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Herpes zoster (HZ) is a painful, vesicular, cutaneous eruption from reactivation of varicella zoster virus (VZV), which can lead to potentially debilitating complications. The lifetime risk of HZ is estimated to be 20%-30% in the general population, with an increased risk in the elderly and immunocompromised populations. The most effective strategy to prevent HZ and its complications is by vaccination. Two types of HZ vaccines, zoster vaccine live and recombinant zoster vaccine, have been approved for use. This guidance offers recommendations and suggestions for HZ vaccination in adults, aiming to reduce the disease burden of HZ and its complications. It is intended as a guide to first-line healthcare providers, but does not supersede clinical judgement when assessing risk and providing recommendations to individuals. The Working Group on Adult Immunization Practice was appointed by the Infectious Diseases Society of Taiwan (IDST) and recommendations were drafted after a full literature review, using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. The recommendations were reviewed and revised by expert review panels during a series of consensus meetings and endorsed by the IDST, Taiwan Association of Family Medicine, the Taiwanese Dermatological Association, the Taiwan Oncology Society, the Taiwan Society of Blood and Marrow Transplantation, the Transplantation Society of Taiwan, the Taiwan AIDS Society, and the Taiwan College of Rheumatology. This guidance describes the epidemiology of HZ and provides recommendations for HZ vaccination in adults with varying levels of risk, differing history of previous VZV infection and past varicella or zoster vaccinations., Competing Interests: Declaration of competing interest The authors declare no potential conflicts of interest with regards to the research, authorship, or publication of this article., (Copyright © 2024. Published by Elsevier B.V.)

Background: The accelerating prevalence of extended-spectrum β-lactamase (ESBL)-producing and multidrug-resistance (MDR) Escherichia coli(E. coli) become a public health challenge worldwide. This study aimed to discuss the prevalence of drug-resistant E. coli colonization and analyze its risk factors and clinical characteristics among young infants in Southern Taiwan., Methods: Stool samples were collected from young infants, aged less than three months, within three days of their hospitalization from September to December 2019 in a tertiary hospital. A questionnaire was designed for parents to complete. E. coli colonies were selected and analyzed for antimicrobial susceptibility. PCR-based multilocus sequence typing was to detect the presence of sequence type ST131 and bla CTX-M genes., Results: Among 100 enrolled infants, 36% had fecal carriage of E. coli isolates, of which twenty nine (80.5%) were MDR, thirteen (36.1%) were ESBL-producing isolates and five (13.8%) and ten (27.7%) were ST131 and strains carrying CTX-M-14 gene, respectively. Compared to non-ST131 and non-CTX-M-14 gene carrier, isolates of ST131 and CTX-M-14 gene carrier showed a significantly higher resistance rate to cefixime, ceftriaxone, and gentamycin, with p value all <0.05., Conclusion: The prevalence of ESBL-producing and MDR E. coli fecal carriage were both high in young infants. The most common sequence type is ST131, of which all are strains carrying CTX-M-14. Further surveillance and investigation to control for the high prevalence of antimicrobial-resistant E. coli fecal carriage among infants in Taiwan are warranted., Competing Interests: Conflict of interest The authors declare that they have no potential conflicts of interest., (Copyright © 2023 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)

Cell-based influenza vaccines avoid egg-adaptive mutations, potentially improving vaccine effectiveness. We assessed the one-season cost-effectiveness of cell-based quadrivalent influenza vaccine (QIVc) against that of egg-derived quadrivalent influenza vaccines (QIVe) in children (6 months to 17 years of age) from payer and societal perspectives in Taiwan using an age-stratified static model. Base case and high egg adaptation scenarios were assessed. Deterministic and probabilistic sensitivity analyses were performed. The incremental cost-effectiveness ratio (ICER) threshold in Taiwan was assumed to be USD 99 177/quality-adjusted life year (QALY). Compared to QIVe, QIVc would prevent 15 665 influenza cases, 2244 complicated cases, and 259 hospitalizations per year. The base case ICER was USD 68 298/QALY and USD 40 085/QALY from the payer and societal perspective, respectively. In the high egg adaptation scenario, the ICER was USD 45 782/QALY from the payer's perspective and USD 17 489/QALY from the societal perspective. Deterministic sensitivity analyses indicated that infection incidence rate, vaccination coverage, and prevalence of the A/H3N2 strain were the main drivers of ICER. In conclusion, switching the immunization strategy from QIVe to QIVc is predicted to reduce the influenza-associated disease burden and be cost-effective for the pediatric population in Taiwan. The potential benefits of QIVc would be even higher during influenza seasons with high levels of egg adaptation., (© 2024 CSL Seqirus Inc and The Authors. Journal of Medical Virology published by Wiley Periodicals LLC.)

