasks. The outcome was measured in terms of reaction times for task completion, accuracy rates, and driver's driving behavior.The effects of BrAC vary depending on the task. Performance of tasks involving attention shift, information processing, and short-term memory showed significant deterioration with increasing BrAC, while dangerous external vehicle driving behavior occurred only when the BrAC reached 0.4 mg/l and the deterioration was marked.We can conclude that the cognitive faculty is the first to be impaired by drinking resulting in deteriorated performance in tasks related to divided attention, short-term memory, logical reasoning, followed by visual perception. On the other hand, increasing alcohol dose may not pose an immediate impact on the external vehicle driving behavior but may negatively affect the driver's motor behavior even at low BrAC levels. Experience and will power could compensate for the negative influence of alcohol enabling the drivers to remain in full steering control. This lag between alcohol consumption and impaired driving performance may mislead the drivers in thinking that they are still capable of safe steering and cause them to ignore the potential dangers of drunk driving.

Nontuberculous mycobacterium (NTM) is one of the well-known causes of cervicofacial lymphadenopathy in children under 5 years of age. Children often present with a painless cervical mass that fails to respond to conventional antibiotics. They are often referred under the suspicion of a neoplasm or bacterial adenitis rather than NTM cervical lymphadenitis. The lack of systemic symptoms, modest or negative purified protein derivative test and absence of exposure to active tuberculosis are characteristics of NTM lymphadenitis. The diagnosis usually requires the isolation of pathogen or pathologic proof. Complete excision is the choice of treatment by the majority of authors in the literature. This not only enables rapid diagnosis but ensures the lowest recurrence rate. Medical management is sometimes successful when complete resection is impossible or refused. To our knowledge, the incidence of NTM cervical lymphadenitis in children is increasing throughout the world. However, such reports of children in Taiwan is lacking. Clinicians should suspect a possible nontuberculous mycobacterial infection when a cervical lump is found in a child.

The human immunodeficiency virus type 1 (HIV-1) epidemic in Taiwan is rapidly escalating because of an increasing number of injection drug users (IDUs). A molecular epidemiological study of HIV-1-infected IDUs in Taiwan was conducted from January 2004 to April 2005. Of the 131 HIV-1-positive specimens collected all contained detectable sequences including 105 from the C2-V3 region of env and 87 from the protease and reverse transcriptase genes of pol. Phylogenetic analysis of these sequences indicated that 128 individuals harbored CRF07_BC which resembles the dominant strains circulating among IDUs in China. Twenty-three individuals had a history of travel to the southwest provinces of China and shared needles or apparatuses there. This suggests that CRF07_BC might have been transmitted from China into Taiwan thereby causing an outbreak among IDUs in Taiwan. This is the first report in the English literature of the appearance of HIV-1 CRF07_BC in Taiwan. These provide information relevant to the development of antiviral therapy and vaccine in Taiwan and may assist public health workers in the prevention of HIV-1 spread. (authors)

Production of extended-spectrum β-lactamases and plasmid-mediated AmpC enzymes was investigated among 291 Escherichia coli and 282 Klebsiella pneumoniae isolates that showed decreased susceptibilities to extended-spectrum cephalosporins from seven Taiwanese medical centers. CTX-M-type and SHV-type enzymes were the most prevalent extended-spectrum β-lactamases. CMY-2-like and DHA-1-like β-lactamases were the most prevalent AmpC-type enzymes.

Summary Objective The resurgence of tuberculosis (TB) and the emergence of drug resistance of Mycobacterium tuberculosis (MTB) isolates are of great impact on public health. Methods Taiwanese data on disease burden of TB and anti-microbial resistance of MTB identified from Annual Reports of Centre for Disease Control, Department of Health, Taiwan and from peer-reviewed publications from MEDLINE (1995–2004). Results In Taiwan in 2002, the incidence (per 100 000 population) of tuberculosis was 74.6 and it was higher in aborigines (289.8) and in people living in mountainous regions (256.0). The mortality rate of tuberculosis in Taiwan in 2002 was 5.68 per 100 000 population. Susceptibility data summarized from 1990 to 2002 reports showed primary resistance ranged from 4.7 to 12% for isoniazid, 0.7 to 5.9% for rifampin, 1 to 6% for ethambutol, and 4 to 11% for streptomycin. The overall rates of multidrug-resistant tuberculosis (MDRTB) among new cases and previously treated cases were 1 to 3% and 15 to 46%, respectively. The increasing burden of patients with MDRTB infection, the persistent high rate of mortality, the lack of nationwide surveillance system using the standard methodology to determine the trends and current status of resistance, and the inadequate current TB control infrastructure and training to accomplish the tasks required to implement the directly observed treatment short-course (DOTS) strategy are having a great impact on public health in Taiwan. Conclusions High disease burden of TB and high resistance rates in MTB as well as inappropriateness of the current control infrastructure for TB services illustrate increasingly serious health problems from TB in Taiwan.

A laboratory-based surveillance network of 11 clinical virological laboratories for influenza viruses was established in Taiwan under the coordination of the Center for Disease Control and Prevention (CDC), Taiwan. From October 2000 to March 2004, 3,244 influenza viruses were isolated, including 1,969 influenza A and 1,275 influenza B viruses. The influenza infections usually occurred frequently in winter in the northern hemisphere. However, the influenza seasonality in Taiwan was not clear during the four seasons under investigation. For example, the influenza A viruses peaked during the winters of 2001, 2002, and 2003. However, some isolated peaks were also found in the summer and fall (June to November) of 2001 and 2002. An unusual peak of influenza B also occurred in the summer of 2002 (June to August). Phylogenetic analysis shows that influenza A isolates from the same year were often grouped together. However, influenza B isolates from the year 2002 clustered into different groups, and the data indicate that both B/Victoria/2/87-like and B/Yamagata/16/88-like lineages of influenza B viruses were cocirculating. Sequence comparison of epidemic strains versus vaccine strains shows that many vaccine-like Taiwanese strains were circulating at least 2 years before the vaccine strains were introduced. No clear seasonality of influenza reports in Taiwan occurred in contrast to other more continental regions.

