Genitourinary infections caused by nontuberculous mycobacteria at a university hospital in Taiwan, 1996–2008

Genitourinary infections caused by nontuberculous mycobacteria (NTM) are rarely reported. The medical records of all patients with genitourinary NTM infections treated at National Taiwan University Hospital from 1996–2008 were retrospectively reviewed. Fifteen patients were identified, of whom 10 (67%) were male. More than two-thirds of patients had underlying conditions, the most common of which was chronic renal disease. Only one patient had AIDS. Acid-fast smears of urine were negative in all patients. Eleven isolates were available for further confirmation by sequencing of the 16S rRNA gene. Mycobacterium avium complex was the most common (n = 5, 33%), followed by both Mycobacterium abscessus (n = 2; 13%) and Mycobacterium fortuitum (n = 2; 13%). Of the 12 patients receiving anti-NTM treatment, only four received adequate prescribed regimens and none died of NTM infections. Two patients died of refractory urosepsis before the urinary NTM infections were diagnosed. The clinical characteristics of the 15 patients were also compared with 43 previously reported patients with genitourinary tuberculosis. Patients with genitourinary NTM infections were more likely to report constitutional symptoms, seek medical help within 1 month after the onset of symptoms and develop leukocytosis. Patients with genitourinary tuberculosis were more likely to have ureteral strictures and abnormal chest radiographs associated with active or inactive tuberculosis. Although rare, genitourinary NTM infections pose a significant threat to life and should be considered in the differential diagnosis of genitourinary infections, especially when patients are unresponsive to conventional antibiotic treatment.     

Invasive infections caused by non-Aspergillus moulds identified by sequencing analysis at a tertiary care hospital in Taiwan, 2000–2008

The clinical and microbiological characteristics of 103 patients with cultures positive for non-Aspergillus moulds in the period 2000 to 2008 were described. Among these patients, 27 had proven or probable invasive infections caused by Fusarium (n = 12), Paecilomyces (n = 7), Zygomycetes (n = 5) and Scedopsorium species (n = 3). The incidence of invasive infections caused by these moulds has not increased during the study period. Lung was the most common infection site and disseminated disease was observed in three leukaemic patients. The overall mortality rate was 40.7%, and was highest in cases zygomycosis. Antifungal susceptibility varied considerably among species. Amphotericin B and posaconazole demonstrated greatest activity against these moulds.     

Bacteremia caused by Acinetobacter junii at a medical center in Taiwan, 2000–2010

We investigated the clinical characteristics and outcomes of 43 patients with Acinetobacter junii bacteremia at a 2,500-bed tertiary care center in northern Taiwan. These organisms were confirmed to the species level by an array assay and 16S rRNA gene sequence analysis. The antimicrobial susceptibilities of the 43 A. junii isolates to 13 agents were determined using the agar dilution method. Susceptibility testing for tigecycline was determined using the broth microdilution method. Most of the patients were hospital-acquired (n?=?36, 83.7?%) or healthcare facility-related infections (n?=?6, 13.9?%), and 55.8?% had impaired immunity. Central venous access devices were present in 35 (81.4?%) patients; among the total of 43 patients with A. junii bacteremia, 8 patients were diagnosed as catheter-related bloodstream infection and 19 patients were diagnosed as catheter-associated bloodstream infection. Shock requiring inotropic agents occurred in 2 patients (4.6?%). Most patients developed bacteremia in general wards (n?=?36, 83.7?%). The overall in-hospital mortality rate was low (7?%), despite the low rate of removal of central venous devices, low rate of holding usage of original central venous devices, and high rate of inappropriate antimicrobial regimens. Carbapenems, fluoroquinolones, and amikacin had potent activity (>95?% susceptible rate) against A. junii isolates. Interestingly, 35?% of the A. junii isolates were resistant to colistin. Tigecycline exhibited low minimum inhibitory concentration (MIC) values (range, 0.06-2 μg/ml, MIC(90), 1 μg/ml) against the A. junii isolates.     

Clinical manifestations of candidemia caused by uncommon Candida species and antifungal susceptibility of the isolates in a regional hospital in Taiwan, 2007–2014