Background: The geographic distribution of the major clone of sequence type 131 (ST131) in extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) infections is not known. We analyzed the clinical features, resistance mechanisms, and geographic distribution of ESBL-producing E. coli clones in 120 children., Methods: We studied the 120 ESBL-producing E. coli strains from children younger than 18 years. A VITEK 2 automated system was used to determine bacterial identification and ESBL production. Sequence type was determined by multi-locus sequence typing (MLST). The genetic relationship of the ESBL-producing strains was studied using pulsed-field gel electrophoresis (PFGE). Phylogenetic group and blaCTX-M group was performed using polymerase chain reaction (PCR). Multiplex PCR for detecting the common group 9 variant, CTX-M-14, and group 1 variant, CTX-M-15, was also performed. The addresses of the 120 children were collected, and plotted on the Taiwan map., Results: The groups in the center of Kaohsiung City lived mainly in urban areas with a population density of over 10,000 people per square kilometer, and the majority of the Kaohsiung groups on the outskirts of the city center lived in suburban areas with a population density of under 6000 people per square kilometer. There was no statistically significant difference between the city center and outskirt groups in terms of clinical presentation, laboratory, and imaging data. However, more ST131 clones, major pulsotype groups, and phylogenetic group B2 strains were found in the center of Kaohsiung than on the outskirts., Conclusion: ESBL-producing E. coli clones may be more challenging to treat clinically. Most infections were community-acquired, and there appeared to be major pulsotype clones, mainly in urban areas. This reinforces the necessity of environmental surveillance and sanitary procedures for ESBL-producing E. coli., Competing Interests: Declaration of Competing Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This study aimed to investigate the relationship between nontyphoidal salmonellosis (NTS) and new-onset hematological malignancy. We conducted a 17-year nationwide, population-based, retrospective cohort study to examine the association between NTS and the risk of hematological malignancies by using the Longitudinal Health Insurance Database (LHID) of Taiwan. Participants were enrolled from 2000 to 2015 and were monitored until 2017. We traced the years 1998-2000 to ensure that the cases included were newly diagnosed with NTS. The NTS cohort included 13,790 patients with newly diagnosed NTS between 2000 and 2015. Each patient was propensity score matched at a 1:4 ratio with people without NTS. Cumulative incidence, hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated after adjusting for age, sex, income, urbanization, and medical comorbidities. The adjusted hazard ratio (aHR) of hematological malignancies for NTS patients relative to those without NTS was 1.42 (95% CI 0.91-2.20). In the age subgroup analysis, NTS had a significantly greater risk of hematological malignancies for patients older than 60 (aHR 3.04, 95% CI 1.46-6.34), with an incidence rate of 11.7 per 10,000 person-years. In patients over 60 years of age, a prominent risk of hematological malignancies was observed at a follow-up of more than 3 years after the index date (aHR 3.93, 95% CI 1.60-9.65). A history of NTS is associated with the risk of subsequent hematological malignancies in Taiwanese subjects older than 60.

Background: The rapidly increasing prevalence of antimicrobial-resistant Escherichia coli (E. coli) is a global concern. This study determined the prevalence and risk factors for the fecal carriage of drug-resistant E. coli and extraintestinal pathogenic E. coli (ExPEC) among children., Materials and Methods: In this prospective study, stool samples from children aged 0-18 years were obtained within three days of hospitalization between April 2016 and March 2019. E. coli were selected and tested for extended-spectrum β-lactamase (ESBL)-production and antimicrobial susceptibility. Multilocus sequence typing, blaCTX-M gene groups and ExPEC were determined using polymerase chain reactions. Questionnaires were recorded for risk factor analysis., Results: Among 179 E. coli isolates, 44.1% were multi-drug resistant, 20.7% produced ESBL, and 50.3% were ExPEC. Children carrying ESBL-producing E. coli were younger than those carrying non-ESBL strains. Several anthropogenic factors, including drinking water process, pork consumption, pets and household density might be associated with ESBL-producing E. coli, sequence type (ST) 131 E. coli, or ExPEC fecal carriage. Compared with families who live in less crowded houses, participants with pets had a similar trend of higher risks of ESBL-producing E. coli, ST131 E. coli, and ExPEC fecal carriage among those living in houses accommodating relatively more people., Conclusions: Children accounted for a large proportion of instances of feces carrying ESBL E. coli. In addition to antimicrobial control for people and livestocks, avenues of exposure, such as drinking water, food, pets, household density, and socioeconomic deprivation might present potentially novel opportunities to reduce the burden of nonsusceptible E. coli and ExPEC., (Copyright © 2022. Published by Elsevier B.V.)

To monitor trends in the distribution of yeast species and the susceptibilities of these species to commonly prescribed antifungal drugs, we conduct the Taiwan Surveillance of Antimicrobial Resistance of Yeasts (TSARY) every 4 years. We found that 25 of 294 Candida tropicalis isolates from TSARY 2014 and 31 of 314 C. tropicalis isolates from TSARY 2018 were resistant to fluconazole. We determined the genetic relatedness among fluconazole-resistant C. tropicalis isolates by multilocus sequence typing (MLST). Among 174 C. tropicalis isolates, including all 56 fluconazole-resistant, all 26 susceptible-dose dependent and 92 selected fluconazole-susceptible isolates, 59 diploid sequence types (DSTs) were identified. We found that 22 of the 25 fluconazole-resistant C. tropicalis from TSARY 2014 and 29 of the 31 fluconazole-resistant C. tropicalis from TSARY 2018 were genetically related and belonged to the same cluster (clade 4). A combination of mutation and overexpression of ERG11, encoding the target of azole drugs, was the major mechanism contributing to drug resistance. Approximately two-thirds of reviewed patients infected or colonised by fluconazole-resistant C. tropicalis were azole-naïve. Furthermore, there was no evidence of patient-to-patient transmission. Because the clade 4 fluconazole-resistant C. tropicalis strain persists in Taiwan, it is important to identify the source of azole-resistant C. tropicalis to prevent the spread of this resistant strain., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background/purpose: The prevalence of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli is increasing worldwide. This study investigated the clinical features and bacteriology of pediatric patients with ESBL-producing E. coli bacteremia and compared their characteristics with those of adult patients., Methods: Clinical and laboratory data from all of the 41 patients aged ≤18 years diagnosed with E. coli bacteremia were collected over 5 years. Patients aged >18 years diagnosed with E. coli bacteremia, matched 1:1 for calendar time, were enrolled as the adult group. All E. coli isolates were tested for their blaCTX-M group and sequence type 131 (ST131). A novel seven-single nucleotide polymorphism-based clonotyping test was applied to detect the septatypes of each isolate., Results: In the adult group, patients with ESBL-producing E. coli bacteremia had more previous hospitalizations and antimicrobial agent use than did those with non-ESBL-producing E. coli bacteremia, but these differences were not found in pediatric group. In the pediatric group, the proportion of isolates producing CTX-M group 9 was higher than that in the adult group (85.7% vs. 42.9%; p < 0.05). Among both groups, there were more E. coli ST131 in ESBL isolates in than there were non-ESBL isolates. The distribution of septatypes was more homogenous in ESBL-producing E. coli among the pediatric patients than among the adult patients., Conclusion: ST131 was the major clone causing E. coli bacteremia in both pediatric and adult populations. The pediatric population demonstrated a higher number of isolates producing CTX-M group 9 with more homogenous septatypes compared with the adult population., (Copyright © 2017. Published by Elsevier B.V.)