Clinical features of 84 patients with V. vulnificus infection are analyzed and molecular features of isolates are described., Residents in Taiwan are often exposed to marine microorganisms through seafood and occupational exposure. The number of reported cases of infection attributable to this organism has increased since the first case was reported in 1985. The increasing number of cases may be caused by greater disease activity or improved recognition by clinicians or laboratory workers. We analyze a clinical-case series of 84 patients with Vibrio vulnificus infection from 1995 to 2000 and describe the molecular epidemiologic features of pathogens isolated from these patients. The spectrum of clinical manifestations and outcomes, options of antimicrobial therapy, and virulence mechanisms were investigated. Results of molecular typing of isolates from humans and marine environment in this country had a high genetic divergence among these isolates. Education and measures are needed to prevent this emerging disease.

The most common cause of eosinophilic meningitis is the rat lungworm Angiostrongylus cantonensis a parasite that is endemic in the southeast Asian and Pacific regions. Outbreaks of eosinophilic meningitis associated with drinking raw vegetable juice are rarely reported, even in regions of endemic infection. We performed a cohort study among Taiwanese with eosinophilic meningitis who drank raw vegetable juice within three months of the onset of the outbreak. Clinical manifestations, laboratory examinations, and outcomes were prospectively followed. Five native Taiwanese met the case definition of eosinophilic meningitis. Specific antibodies to A. cantonensis were detected in the serum of five of the patients and in the cerebrospinal fluid (CSF) of four of the patients. Central nervous system manifestations included headache (n = 5 [100%]), Brudzinski's sign/stiff neck (n = 5 [100%]), hyperesthesia/paresthesias (n = 5 [100%]), and cranial nerve palsy (n = 1 [20%]). Laboratory findings included peripheral (n = 5 [100%]) and CSF eosinophilia (n = 4 [80%]), transient increases in the white blood cell count (n = 1 [20%]), and in serum levels of creatine kinase (n = 1 [20%]). Meningeal enhancement, as well as high signal intensity, at the subcortical white matter on T2 weighted and fluid attenuated inversion recovery images were observed on magnetic resonance imaging in four patients. There were three episodes of relapse during treatment and all resolved with after a lumbar puncture and/or administration of steroids. At the 12-month follow up, all five patients had recovered without neurologic sequelae. Risk factors identification showed that consumption of raw vegetable juice was associated with illness (Pearson correlation test r = 0.867, P = 0.01). There was association between the presence of raw vegetable juice and CSF eosinophilia (Spearman's correlation test r = 0.816, P = 0.004).

We evaluated the disk susceptibility data of 671 nontyphoid Salmonella isolates collected from different parts of Taiwan from March 2001 to August 2001 and 1,261 nontyphoid Salmonella isolates from the National Taiwan University Hospital from 1996 to 2001. Overall, ciprofloxacn resistance was found in 2.7% (18/671) of all nontyphoid Salmonella isolates, in 1.4% (5/347) of Salmonella enterica serotype Typhimurium and in 7.5% (8/107) in S. enterica serotype Choleraesuis nationwide. MICs of six newer fluoroquinolones were determined for the following isolates: 37 isolates of ciprofloxacin-resistant (human) S. enterica Typhimurium (N = 26) and Choleraesuis (N = 11), 10 isolates of ciprofloxacin-susceptible (MIC 0.12 μg/mL). Sequence analysis of the gryA, gyrB, parC, parE, and acrR genes, ciprofloxacin accumulation; and genotypes generated by pulsed-field gel electrophoresis with three restriction enzymes (SpeI, XbaI, and BlnI) were performed. All 26 S. enterica Typhimurium isolates from humans and pigs belonged to genotype I. For S. enterica Choleraesuis isolates, 91% (10/11) of human isolates and 54% (7/13) of swine isolates belonged to genotype B. These two genotypes isolates from humans all exhibited a high-level of resistance to ciprofloxacin (MIC 16–64 μg/mL). They had two-base substitutions in the gyrA gene at codons 83 (Ser83Phe) and 87 (Asp87Gly or Asp87Asn) and in the parC gene at codon 80 (Ser80Arg, Ser80Ile, or Ser84Lys). Our investigation documented that not only did these two S. enterica isolates have a high prevalence of ciprofloxacin resistance nationwide but also that some closely related ciprofloxacin-resistant strains are disseminated from pigs to humans.