Background: The emergence of multidrug-resistant (MDR) Escherichia coli (E. coli), particularly E. coli sequence type ST131, is becoming a global concern. Commensal bacteria, an important reservoir of antibiotic resistance genes, facilitate the spread of such genes to pathogenic bacterial strains. The objective of the study is to investigate the fecal carriage of MDR E. coli and ST131 E. coli in community children in Southern Taiwan., Methods: In this prospective study, stool samples from children aged 0-18 years were obtained within 3 days of hospitalization from October 2013 to September 2014. Children with a history of underlying diseases, antibiotic treatment, or hospitalization in the 3 months before specimen collection were excluded. E. coli colonies were selected and tested for antimicrobial susceptibility, and O25b-ST131, multilocus sequence typing, and blaCTX-M gene groups were detected., Results: Among 157 E. coli isolates, the rates of nonsusceptibility to ampicillin, amoxycillin + clavulanate, trimethoprim-sulfamethoxazole, and cefazolin were 70, 65.6, 47.1, and 32.5%, respectively. Twenty-nine (18.5%) isolates were nonsusceptible to ciprofloxacin. MDR E. coli accounted for 58 (37%) of all isolates. Thirteen (8.3%) isolates produced extended-spectrum β-lactamase (ESBL). Furthermore, 26 (16.6%) and 13 (8.3%) isolates were O25b and ST131 positive, respectively. Five (38.5%) of the 13 ESBL-producing E. coli belonged to blaCTX-M group 9, among which were CTXM-14 and 4 (80%) were O25b-ST131 positive. Compared with the non-ESBL and ciprofloxacin-susceptible groups, the ESBL and ciprofloxacin-nonsusceptible groups showed significantly higher rates of O25b-ST131 positivity., Conclusions: The prevalence of the fecal carriage of nonsusceptible E. coli in children was high; among these E. coli, 37% were MDR, 18.5% were nonsusceptible to ciprofloxacin, and 8.3% produced ESBL. O25b-ST131 was the most common ESBL-producing E. coli clonal group present in the feces of children, and the ESBL and ciprofloxacin-nonsusceptible groups showed significantly higher rates of O25b-ST131 positivity.

Background: The relationship of enterovirus (EV) infection and Kawasaki disease (KD) is still unclear. The purpose of this study was to conduct a population-based cohort study to determine the relationship between KD and EV infection in Taiwan., Methods: A population-based cohort study was conducted to analyze the children file (age < 18 years) of the Taiwan National Health Insurance program between 2000 and 2008. In total, 285,636 children with EV infection and 285,636 children without EV infection were included and followed up. The subsequent KD was the major outcome event., Results: The cumulative incidence of KD was significantly higher in the EV-infected cohort than in the non-EV-infected cohort (log-rank test, P < 0.001). The overall incidence of KD was 56% higher in the EV-infected cohort than in the non-EV-infected cohort, with an adjusted hazard ratio of 1.56 (95% confidence interval: 1.44-1.69). Stratified analysis showed higher KD risk associated with previous EV infection in children 3-5 years old, in girls, in children living in less urbanization levels, in children with parental low-income occupation, and in children with allergic diseases., Conclusions: There is a higher association between KD and previous EV infection in Taiwanese children, especially in those 3-5 years old, with female sex, with less urbanization level, with low-income parental occupation, and with allergy.

Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli sequence type ST131 has emerged as the leading cause of community-acquired urinary tract infections and bacteremia worldwide. Whether environmental water is a potential reservoir of these strains remains unclear. River water samples were collected from 40 stations in southern Taiwan from February to August 2014. PCR assay and multilocus sequence typing (MLST) analysis were conducted to determine the CTX-M group and sequence type, respectively. In addition, we identified the seasonal frequency of ESBL-producing E. coli strains and their geographical relationship with runoffs from livestock and poultry farms between February and August 2014. ESBL-producing E. coli accounted for 30% of the 621 E. coli strains isolated from river water in southern Taiwan. ESBL-producing E. coli ST131 was not detected among the isolates. The most commonly detected strain was E. coli CTX-M group 9. Among the 92 isolates selected for MLST analysis, the most common ESBL-producing clonal complexes were ST10 and ST58. The proportion of ESBL-producing E. coli was significantly higher in areas with a lower river pollution index (P = 0.025) and regions with a large number of chickens being raised (P = 0.013). ESBL-producing E. coli strains were commonly isolated from river waters in southern Taiwan. The most commonly isolated ESBL-producing clonal complexes were ST10 and ST58, which were geographically related to chicken farms. ESBL-producing E. coli ST131, the major clone causing community-acquired infections in Taiwan and worldwide, was not detected in river waters., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

Background: To compare the epidemiological and clinical features and outcome in clonal group O25b/ST131 and non-clonal group O25b/ST131 in adult patients with non-extended-spectrum B-lactamase (ESBL)-producing Escherichia coli (E. coli) bacteraemia., Methods: We collected 371 consecutive isolates with community-onset non-ESBL producing E. coli bloodstream infection in 2010 in a 1200-bed hospital in Taiwan. Twenty adult patients with clonal group O25b/ST131 and 40 patients with non-clonal group O25b/ST131 were compared., Result: Clonal group O25b/ST131 accounted for 5.9% of total isolates. The underlying disease and healthcare-associated risk factors were similar in the case and control groups. Patients with the clonal group O25b/ST131 were less likely to have intra-abdominal infection (0% vs. 22.5%; p < 0.05) than patients from the control group. The Day 30 mortality rate was similar in the case and control groups (15% vs. 12.5%)., Conclusions: Clonal group O25b/ST131 was found in both multidrug-resistant and susceptible E. coli strains, causing community-onset bloodstream infection. Although O25b/ST131 does not lead to a higher mortality than other isolates, choosing an appropriate antimicrobials in the empirical therapy of community-onset E. coli bacteraemia has become more challenging.