This study evaluated the current status of antimicrobial resistance in clinical isolates of Streptococcus pyogenes in Taiwan as part of the SMART (Surveillance from Multicenter Antimicrobial Resistance in Taiwan) program. In 2001, 419 different isolates of S. pyogenes , including 275 from respiratory secretions, 87 from wound pus, and 31 from blood, were collected from nine hospitals in different parts of Taiwan. MICs of 23 antimicrobial agents were determined at a central location by the agar dilution method. All of the isolates were susceptible to penicillin (MIC at which 90% of the isolates were inhibited [MIC 90 ], ≤0.03 μg/ml), cefotaxime (MIC 90 , ≤0.03 μg/ml), cefepime (MIC 90 , 0.06 μg/ml), meropenem (MIC 90 , ≤0.03 μg/ml), moxifloxacin (MIC 90 , 0.25 μg/ml), vancomycin (MIC 90 , 0.5 μg/ml), and linezolid (MIC 90 , 1 μg/ml). Overall, 78% of isolates were not susceptible to erythromycin (54% were intermediate, and 24% were resistant), and 5% were not susceptible to clindamycin. Of the 101 erythromycin-resistant isolates, 80.2% exhibited the M phenotype ( mefA gene positive), 18.9% exhibited the cMLS (constitutive resistance to macrolides-lincosamides-streptogramin B [MLS]) phenotype ( ermB gene positive), and 1% exhibited the iMLS (inducible resistance to MLS) phenotype ( ermB gene positive). Fluoroquinolones (sitafloxacin > moxifloxacin > ciprofloxacin = levofloxacin = gatifloxacin > gemifloxacin) demonstrated potent activity against nearly all of the isolates of S. pyogenes tested. Thirty-two isolates (8%) were not susceptible to quinupristin-dalfopristin. Seventeen percent of isolates had telithromycin MICs of ≥1 μg/ml, and all of these isolates exhibited erythromycin MICs of ≥32 μg/ml. The high prevalence of resistance to telithromycin (which is not available in Taiwan) limits its potential use in the treatment of S. pyogenes infections, particularly in areas with high rates of macrolide resistance.

There is a high prevalence of β-lactam- and macrolide-resistant Streptococcus pneumoniae in Taiwan. To understand the in vitro susceptibilities of recent isolates of S. pneumoniae to fluoroquinolones and telithromycin (which is not available in Taiwan), the MICs of 23 antimicrobial agents for 936 clinical isolates of S. pneumoniae isolated from different parts of Taiwan from 2000 to 2001 were determined by the agar dilution method. Overall, 72% of isolates were not susceptible to penicillin (with 61% being intermediate and 11% being resistant) and 92% were resistant to erythromycin. Telithromycin MICs were ≥1 μg/ml for 16% of the isolates, and for 99% of these isolates the MICs of all macrolides tested were ≥256 μg/ml; all of these isolates had the constitutive macrolide-lincosamide-streptogramin B phenotype. Eighty-eight percent of the isolates were resistant to three or more classes of drugs. The ciprofloxacin MICs were ≥4 μg/ml for six (0.6%) isolates from five patients collected in 2000 and 2001, and the levofloxacin MICs were ≥8 μg/ml for five of these isolates. Seven isolates for which ciprofloxacin MICs were ≥4 μg/ml, including one isolate recovered in 1999, belonged to three serotypes (serotype 19F, five isolates; serotype 23A, one isolate; and serotype 23B, one isolate). The isolates from the six patients for which ciprofloxacin MICs were ≥4 μg/ml had different pulsed-field gel electrophoresis profiles and random amplified polymorphic DNA patterns, indicating that no clonal dissemination occurred over this time period. Despite the increased rate of fluoroquinolone use, the proportion of pneumococcal isolates for which ciprofloxacin MICs were elevated (≥4 μg/ml) remained low. However, the occurrence of telithromycin resistance is impressive and raises concerns for the future.

Purpose To describe two outbreaks of Angiostrongylus cantonensis infection that occurred in Kaohsiung, Taiwan, during 1998 and 1999, and to characterize the source of the outbreaks and the clinical manifestations of the disease. Subjects and methods We performed a retrospective cohort study among Thai laborers with eosinophilic meningitis who ate raw snails ( Ampullarium canaliculatus ), as well as an environmental surveillance of larvae in snails. Results We enrolled 17 Thai laborers in whom severe headache and eosinophilia developed within 4 to 23 days after eating raw snails. Twelve (71%) developed eosinophilic meningitis. Third-stage larvae were found in the cerebrospinal fluids of 2 patients and in all 12 tested snails. Specific antibodies to A. cantonensis were detected in serum from 16 of the patients and in cerebrospinal fluid from 5 of the patients. Central nervous system manifestations included headache (n = 17 [100%]), fever (n = 11 [65%]), Brudzinski's sign/stiff neck (n = 11 [65%]), hyperesthesia (n = 3 [18%]), cranial nerve palsy (n = 2 [12%]), diplopia (n = 2 [12%]), and ataxia (n = 1 [6%]). Laboratory findings included peripheral eosinophilia (n = 15 [88%]) and cerebrospinal fluid eosinophilia (n = 12 [71%]); elevated immunoglobulin (Ig) E levels (n = 13 [100%]); and transient increases in white blood cell count (n = 7 [41%]) and in serum levels of creatine kinase (n = 7 [41%]), transaminase (n = 3 [18%]), and lactate dehydrogenase (n = 2 [12%]). The severity of illness and eosinophilia were correlated with the number of ingested snails. Meningeal and basal ganglion enhancement was noted on magnetic resonance imaging in several patients. Treatment with mebendazole combined with glucocorticosteroids appeared to shorten the course of the infection, but not the number of relapses. The eosinophil count fell to normal within 3 months, but IgE levels remained elevated for as long as 6 months. All patients recovered with minimal neurologic sequelae. Conclusion Eosinophilic meningitis caused by A. cantonensis should be considered in patients who have headache or central nervous system manifestations after eating raw snails.

Resistance (intermediate and high) to penicillin among Streptococcus pneumoniae strains is an emerging problem worldwide. From 1995 to 1997, isolates of S. pneumoniae not susceptible to penicillin were seen with increasing frequency from blood, cerebrospinal fluid, pleural fluid, and middle ear fluid from pediatric patients at the Veterans General Hospital-Kaohsiung. To determine the prevalence of carriage of these penicillin-nonsusceptible S. pneumoniae isolates, we obtained nasopharyngeal swab specimens from 2,905 children (ages, 2 months to 7 years) attending day-care centers or kindergartens or seen in our outpatient clinic. S. pneumoniae was isolated from 611 children, and 584 strains were available for analysis. The oxacillin disc test was used as a screening test to evaluate penicillin susceptibility. The MICs of 11 antibiotics (penicillin, cefaclor, cefuroxime, ceftriaxone, cefotaxime, imipenem, chloramphenicol, clarithromycin, rifampin, vancomycin, and teicoplanin) were determined by the E-test. Only 169 (29%) of the strains were susceptible to penicillin; 175 (30%) strains were intermediately resistant and 240 (41%) were highly resistant. The isolates also demonstrated high rates of resistance to other β-lactams (46% were resistant to cefaclor, 45% were resistant to cefuroxime, 45% were resistant to ceftriaxone, 31% were resistant to cefotaxime, and 46% were resistant to imipenem). The rate of resistance to macrolide antimicrobial agents was strikingly high; 95% of the isolates were not susceptible to clarithromycin. However, 97% were susceptible to rifampin and 100% were susceptible to the two glycopeptides (vancomycin and teicoplanin). While reports of penicillin-resistant S. pneumoniae increased worldwide through the 1980s, the high prevalence (71%) of resistance reported here is astonishing. Surveillance of nasopharyngeal swab specimen cultures may provide useful information on the prevalence of nonsusceptible strains causing invasive disease. Such information could be used to guide therapy of pneumococcal infections.

Pyogenic liver abscess is an uncommon complication of intra-abdominal or biliary tract infection and is usually a polymicrobial infection associated with high mortality and high rates of relapse. However, over the past 15 years, we have observed a new clinical syndrome in Taiwan: liver abscesses caused by a single microorganism, Klebsiella pneumoniae. We reviewed 182 cases of pyogenic liver abscess during the period September 1990 to June 1996; 160 of these cases were caused by K. pneumoniae alone, and 22 were polymicrobial. When patients with K. pneumoniae liver abscess were compared with those who had polymicrobial liver abscess, we found higher incidences of diabetes or glucose intolerance (75% vs. 4.5%) and metastatic infections (11.9% vs. 0) and lower rates of intra-abdominal abnormalities (0.6% vs. 95.5%), mortality (11.3% vs. 41%), and relapse (4.4% vs. 41%) in the former group. Liver abscess caused by K. pneumoniae is a new clinical syndrome that has emerged as an important infectious complication in diabetic patients in Taiwan.

Cefpodoxime proxetil is a new orally administered prodrug which is absorbed and de-esterified by the intestinal mucosa to release the third-generation cephalosporin, cefpodoxime, and which is undergoing in vitro and in vivo evaluations. Using the standard agar dilution method, we compared the in vitro activity of this drug with other oral cephalosporins and quinolones against 637 recent clinical isolates from Kaohsiung Veterans General Hospital in Taiwan. Against Escherichia coli and Klebsiella pneumoniae, cefpodoxime showed excellent activity, inhibiting over 90% of these isolates at 1 mg/l. Like other oral drugs of its class, it had little activity against Pseudomonas aeruginosa and Acinetobacter spp. Against Haemophilus influenzae, irrespective of beta-lactamase production, its activity was similar to comparative drugs. Against methicillin-susceptible Staphylococcus aureus, cefpodoxime showed moderate activity, inhibiting 90% of these isolates at 4 mg/l, whereas it was inactive against methicillin-resistant S. aureus. However, all cephalosporins have shown little in vivo activity against methicillin-resistant S. aureus regardless of in vitro results. Cefpodoxime was inactive against Enterococcus spp. Against other streptococci, its activity was similar to other oral cephalosporins and quinolones tested. The results of this in vitro study indicated that oral administration of cefpodoxime should be an ideal agent in the empirical outpatient treatment for community-acquired cutaneous, respiratory and urinary tract infections.

The Study for Monitoring Antimicrobial Resistance Trends (SMART) is a worldwide surveillance program designed to longitudinally monitor the in vitro activity of antimicrobial agents against pathogens that cause intra-abdominal infections (IAIs). In this study, trends in antimicrobial resistance during the period 2006 to 2010 were analyzed at five tertiary-care hospitals in Taiwan. Enterobacteriaceae accounted for the majority (80.9%) of the 2417 Gram-negative isolates, and the two most common species were Escherichia coli (38.8%) and Klebsiella pneumoniae (23.5%). The rates of susceptibility of Enterobacteriaceae isolates to cephalosporins decreased during the study period. Although carbapenems, fluoroquinolones, piperacillin-tazobactam, and amikacin were active in vitro against more than 80% of the Enterobacteriaceae isolates, the activity of carbapenems declined during the study period. Extended-spectrum β-lactamase (ESBL) production in E. coli was steady, but that in K. pneumoniae decreased during the study period. The rate of ESBL-producing species was three-fold higher among patients with nosocomial IAIs than among patients with community-acquired IAIs. The majority of isolates from liver were K. pneumoniae (69%) and very few of those isolates were ESBL producers (0.9%). Pseudomonas aeruginosa (9.3%) and Acinetobacter baumannii (3.8%) were the two most common non-Enterobacteriaceae. P. aeruginosa showed improved susceptibility, whereas A. baumannii showed a rapid development of resistance during the study period. There was marked geographic variation in resistance patterns of the isolates obtained during the study period. Northern Taiwan had the highest rate of ESBL producers and the highest rate of ceftazidime resistance among P. aeruginosa isolates. Central Taiwan had the lowest rate of ESBL producers but the highest rates of carbapenem resistance among P. aeruginosa and A. baumannii isolates. Continuous monitoring and regular updates of epidemiological data are needed to guide appropriate empiric antimicrobial therapy.