Background: To evaluate if a severity score could differentiate the severity of children with nontyphoid salmonellosis; clinical outcomes of antimicrobial therapy in nontyphoid salmonellosis children with different severities., Methods: Admitted children with nontyphoid salmonellosis from 1996 to 2009 were monitored. Enrolled patients were divided into no antibiotics, concordant, and discordant therapies. Besides, the patients were classified into mild, moderate, and severe group according to the severity score. Clinical outcomes were compared among them., Results: A total of 558 patients were enrolled. In no therapy subset, compared with mild group, patients had worse clinical outcomes and more complications in severe group. Patients receiving no therapy had better clinical outcomes in mild group. However, patients receiving concordant therapy (ceftriaxone) had better clinical outcomes in severe group., Conclusions: The severity score and local antibiotic susceptibility could serve as guides for antibiotic prescription for severe nontyphoid salmonellosis in children. Inappropriate antibiotic use would worsen clinical outcomes in children with mild nontyphoid salmonellosis., (© The Author(s) 2014.)

A total of 35 Trichosporon isolates were collected from the Taiwan Surveillance of Antimicrobial Resistance of Yeasts (TSARY) project from 1999 to 2006, and their identifications as well as drug susceptibilities were determined. The most frequently isolated species was T. asahii (62.9%), and the most common clinical sample that yielded Trichosporon isolates was urine (37.1%). The etiology of all seven invasive trichosporonosis was T. asahii. For the 22 T. asahii isolates, the MIC(50) and MIC(90) for amphotericin B were 0.25 and 1 μg/mL, respectively. Those for fluconazole were 2 and 4 μg/mL, respectively, and for voriconazole 0.031 and 0.063 μg/mL, respectively. When the intraclass correlation coefficients (ICCs) and agreements were calculated, we found that the MICs of fluconazole obtained from different methods were similar and the inter-method discrepancies were low. Nevertheless, no unanimous MIC of amphotericin B and voriconazole was obtained among different methods.

Background and Aim: Infiltrative hepatic lesions in conventional imaging modalities are a continuing diagnostic challenge in clinical practice, especially in an endemic area of viral hepatitis. The purpose of this study isto prospectively assess the role of F-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography/computed tomography (PET/CT) in indeterminate infiltrative hepatic lesions seen in conventional CT or magnetic resonance imaging (MRI)., Methods: Dual-phase FDG-PET/CT was performed on35consecutive patients with indeterminate infiltrative hepatic lesions in CT or MRI. The variables analyzed included visual score and maximum standardized uptakevalue. Final diagnosis was histopathology orclinicalfollow-up for at least 12 months., Results: Malignancy was proven in 28 patients and there were benign strictures in seven patients. Sensitivity, specificity, and overall diagnostic accuracy of FDG-PET/CT using visual score were 85.7% (24/28), 71.4% (5/7), and 82.9% (29/35). Early and delayed maximum standardized uptake values were significantly higher in infiltrative hepatic malignancies than in benign lesions. Furthermore, PET/CT detected 13 unexpected distant metastatic foci notseen in other imaging studies. Thirteen patients (37.1%)had the plans of clinical treatment altered by FDG-PET/CT alone., Conclusion: FDG-PET/CT can help to clarify the diagnosis of indeterminate infiltrative hepatic lesions in CT or MRI. Inthis patient population, FDG-PET/CT may hold promisein the detection of unsuspected occult metastases, facilitating decision making and treatment planning.

Background: The left ventricular (LV) ejection fraction (EF) and end-diastolic and end-systolic volumes are strong predictors for prognosis of cardiac death. Quantitative-gated myocardial perfusion single-photon emission computed tomography (SPECT) is widely used to measure LV functional parameters. However, systematic differences may exist between referred populations. We sought to derive sex-specific normal values for LV functional parameters obtained using two quantitative methods., Methods: Among 1044 consecutive patients who underwent dipyridamole stress myocardial perfusion-gated 201Tl SPECT in 2008, a total of 140 (56 men) with normal perfusion imaging were selected. None had cardiac diseases or experienced cardiac events during 1-year follow-up. LV EF and end-diastolic and end-systolic volumes were calculated by quantitative-gated SPECT (QGS) and four-dimensional-myocardial single photon emission computed tomography (4D-MSPECT), respectively., Results: There was excellent intrareader and interreader reproducibility for both QGS and 4D-MSPECT algorithms. The differences in LV volumes and EF between the software packages were small. High prevalence of small heart was noted in the study population, especially in women (>60%). Volumetric measures were significantly greater (P<0.001) in men than in women, even after adjustment for body surface area. Women had a higher LV EF than men when using QGS methods, but not when using the 4D-MSPECT method. Compared with 4D-MSPECT, sex remained significantly associated with EF determined by QGS methods, independent of age and body weight., Conclusion: LV functional parameters determined by means of gated 201Tl SPECT need to be corrected for sex and algorithms. Separate reference values of LV EF and volumes need to be applied in both women and men depending on the software package used.

Background/purpose: Pediatric acute osteoarticular infections remain a challenging clinical issue for physicians. This paper provides recent clinical experiences on acute community-acquired osteoarticular infections in children in Taiwan., Methods: Children with acute community-acquired osteoarticular infections admitted to hospital were retrospectively reviewed and the findings compared with related infections in Taiwan published during the past 10 years., Results: We enrolled 27 children in our study, and reviewed 692 patients reported from six major studies in Taiwan. Of the 27 patients, 15 (55.6%) had concomitant bone and joint involvement. Blood cultures were positive in 44.4% of the children in this study and 48-52% in the other studies. Pathogens could be identified in 66.7% of our children and 63-76% in the other studies, when surgical specimens were available for culture. Staphylococcus aureus was consistently the most common pathogen found in all studies. Of the S. aureus isolates, methicillin-resistant S. aureus accounted for 13.3% in our study and 22-24% in the others., Conclusion: Concomitant osteomyelitis and septic arthritis occurred in over half of our patients. The long-term effect of combined bone and joint infection on bone growth remains to be determined. Surgical intervention remains an important component of management of osteoarticular infections. Our findings are consistent with current recommendations of aggressive microbiology diagnosis and initiation of empirical monotherapy with oxacillin or oxacillin plus an agent effective against Gram-negative bacteria in most cases of community-acquired osteoarticular infections., (Copyright (c) 2010 Taiwan Society of Microbiology. Published by Elsevier B.V. All rights reserved.)