We investigated the trend in resistance to carbapenems among isolates of Enterobacteriaceae that had been collected from patients with intra-abdominal infections at five medical centers in Taiwan from 2006 to 2010 and evaluated the correlation between resistance to carbapenems and consumption of said agents as part of the Study for Monitoring Antimicrobial Resistance Trends (SMART). During the study period, the usage of ertapenem and that of total carbapenems (ertapenem, imipenem, and meropenem) increased significantly from 6.13 to 13.38 defined daily doses per 1000 patient-days for ertapenem and from 20.43 to 34.25 defined daily doses per 1000 patient-days for total carbapenems. The most common species were Escherichia coli (n = 1095), Klebsiella spp. (n = 663), and Enterobacter spp. (n = 202). The susceptibility of all isolates to ertapenem and to imipenem varied during the study period. For ertapenem, the rates of nonsusceptibility ranged from 3.5% to 10.3% and those for imipenem ranged from 3.5% to 10.7%. Although the use of carbapenems increased during the study period, there was no marked increase in resistance to carbapenems. Continuous monitoring of resistance trends is necessary so that antimicrobial prescription policies can be adjusted and infection control intervention programs can be implemented.

Summary Background The use of a vancomycin dosing nomogram is an alternative and more cost-effective method to conventional dosing; it reliably allows the achievement of trough vancomycin serum concentrations of 5–15mg/l, with a successful clinical response. Recent guidelines have further recommended that the trough concentration be maintained at 15–20mg/l for complicated infections. However, to date no published nomogram has been constructed to achieve the optimal trough of 15–20mg/l in an Asian population. This study aimed to develop two vancomycin nomograms for the achievement of trough concentrations of 5–15mg/l and 15–20mg/l in the Taiwanese population, and to ensure the clinical efficacy and safety of such nomograms. Methods The estimated concentrations and the real concentrations in our patient population were compared between six pharmacokinetic models to see which was the most precise. As the Ambrose method was the best at predicting the trough, this was used to create two nomograms, one for a target trough at 5–15mg/l and the other for a target trough at 15–20mg/l. We then evaluated the nomograms by analyzing the number of patients with the target vancomycin trough concentration, clinical and microbiological outcomes, and safety. Results More patients who had dosing according to the nomogram had a vancomycin trough concentration within the desired target range than patients who had conventional dosing (65.1% vs. 32.1%, p = 0.001). These patients also had a higher rate of ‘cure' as the clinical response (35.7% vs. 27.1%) and ‘eradication' as the microbiological response (46.4% vs. 29.2%), and a lower rate of nephrotoxicity (14.3% vs. 22.9%). For the patients with a complicated infection, more had a trough between 15 and 20mg/l when vancomycin was dosed with the nomogram than when dosed conventionally (41.2% vs. 12.1%, p = 0.019). Conclusions We found that when dosing vancomycin with these nomograms, patients tended to have vancomycin trough concentrations within the target range and also to have a better outcome with regard to clinical efficacy and the safety profile.

The Tigecycline In Vitro Surveillance in Taiwan (TIST) study, a nationwide, prospective surveillance during 2006 to 2010, collected a total of 7,793 clinical isolates, including methicillin-resistant Staphylococcus aureus (MRSA) ( n = 1,834), penicillin-resistant Streptococcus pneumoniae (PRSP) ( n = 423), vancomycin-resistant enterococci (VRE) ( n = 219), extended-spectrum β-lactamase (ESBL)-producing Escherichia coli ( n = 1,141), ESBL-producing Klebsiella pneumoniae ( n = 1,330), Acinetobacter baumannii ( n = 1,645), and Stenotrophomonas maltophilia ( n = 903), from different specimens from 20 different hospitals in Taiwan. MICs of tigecycline were determined following the criteria of the U.S. Food and Drug Administration (FDA) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST-2011). Among drug-resistant Gram-positive pathogens, all of the PRSP isolates were susceptible to tigecycline (MIC 90 , 0.03 μg/ml), and only one MRSA isolate (MIC 90 , 0.5 μg/ml) and three VRE isolates (MIC 90 , 0.125 μg/ml) were nonsusceptible to tigecycline. Among the Gram-negative bacteria, the tigecycline susceptibility rates were 99.65% for ESBL-producing E. coli (MIC 90 , 0.5 μg/ml) and 96.32% for ESBL-producing K. pneumoniae (MIC 90 , 2 μg/ml) when interpreted by FDA criteria but were 98.7% and 85.8%, respectively, when interpreted by EUCAST-2011 criteria. The susceptibility rate for A. baumannii (MIC 90 , 4 μg/ml) decreased from 80.9% in 2006 to 55.3% in 2009 but increased to 73.4% in 2010. A bimodal MIC distribution was found among carbapenem-susceptible A. baumannii isolates, and a unimodal MIC distribution was found among carbapenem-nonsusceptible A. baumannii isolates. In Taiwan, tigecycline continues to have excellent in vitro activity against several major clinically important drug-resistant bacteria, with the exception of A. baumannii .

Cefepime is a new parenterally active fourth-generation cephalosporin which is undergoing in vitro and in vivo evaluations. Using the standard agar dilution method we compared the in vitro activity of this drug with other cephalosporins and ciprofloxacin against clinical isolates of Escherichia coli (98 strains), Klebsiella pneumoniae (99 strains), Acinetobacter spp. (24 strains), Pseudomonas aeruginosa (98 strains), Haemophilus influenzae (108 strains), Staphylococcus aureus (100 strains), Enterococcus spp. (45 strains), Streptococcus pneumoniae (10 strains), Streptococcus pyogenes (group A; 19 strains) and Streptococcus agalactiae (group B; 36 strains). Cefepime showed excellent activity against E. coli and K. pneumoniae, inhibiting 90% of these isolates at 0.12 mg/l. The in vitro activity of cefepime was superior to or comparable to the third-generation cephalosporins tested but was inferior to ciprofloxacin against Acinetobacter spp. and P. aeruginosa. Against H. influenzae, whether or not the strains produced beta-lactamase, its activity was similar to comparable drugs. All 84 isolates of methicillin-susceptible S. aureus were inhibited by 8 mg/l of cefepime whereas, like other cephalosporins, it had little activity against methicillin-resistant S. aureus. Of the 45 enterococci isolates tested, 44.4% were inhibited by 8 mg/l of cefepime. Against streptococci, its activity was superior to any drug tested. This in vitro study indicates that cefepime has the potential to be a valuable agent for the treatment of community- and hospital-acquired cutaneous, respiratory and urinary tract infections.

This study used a driving simulator to investigate the effect of using a Bluetooth hands-free cellular phone earpiece on the driving behavior of two age groups.Forty-eight participants (24 aged 20-26 and 24 aged 65-73) were examined to assess their performance on the following divided-attention tasks under 2 driving load conditions (high and low): (1) attempting to maintain the speed limit and (2) using a cellular phone while driving. The length of the call conversation (long vs. short) and the conversational content (complex vs. simple) were manipulated as within-subject independent variables. The driving behavior of the participants, their task reaction times and accuracy, and subjective ratings were collected as dependent variables.The results indicate that under low driving loads, short talk times, and simple conversational content, the driving behavior of the participants showed low variance in the vehicle's mean speed. In contrast, complex conversation had a significantly negative impact on driving behavior. Notably, under a low driving load, motorists' driving behaviors, measured in lateral acceleration, caused significantly smaller variance in complex conversations compared to no call and simple conversations. The use of a hands-free cellular phone affected the performance (acceleration, lane deviation, reaction time, and accuracy) of older drivers significantly more than younger drivers. While performing divided attention tasks, the accuracy of the older drivers was 66.3 percent and that of the younger drivers was 96.3 percent. Although this study did not find a clear impact of cellular phone use on the driving behavior of younger drivers, their divided-attention task reaction times and accuracy were better under no-call than calling conditions.This study indicates that the use of hands-free cellular phones could significantly affect the safety of driving among the older and present risks, although lesser, for younger drivers.

The purpose of this study was to investigate the effects of age and symbol design features on passengers' comprehension of symbols and the performance of these symbols with regard to route guidance. In the first experiment, 30 young participants and 30 elderly participants interpreted the meanings and rated the features of 39 symbols. Researchers collected data on each subject's comprehension time, comprehension score, and feature ratings for each symbol. In the second experiment, this study used a series of photos to simulate scenarios in which passengers follow symbols to arrive at their destinations. The length of time each participant required to follow his/her route and his/her errors were recorded. Older adults experienced greater difficulty in understanding particular symbols as compared to younger adults. Familiarity was the feature most highly correlated with comprehension of symbols and accuracy of semantic depiction was the best predictor of behavior in following routes.

Chlamydia pneumoniae (TWAR) is a relatively newly discovered respiratory tract pathogen which was first isolated in Taiwan. In order to describe the seroepidemiology of C. pneumoniae in Taiwan, we evaluated 1,085 stored serum samples: 904 from patients, 97 from umbilical cord blood samples, and 84 from medical personnel at the Veterans General Hospital-Kaohsiung, between January 1 and April 30, 1991. Antibodies were determined by the use of a microimmunofluorescence test using elementary bodies of C. pneumoniae AR-39 as antigen. Sera were tested with screening titres of 16 and 512 for immunoglobulin G antibody. The antibody prevalence was found to be 23.1% in young children (6 months to 10 years old), rising to 66.7% in teenagers, and to 96.2% in older age groups. These rates were higher than any reported earlier. The progressively increasing rates of seropositivity found in older individuals indicated a surge of reinfection in these age groups. Only 5 cases were found with micro-IF IgG titres equal to or greater than 512. All were asymptomatic according to the hospital records. In addition to a high prevalence rate in Taiwan, the data also showed high infection rates in teenagers and elderly people.

This study describes a Salmonella outbreak in a 9-member family in Southern Taiwan, and emphasizes the risk of Salmonella infection in extreme age.Salmonella infection was identified by blood culture, stool swab, and Widal test. A questionnaire was designed for the family to ascertain the underlying disease, symptoms, and history of untreated water and food exposure.Of 9 members in the family, 4 had symptoms of fever, abdominal pain, and watery diarrhea. There was a relationship between Salmonella infection and age, and associated symptoms included fever, nausea, diarrhea, abdominal pain, and weakness.Salmonella infection tends to occur more frequently in very young or very old people, especially elderly patients with chronic pre-existing comorbidities. Therefore, age is a significant risk factor for this symptomatic disease.