To study the demographic changes of yeasts causing invasive infections in Taiwan, especially with respect to species distribution and antifungal susceptibility, we analyzed isolates obtained from four sterile sites of patients in 19 hospitals in 2002 (155 strains) and again from the same hospitals in 2006 (208 strains). Blood was the most common source of the yeasts, accounting for 73.8% of the total isolates, followed by ascites (21.5%), cerebrospinal fluid (3%), and synovia (1.7%). Candida albicans was the most frequently recovered species (50.1% of the total), followed by Candida tropicalis (20.7%), Candida glabrata (11.6%), Candida parapsilosis (8.5%), Cryptococcus neoformans (3.9%), Candida krusei (0.8%), and nine other species (4.3%). There were one (0.3%) and seven (1.9%) isolates with minimum inhibitory concentrations (MICs) of amphotericin B > or =2 mg/l after 24 h and 48 h incubation, respectively. In addition, there were 15 (4.3%) and 31 (8.6%) isolates with MICs of fluconazole > or =64 mg/l under the same conditions. The MIC(90) value of amphotericin B was 1 mg/l. The MIC(90) values of fluconazole were 4 mg/l after 24 h incubation and 32 mg/l after 48 h incubation. Interestingly, MICs for fluconazole > or =64 mg/l after 24 h were significantly higher for isolates obtained in 2006 than those in 2002 after 24 h (7.1% vs. 0.7%, p =0.009) and 48 h (13.5% vs. 2%, p =0.0003) incubations. The demographic difference between these two surveys is mainly due to one species, C. tropicalis.

Recent studies have shown that air pollution is a risk factor for hospitalization for pneumonia. However, there is limited evidence to suggest what subpopulations are at greater risk from air pollution. This study was undertaken to examine the modifying effect of specific secondary diagnosis (including hypertension, diabetes, asthma, and upper respiratory infections) on the relationship between hospital admissions for pneumonia and ambient air pollutants. Hospital admissions for pneumonia and ambient air pollution data for Kaohsiung were obtained for the period 1996-2006. The relative risk of hospital admission was estimated using a case-crossover approach. We found that an interquartile range (IQR) increase in PM(10), NO(2), and CO on warm days was associated with a 28% (95% confidence interval [CI], 11-48%), 40% (95% CI, 20-63%), and 31% (95% CI, 19-45%), respectively, increase in admissions for pneumonia with upper respiratory infections (URI), but only 23% (95% CI, 18-28%), 30% (95% CI, 25-36%), and 24% (95% CI, 21-28%), respectively, increase for persons without URI. An IQR increase in PM(10), SO(2), and CO on cool days was associated with a 70% (95% CI, 50-92%), 30% (95% CI, 15-47%), and 64% (95% CI, 47-83%), respectively, increase in admissions in persons with URI, and an increase of 64% (95% CI, 57-70%), 18% (95% CI, 14-22%), and 55% (95% CI, 50-60%), respectively, in admissions in persons without URI. Our findings provide evidence that patients with comorbid URI may increase the risk of hospital admissions for pneumonia, in relation to air pollutant levels.

This study was undertaken to determine whether there was an association between air pollutant levels and increased hospital admissions for myocardial infarction (MI) in Kaohsiung, Taiwan. Hospital admissions for MI and ambient air pollution data for Kaohsiung were obtained for the period 1996-2006. The relative risk of hospital admissions was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (>25 degrees C), statistically significant positive associations were found in all pollutants except particulate matter (PM(10)) and sulfur dioxide (SO(2)). On cool days (<25 degrees C), all pollutants were significantly associated with MI admissions except for ozone (O(3)). For the two-pollutant model, O(3) and carbon monoxide (CO) were significant in combination with each of the other four pollutants on warm days. On cool days, nitrogen dioxide (NO(2)) remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient air pollutants increase the risk of higher frequency of hospital admissions for MI.

Nosocomial yeast infections have significantly increased during the past two decades in industrialized countries, including Taiwan. This has been associated with the emergence of resistance to fluconazole and other antifungal drugs. The medical records of 88 patients, colonized or infected with Candida species, from nine of the 22 hospitals that provided clinical isolates to the Taiwan Surveillance of Antimicrobial Resistance of Yeasts (TSARY) program in 1999 were reviewed. A total of 35 patients contributed fluconazole resistant strains [minimum inhibitory concentrations (MICs) > or = 64 mg/l], while the remaining 53 patients contributed susceptible ones (MICs < or = 8 mg/l). Fluconazole resistance was more frequent among isolates of Candida tropicalis (46.5%) than either C. albicans (36.8%) or C. glabrata (30.8%). There was no significant difference in demographic characteristics or underlying diseases among patients contributing strains different in drug susceptibility.

Purpose: This study was to compare (18)F-FDG positron emission tomography (PET) with thoracic contrast-enhanced CT (CECT) in the ability of lymph node (LN) staging non-small cell lung cancer (NSCLC) in a tuberculosis-prevalent country. The usefulness of dual time point PET imaging (DTPI) in NSCLC nodal staging was also evaluated., Methods: We reviewed 96 NSCLC patients (mean age, 65.3+/-11.7 years) who had received PET studies before their surgery. DTPI were performed on 37 patients (mean age, 64.8+/-12.2 years) who received an additional scan of thorax 3 h after tracer injection. The accuracies of nodal staging by CECT and PET were evaluated according to final histopathology of hilar and mediastinal LN resected by surgery., Results: The accuracy for nodal staging by CECT was 65.6% and that by PET was 82.3% (p<0.05). Six patients were over-staged and 11 were under-staged by PET. Tuberculosis (n=3, 50%) were mostly responsible for false-positive, while small tumor foci (n=7, 63.6%) were mostly accountable for false-negative. For the 37 patients with DTPI, 45 min standardized uptake value (SUV) and 3 h SUV for negative LNs are significantly lower than those for positive LNs (p<0.0001). Nevertheless, the retention index (RI) showed no significant difference between these two groups., Conclusions: Our study demonstrates that PET is more accurate than CECT in LN staging NSCLC patients in Taiwan where TB is still prevalent. Semi-quantitative SUV method or DTPI with RI does not result in better diagnostic accuracy than visual analysis of PET images.