Data on the clinical characteristics of pediatric tuberculosis (TB) are limited. This retrospective study was performed to evaluate the demographic characteristics and clinical features of pediatric TB.The medical records of children with TB at Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, between 1992 and 2002 were analyzed for demographic and clinical characteristics, and treatment regimens.103 children aged 0 to 14 years with probable or confirmed TB were enrolled. Ninety patients (87.4%) had pulmonary tuberculosis (PTB) and 13 (12.6%) had extrapulmonary tuberculosis (EPTB). The mean +/- standard deviation age of children with PTB and with EPTB was 6.0 +/- 4.2 years and 4.5 +/- 5.4 years, respectively. Household contact was the route of infection for 44.4% of patients with PTB and 7.7% of patients with EPTB. TB in children aged 0 to 4 years most commonly involved the lung (53.3%) or the extrapulmonary region (69.2%). Common symptoms of PTB were cough (81.1%) and fever (33.3%). The most frequent sites of pediatric EPTB were bone (n = 4) and cervical lymph nodes (n = 4). Tuberculin skin test (TST;or=10 mm) was positive in 69.6% of children with PTB (55/79) and 37.5% of children with EPTB (3/8). Children with PTB had a lower positive acidfast bacilli rate (40.0%) and Mycobacterium tuberculosis culture (27.8%). Eighty percent of patients infected through household contact had a positive TST.Prolonged cough, household TB contact, and positive TST were characteristic factors for children with PTB in southern Taiwan. Young age was associated with high morbidity.

To determine the frequency, risk factors, associated pathogens, and outcomes of ventilator-associated pneumonia (VAP) after pediatric cardiac surgery.This was a retrospective review of the medical records of patients younger than 18 years with congenital heart disease (CHD) who underwent cardiac surgery from January 2005 to December 2007. Patients were categorized into 2 groups: with and without VAP.Of 100 patients, 13% acquired VAP. Most patients (85%) who developed VAP were infants younger than 1 year. Patients with complex CHD were more likely to develop VAP than patients with simple CHD (chi(2) = 7.69; p0.03). Two independent and modifiable risk factors were identified: prolonged use of mechanical ventilation (adjusted odds ratio [AOR], 15.196; 95% confidence interval [CI], 2.158-107.2) and prolonged use of a central venous catheter (AOR, 7.342; 95% CI, 1.054-51.140). The cardiopulmonary bypass time and duration of chest tube drainage were not risk factors. The development of VAP increased pediatric intensive care unit duration of stay (p0.006), duration of hospital stay (p0.001), and mortality rate (p0.001). Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were the most common pathogens isolated from endotracheal aspirate.VAP is common after congenital heart surgery. Physicians must pay special attention to infants with complex CHD because they are at high risk for the development of VAP after congenital heart surgery. Shortening the duration of mechanical ventilation and central venous catheter placement are critical factors for reducing the risk for VAP.

The potential mechanisms for altered matrix metalloproteinase (MMP) or tissue inhibitors of matrix metalloproteinase (TIMP) function in patients with syphilis and HIV-1 co-infection (HIV-S) was unclear. To determine the expression of MMP-2, 9 and TIMP-1, 2, 4 in the serum and cerebrospinal fluid (CSF) of HIV-S patients, a total of 20 HIV-S patients and 8 controls were enrolled in a HIV-1 clinical cohort for diagnosis of neurosyphilis in Taiwan. Serum and CSF concentrations of MMP-2, 9, and TIMP-1, 2, 4 were determined by ELISA. Gelatin zymography was used to detect the expression of MMP-2 and MMP-9 in the CSF. Neurosyphilis was defined as a CSF white blood cell count ≥ 20 cells/μL or a reactive CSF Venereal Disease Research Laboratory (VDRL). All the patients with HIV-S were males. Most (85%) had sex with men (MSM) and serum rapid plasma reagin (RPR) titers of ≥ 1:32. The median age was 35 years (IQR 30-43). The median CD4 T cell counts at the time of the diagnosis of syphilis were 270 cells/μL (IQR 96-484). Ten patients (50%) had neurosyphilis based on a reactive CSF VDRL test (n=8) or increased CSF white cell counts ≥ 20/μL (n=2). The concentrations of CSF MMP-9, TIMP-1, and TIMP-2 were significantly higher in patients with HIV-S than the controls (P

Purpose Older patients with hip fracture have a mortality rate one year after surgery of 20–30%. The purpose of this study is to establish a predictive model to assess the outcome of surgical treatment in older patients with hip fracture. Methods A database of information from 286 consecutive cases of surgery for hip fracture from the Department of Orthopedics, National Taiwan University Hospital Yun-Lin Branch, was utilised for model building and testing. Both logistic regression and artificial neural network (ANN) models were developed. Cases were randomly assigned to training and testing datasets. A testing dataset was utilised to test the accuracy of both models (n = 89). Results The areas under the receiver operator characteristic curves of both models were utilised to compare predictability and accuracy. The logistic regression training and testing datasets had an area of 0.938 (95% CI: 0.904, 0.972) and 0.784 (95% CI: 0.669, 0.899), respectively, below the 0.998 (95% CI: 0.995, 1.000) and 0.949 (95% CI: 0.857, 1.000) of the final ANN model. Conclusion Overall, ANNs have higher predictive ability than logistic regression, perhaps because they are not affected by interactions between factors. They may assist in complex decision making in the clinical setting.