Although polymerase chain reaction (PCR) is a highly sensitive procedure for the diagnosis of enteroviruses, it has never been systemically applied to the treatment of enteroviral encephalitis using intravenous immunoglobulin (IVIg). We conducted a 2-year randomized, controlled comparison of reverse transcription (RT)-PCR of cerebrospinal fluid (CSF) with traditional viral isolation to guide IVIg treatment. Seventy-five patients were enrolled and classified into three groups: one group with clinical manifestations of enteroviral infections and two without. The latter two groups were separated on the basis of whether IVIg treatment was guided by RT-PCR or virus culture assay. CSF specimens from the 18 confirmed cases of enteroviral encephalitis were RT-PCR positive for enterovirus in all but one case. Of the remaining 57 cases of nonenteroviral encephalitis, only 4 were positive for enterovirus RT-PCR. One patient in the group of IVIg treatment guided by viral isolation subsequently displayed a sequel of epilepsy. No patients in the IVIg treatment groups guided by RT-PCR had any neurological sequelae. In conclusion, the use of RT-PCR allowed rapid, sensitive, and specific detection of enteroviral RNA in CSF. When used to guide IVIg treatment, RT-PCR may shorten hospitalization and improve outcomes of patients with enteroviral encephalitis.

In spring, windblown dust storms originating in the deserts of Mongolia and China travel to Taipei city. These occurrences are known as Asian dust storm (ADS) events. The objective of this study was to assess the possible associations of constituents of ADS with hospital pneumonia admissions of residents in Taipei, Taiwan, during the period 1996-2001. Fifty-four dust storm episodes were identified and were classified as index days. Daily pneumonia admissions on the index days were compared with admissions on comparison days. Two comparison days for each index day, 7 d before the index days and 7 d after the index days, were selected. The study results indicated a statistically significant association between ADS events and daily pneumonia admissions 1 d after the event. It is worthwhile to pay more attention to ADS events and health in the future based on the findings in this investigation.

Human metapneumovirus (HMPV) has been described as a human pathogen associated with respiratory disease in most parts of the world from all age groups. This report presents the first 4 cases of HMPV disease confirmed by the sequences of PCR products in Taiwan.

Background: The Taiwan19F-14 Streptococcus pneumoniae clone and its variants are being found with increasing frequency in the Asia-Pacific region. A 5-year old child with S. pneumoniae meningitis caused by a high-level penicillin resistant strain (MIC = 4 microg/ml) was admitted to a hospital in southern Taiwan. We carried out a study to determine the potential source of this strain., Methods: Nasopharyngeal cultures were obtained from all children attending the same kindergarten as the index case. To determine their relatedness all isolates were compared by serotype, antimicrobial susceptibility profile and pulsed field gel electrophoresis (PFGE)., Results: A high proportion of the children including the index case (32/78, 41.0%) carried S. pneumoniae in their nasopharynx (NP). The most common serotype was 19F (13/32, 40.6%). The PFGE types of the 19F serotype isolates obtained from the patient's blood, CSF and NP were identical and were related to 11 other serotype 19F NP isolates including 10 that were indistinguishable from the Taiwan19F-14 clone. All 14 isolates had similar high-level penicillin and multi-drug resistance. The serotypes of the other 19 NP isolates included 6A (2), 6B (10), 23F (5), 9V (1) and 3 (1). The overall rate of penicillin resistance in these S. pneumoniae from these children was 87.5% (28/32), with an MIC50 of 2 and MIC90 of 4 ug/ml. In addition, multi-drug resistant-isolates (isolates resistant to 3 different classes of antimicrobials) accounted for 87.5% (28/32) of all isolates., Conclusion: The high carriage rate of high-level penicillin- and multi-drug- resistant S. pneumoniae in a kindergarten associated with a case of pneumococcal meningitis emphasizes the need for restraint in antibiotic use and consideration of childhood immunization with conjugate pneumococcal vaccine to prevent the further spread of resistant S. pneumoniae in Taiwan.

The objective of this study was to examine the relationship between indoor environmental factors and atopic eczema in a subtropical area. A case-control study was performed using participants from a survey that included 144 school children with atopic eczema and 144 age- and gender-matched controls. The study was confined to 4,164 primary school children aged 6-12 yr attending 8 primary schools in Kaohsiung rural municipalities who participated in the study. Cases of atopic eczema were ascertained by asking whether a physician had ever diagnosed this condition in the child. Information regarding the home environment was obtained using a structured written questionnaire, completed by the parents of the children. Of the many indoor environmental factors included in this study, such as dampness and smoking, none was found to be associated with atopic eczema.

The relationship between mortality from breast cancer and the levels of calcium and magnesium in drinking water was examined using an ecological design. The study area consisted of 2.52 municipalities in Taiwan. Data on the levels of calcium and magnesium in drinking water were collected from the Taiwan Water Supply Corporation (TWSC). The age-standardized mortality rate (ASR) for breast cancer ( 1982-1991) was compared among municipalities with different levels of magnesium and calcium in drinking water. Weighted multivariate regression analysis was used, and after adjusting for fertility rates and urbanization, there was a significant inverse relationship between the levels of calcium and magnesium in drinking water and risk of death from breast cancer.

The possibility that cancer risk is associated with naturally fluoridated water in Taiwan is examined. The 1982-1991 age-adjusted mortality rates for cancer for 10 municipalities whose water supplies contained the highest naturally occurring fluoride concentrations in Taiwan were compared to those rates for 10 matched municipalities with unfluoridated water. The two groups had similar urbanization levels and sociodemographic characteristics. Our study does not support the suggestion that fluoridation of water supplies is associated with an increase in cancer mortality in Taiwan., (Copyright 2000 Academic Press.)