Japanese encephalitis virus infection is a sporadic infectious disease in Taiwan. Despite progress in laboratory examinations and imaging studies, diagnosis of Japanese encephalitis remains underestimated. This study was conducted to identify clinical symptoms and laboratory findings that may assist in early identification of this disease.This retrospective study included all patients diagnosed with Japanese encephalitis at Kaohsiung Veterans General Hospital from January 2000 through December 2007. Epidemiologic data, predisposing factors, neurological and non-neurological signs and symptoms, laboratory data, and treatment were analyzed. Outcomes and neurological complications were evaluated.Eleven patients had Japanese encephalitis, and 10 had sufficient information for enrolment into the study. Nine patients presented with non-significant constitutional symptoms of fever, nausea, or headache. Other signs and symptoms included rhinorrhea, sore throat, abdominal pain, cough, myalgia, or arthralgia. Eight patients had lymphocytic pleocytosis with elevated protein and borderline low glucose levels in the cerebrospinal fluid. Leptomeningeal enhancement and low density lesions were the most common computed tomography findings. T2 hyperintensity lesions and leptomeningeal enhancement were seen in 5 patients. Two patients presenting with acute flaccid paralysis had high intensity lesions on the thalamus and basal ganglion. There were no correlations between clinical, laboratory, and imaging findings. None of the patients had neurological sequelae.Presentations, laboratory examination, and clinical signs are not specific for Japanese encephalitis. Sporadic cases are usually seen from May to August, which are associated with monsoon rains. Hence increased awareness of this disease is recommended during these periods.

Tigecycline In-vitro Surveillance in Taiwan (TIST), initiated in 2006, is a nationwide surveillance programme designed to monitor longitudinally the in-vitro activity of tigecycline against commonly encountered resistant bacteria. This study compared the in-vitro activity of tigecycline against clinical isolates of resistant Gram-negative bacteria determined by the broth microdilution and Etest methods. A total of 622 isolates were collected from patients treated at 20 teaching hospitals. Tigecycline had excellent in-vitro activity against extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (N = 275) with MIC(90) 0.5 microg/mL and a 99.6% susceptibility rate, and also against ESBL-producing Klebsiella pneumoniae (N = 324) with MIC(90) 2 microg/mL and a 98.5% susceptibility rate. For ESBL-producing Proteus mirabilis (N = 15) the MIC(90) was 4 microg/mL with a 73.3% susceptibility rate. For ESBL-producing Klebsiella oxytoca (N = 8) the MIC(50) and MIC(90) were 0.5 and 1 microg/mL, respectively, with a 100% susceptibility rate. Limited agreement (

We performed susceptibility testing using the microdilution method to determine the in-vitro activity of tigecycline against 393 Acinetobacter baumannii clinical isolates collected in 2006 from 19 hospitals in Taiwan. Significant proportions of the isolates were resistant to imipenem (44%), ciprofloxacin (75%), amikacin (69%), sulbactam (34%) and all four antibiotics (22%), and susceptibility to tigecycline among these different resistant phenotypes of A. baumannii varied from 71% to 82%. The minimum inhibitory concentration (MIC) of tigecycline ranged from 0.6 to 16 microg/mL (MIC(50) 2 microg/mL; MIC(90) 4 microg/mL). The cumulative curve of tigecycline MICs showed that when the MIC cut-offs were set at 2 microg/mL and 4 microg/mL, 80.9% and 93.1% of the isolates were susceptible, respectively. As tigecycline will be used in the future for infections caused by multidrug-resistant A. baumannii because of limited antibiotic choice, and as resistance to tigecycline in A. baumannii isolates may develop following antibiotic exposure, continuous monitoring of the susceptibility of A. baumannii isolates to tigecycline is warranted.

Significant increases in the MIC 90 s of linezolid in multidrug-resistant Mycobacterium tuberculosis isolates were seen between the baseline period of 2001 to 2003 (0.5 μg/ml) and 2004 (2 μg/ml). The MICs were 4 μg/ml in three strains. Both fluoroquinolones (except levofloxacin) and kanamycin were found to have statistically significant degrees of concordance with linezolid.

A nationwide surveillance of the antimicrobial susceptibilities of glucose non-fermentative Gram-negative bacteria isolates was conducted from 1 September 2005 to 30 November 2005 in Taiwan. A total of 456 isolates were recovered from patients hospitalised in the Intensive Care Units (ICUs) of ten major teaching hospitals. Rates of resistant pathogens, such as ciprofloxacin-resistant Pseudomonas aeruginosa (19%) and imipenem-resistant Acinetobacter baumannii (25%), were higher than those reported in 2000 (8% and 22%, respectively). Increased rates of isolates with resistant phenotypes correlated with prolonged length of ICU stay (48 h to ≤7 days vs. >7 days) for ceftazidime-non-susceptible P. aeruginosa (20.0% and 29.7%, respectively), imipenem-non-susceptible P. aeruginosa (4.0% and 13.5%, respectively) and imipenem-non-susceptible A. baumannii (15.4% and 29.8%, respectively), but not for ciprofloxacin-resistant P. aeruginosa . Alarming rates of emergence of extensively drug-resistant (XDR) A. baumannii (15%) and XDR P. aeruginosa (1.8%) were found, particularly among those isolates that were not susceptible to tigecycline and colistin. Interhospital dissemination of some clones of XDR A. baumannii in different ICUs was also noted. This study illustrates the crucial nature of continuous nationwide surveillance of resistant pathogens and implementation of effective strategies for ICU infection control and antibiotic restriction.