The possible association between the risk of esophageal cancer and hardness levels in drinking water from municipal supplies was investigated in a matched case-control study in Taiwan. All eligible esophageal cancer deaths (2084 cases) of Taiwan residents from 1987 through 1996 were compared with deaths from other causes (2084 controls), and the hardness levels of the drinking water used by these residents were determined. Data on water hardness throughout Taiwan have been collected from the Taiwan Water Supply Corporation (TWSC). The control group consisted of people who died from other causes and the controls were pair-matched to the cases by sex, year of birth, and year of death. The results show that there is a 42% excess risk of mortality from esophageal cancer in relation to the use of soft water (adjusted odds ratio and 95% confidence intervals was 1.42 (1.22-1.66). This is an important finding for the Taiwan water industry and human health., (Copyright 1999 Academic Press.)

This report examines whether magnesium in drinking water is protective against the probability of dying from diabetes mellitus. All eligible deaths from diabetes (6781 cases) of Taiwan residents from 1990 through 1994 were compared with deaths from other causes (6781 controls), and the levels of magnesium in the drinking water of these residents was determined. Data on magnesium levels in drinking water throughout Taiwan were obtained from the Taiwan Water Supply Corporation (TWSC). Controls were pair matched to the cases by sex, year of birth, and year of death. The results of the present study show that there seems to be a significant protective effect of magnesium intake from drinking water on the risk of dying from diabetes mellitus. This is an important finding for the Taiwan water industry and human health.

To investigate the relationship between petrochemical air pollution and female lung cancer, we conducted a matched case-control study among women who had died in Taiwan from 1990 through 1994. Data about all eligible female lung cancer deaths were obtained from the Bureau of Vital Statistics of the Taiwan Provincial Department of Health. The control group included women who died from nonneoplasms and diseases that were not associated with respiratory problems. We pair-matched the controls to the cases by sex, year of birth, and year of death. Each matched control was selected randomly from the set of possible controls for each case. We used the proportion of a municipality's total population employed in the petrochemical manufacturing industry as an indicator of a resident's exposure to air emissions from the petrochemical manufacturing industry. The subjects were divided into tertiles according to the above indicator. Women who lived in the 2 groups of municipalities characterized by higher levels of petrochemical pollution had a statistically significant higher risk of developing lung cancer than the group that lived in municipalities with the lowest petrochemical air pollution levels (after controlling for possible confounders). The linear trend was also statistically significant (p < .05). The results of this study shed important light on the relationship between the Taiwan petrochemical industry and the resulting risk to human health.

The possible association between the risk of pancreatic cancer mortality and hardness levels in drinking water from municipal supplies was investigated in a matched case-control study in Taiwan. All eligible pancreatic cancer deaths (883 cases) of Taiwan residents from 1990 through 1994 were compared with deaths from other causes (883 controls), and the hardness levels of the drinking water used by these residents were determined. Data on water hardness throughout Taiwan was collected from Taiwan Water Supply Corporation (TWSC). The control group consisted of people who died from other causes and were pair matched to the cancer cases by sex, year of birth, and year of death. The results show that there is a 39 % excess risk of mortality from pancreatic cancer in relation to the use of soft water. Trend analyses showed an increasing odds ratio for pancreatic cancer with decreasing levels of hardness in drinking water. This is an important finding for the Taiwan water industry and human health.

The objective of this study was to examine the relationship between indoor environmental factors and acute otitis media in a subtropical area. A case-control study was performed using participants from a prevalence survey that included 219 school children with acute otitis media and 219 age- and gender-matched controls. The study was confined to 4164 primary school children aged 6-12 yr attending 8 primary schools in Kaohsiung rural municipalities who participated in a prevalence study of the health effects of an indoor environment. An acute otitis media case was defined as a child with acute symptoms (presenting with earache, fever, irritability, and/or discharge from the ear) diagnosed by a physician in the previous year. Controls selected from the same school did not have chronic or acute respiratory illness or an ear-related illness during the same period. Information regarding the home environment was obtained using a structured written questionnaire, completed by the parents of the children. Of the many indoor environmental factors included in this study, only living in a home with indications of dampness (mold, flooding, home dampness) showed an association with acute otitis media. It was concluded that dampness in the home is a new public health issue in subtropical areas.

Objectives: To determine the incidence of nonfatal school-related injuries in adolescent schoolchildren., Design: Nurses completed a Student Accident Report Form (SARF) on all injuries in schools meeting standardized criteria from September 1995 to June 1996., Setting: Six junior high schools in Kaohsiung city, Taiwan., Subjects: 13,335 adolescents aged 13-15 in six schools., Results: A total of 3,640 injuries were reported among the city's 13,335 students, for an overall injury rate of 27.3 injuries/100 student years. Injury rates were higher for boys than for girls at all grade levels. The seventh-grade students had the highest incidence rate. Injuries not involving other students accounted for nearly 64% of all injuries. Injuries occurring on the playground/gymnasium and classroom were the two most common types and were more than twice as frequent as injuries occurring in the hall or stairs. Contusions, abrasions, and swelling were the most frequently reported types of injuries. The body sites most frequently injured were the extremities. When exposure time is taken into account, injury rates were higher in the unsupervised areas of the schools., Conclusions: School-related injury incidence among adolescents attending junior high school is higher than has been previously reported and should be recognized as a significant public health problem in Taiwan.

Chlorination has been the major strategy for disinfection of drinking water in Taiwan. An ecologic epidemiological study design was used to examine whether chlorination of drinking water was associated with cancer risks. A "chlorinating municipality" (CHM) was defined as one in which more than 90% of the municipality population was served by the chlorinated water while an "nonchlorinating municipality" (NCHM) was one in which less than 5% of the municipality population was served by chlorinated water. Age-adjusted mortality rates for cancer during 1982-1991 among the 14 CHMs were compared to rates among the 14 matched NCHMs with similar urbanization level and sociodemographic characteristics. The results of this study suggest a positive association between consumption of chlorinating drinking water and cancer of the rectum, lung, bladder, and kidney. Although these findings must be interpreted with caution because of limitations in the ecological study design, their public health significance should not be disregarded because chlorination of water is so widely practiced in Taiwan.

The possible association between the risk of colon cancer and the levels of calcium and magnesium in drinking water from municipal supplies was investigated in a matched case-control study in Taiwan. All eligible colon cancer deaths (1714 cases) of Taiwan residents from 1989 through 1993 were compared with deaths from other causes (1714 controls), and the levels of calcium and magnesium in drinking water of these residents were determined. Data on calcium and magnesium levels in drinking water throughout Taiwan were obtained from the Taiwan Water Supply Corporation. The control group consisted of people who died from other causes and the controls were pair-matched to the cases by sex, year-of-birth, and year-of-death. The adjusted odd ratios (95% confidence interval) were 0.79 (0.64-0.98) for the group with water calcium levels between 24.4 and 42.3 mg/liter and 0.58 (0.47-0.73) for the group with calcium levels of 42.4 mg/liter or more. The adjusted odd ratios were not statistically significant for the relationship between magnesium levels in drinking water and colon cancer. The results of the present study show that there is a significant protective effect of calcium intake from drinking water against colon cancer.

This study was conducted to determine whether indoor environmental factors affected respiratory symptoms in 4164 primary school children in Kaohsiung rural areas of Taiwan. Information on respiratory health symptoms and characteristics of the housing was obtained using a written questionnaire, completed by the parents of children. Multiple logistic regression analysis examined the relationship between respiratory health symptoms (cough, wheezing, bronchitis, asthma, and allergic rhinitis) and housing factors. Home dampness was significantly associated with all respiratory health symptoms. Incense burning and mosquito repellant burning showed effects on the reporting of coughing symptoms. No apparent associations were found with the other indoor factors included in this study or respiratory health symptoms. We conclude that dampness in the home has a pronounced effects on respiratory health symptoms and is a new public health issue in subtropical areas.

The possible association between the risk of gastric cancer and nitrate and hardness in drinking water from municipal supplies was investigated in a matched case-control study in Taiwan. Data on gastric cancer deaths among eligible residents in Taiwan from 1987 through 1991 (6,766 cases) were obtained from the Bureau of Vital Statistics of the Taiwan Provincial Department of Health. Controls were deaths from other causes (6,766 controls) and were matched individually to the cases by sex, year of birth, and year of death. Data on nitrate-nitrogen (NO3-N) and hardness levels in drinking water throughout Taiwan were collected from the Taiwan Water Supply Corporation (TWSC). The municipality of residence for cases and controls was assumed to be the source of the subject's nitrate and hardness exposure via drinking water. There was no difference in gastric cancer rates between the groups with different levels of nitrate. The odds ratios (95% confidence interval) for death from gastric cancer was 0.95 (0.87-1.03) for the group with water nitrate levels between 0.23 and 0.44 mg/L, and 1.02 (0.93-1.11) for the group with nitrate levels greater than 0.45 mg/L. However, the results show a significant negative relationship between drinking water hardness and gastric cancer mortality. Odds ratios were 1.16 (1.07-1.26) and 1.65 (1.52-1.79), respectively, for exposure to moderately hard water and soft water compared with the use of hard water. This is an important finding for the Taiwan water industry and human health risk.

Mortality from motor vehicle crashes within five urbanization categories in Taiwan between 1981 and 1990 was investigated. Sex-specific standardized mortality ratios (SMRs) were calculated within each urbanization category for motor vehicle crash deaths. Most urban areas demonstrated lower SMRs for both males and females. In contrast, most rural areas exhibited higher SMRs for both males and females. Both males and females demonstrated a significant linear relationship between decreasing urbanization and increasing SMRs for motor vehicle crash mortality. A variety of factors may underlie the inverse correlation between SMRs for motor vehicle crashes and urbanization category. These data are most useful in generating hypotheses for further studies to define specific etiological factors operating within urbanization categories.

The relationship between death from cerebrovascular disease and the levels of magnesium and calcium in drinking water was examined using an ecological design. The study area consisted of 227 municipalities in Taiwan. Data on the levels of magnesium and calcium in drinking water have been collected from the Taiwan Water Supply Corporation (TWSC). These levels of magnesium and calcium were compared using the standardized mortality ratios (SMRs) for cerebrovascular disease (1981-1990). A statistically significant inverse relationship was present between cerebrovascular mortality and levels of both magnesium and calcium after adjusting for urbanization index. After adjustment for calcium levels in drinking water and urbanization index, the weighted multivariate-adjusted regression coefficient indicated a decrease of 0.248 in the standardized mortality ratios (SMRs) for every 100 mg/L increase in magnesium levels in drinking water. The results from this study strengthen the hypothesis that magnesium in drinking water helps to prevent death from cerebrovascular disease.

Reported herewith are the results from an ongoing study of outdoor air pollution and the health of persons living in the communities in close proximity to petrochemical industrial complexes. To determine if there is an excess of adverse health outcomes in the population exposed to petrochemical industrial emissions, a health survey was undertaken in 1996 in this area and in one reference area which has no local industrial emissions. The subjects were 436 adults (30-64 years of age) living in the Sanwei area (exposed area) and 488 in Taicei (reference area). For several indicators of respiratory health, including cough, wheezing, and chronic bronchitis, the prevalence rates were not significantly different between the study and the control populations. Acute irritative symptoms (eye irritation, nausea, throat irritation, and chemical odor perception) were significantly more common in the exposed area, particularly perception of chemical odors (84.6% vs 2.1%). It is concluded that exposure to petrochemical air emissions may be associated with increased rates of acute irritative symptoms. Future studies are needed to identify the potential role of petrochemical industrial emissions (particularly volatile organic compounds) in the genesis of acute irritative symptoms in a nearby petrochemical industrial area.