ObjectiveThis retrospective study investigated clinical manifestations of candidemia caused by uncommon Candida species and antifungal susceptibility of the isolates in a regional hospital in Taiwan.MethodsThe uncommon Candida species was initially defined as Candida species other than C. albicans, C. tropicalis, C. glabrata complex, C. parapsilosis complex and C. krusei. All uncommon Candida isolates were identified and confirmed by molecular methods. In vitro susceptibility testing of the uncommon Candida species to nine antifungal agents was conducted using the broth microdilution method with the Sensititre YeastOne (SYO) system (Trek Diagnostic Systems, Ltd., East Grimstead, UK).ResultsTwenty-one patients, comprising 11 males and 10 females with a median age of 69 years, were recruited. Cancer (n = 11) was the most common underlying disease, 19 (90.5%) cases had prior antibiotic exposure, and only two patients had prior antifungal use. The overall in-hospital mortality rate was 38.1% (n = 8). C. guilliermondii (n = 11) was the most common pathogen, followed by C. curvata (n = 3). C. guilliermondii isolates exhibited relatively high rates of azole minimum inhibitory concentrations (MICs) above epidemiological cut-off values (ECVs), whereas C. pelliculosa and C. lusitaniae isolates all remained susceptible to azoles. All three C. curvata isolates had high caspofungin (>8 mg/L) and fluconazole MICs (8 mg/L) and could be defined as multidrug-resistant.ConclusionsUncommon Candida species frequently exhibit high rates of non-susceptibility to antifungals. Identification of all Candida isolates at the species level from blood samples is of value for treatment.     

Pneumonia caused by Aeromonas species in Taiwan, 2004–2011

We investigated the clinical characteristics of patients with pneumonia caused by Aeromonas species. Patients with pneumonia caused by Aeromonas species during the period 2004 to 2011 were identified from a computerized database of a regional hospital in southern Taiwan. The medical records of these patients were retrospectively reviewed. Of the 84 patients with pneumonia due to Aeromonas species, possible Aeromonas pneumonia was diagnosed in 58 patients, probable Aeromonas pneumonia was diagnosed in 18 patients, and pneumonia due to Aeromonas was conclusively diagnosed in 8 patients. Most of the cases of Aeromonas pneumonia developed in men and in patients of advanced age. A. hydrophila (n?=?50, 59.5 %) was the most common pathogen, followed by A. caviae (n?=?24, 28.6 %), A. veronii biovar sobria (n?=?7, 8.3 %), and A. veronii biovar veronii (n?=?3, 3.6 %). Cancer (n?=?37, 44.0 %) was the most common underlying disease, followed by diabetes mellitus (n?=?27, 32.1 %). Drowning-associated pneumonia developed in 6 (7.1 %) patients. Of 47 patients who were admitted to the intensive care ward, 42 patients developed acute respiratory failure and 24 of those patients died. The overall in-hospital mortality rate was significantly associated with liver cirrhosis, cancer, initial presentation of shock, and usage of mechanical ventilation. In conclusion, Aeromonas species should be considered as one of the causative pathogens of severe pneumonia, especially in immunocompromised patients, and should be recognized as a cause of drowning-associated pneumonia. Cirrhosis, cancer, and shock as the initial presenting symptom are associated with poor outcome.     

Bacteremia caused by <Emphasis Type="Italic">Brevundimonas</Emphasis> species at a tertiary care hospital in Taiwan, 2000–2010

We investigated clinical and microbiological characteristics of 30 patients with Brevundimonas bacteremia treated at a tertiary care hospital in Taiwan during 2000–2010. All the 30 bacteria isolates were confirmed to the species level by 16S rRNA sequencing analysis. Minimum inhibitory concentrations (MICs) of 11 antimicrobial agents against these isolates were determined by the agar dilution method. Seventeen (57%) patients had underlying malignancy, 12 (40%) had undergone central catheter placement, and 13 (43%) had received chemotherapy within the previous three months. Eight (27%) patients had community-acquired bacteremia and the remaining 22 patients (73%) had healthcare-associated bacteremia. The overall 14-day and 30-day mortality rates were 13% and 17%, respectively. Among the 30 isolates, B. vesicularis constituted most commonly (n = 22, 63%), followed by B. nasdae (n = 5) and B. diminuta (n = 3). All isolates were susceptible to piperacillin-tazobactam and amikacin, while all were resistant to ciprofloxacin and colistin. Tigecycline (MICs at which 90% of isolates are inhibited [MIC₉₀] was 0.12 mg/L) and doripenem (MIC₉₀ of 1 mg/L) both possessed good in vitro activities. In conclusions, Brevundimonas should be considered a pathogen that can cause bacteremia in immunocompromised hosts. Piperacillin-tazobactam, amikacin, doripenem, and tigecycline exhibit good in vitro activities against these ciprofloxacin- and colistin-resistant Brevundimonas species.     

Community-onset Clostridium difficile infection at a tertiary medical center in southern Taiwan, 2007–2015

Background

Clostridium difficile infection (CDI) is well-known as the major cause of infectious diarrhea in hospitalized patients. Community-onset CDI (CO-CDI) is an emerging threat. However, clinical information of CO-CDI in Taiwan remains scarce.

Vancomycin-resistant Enterococcus faecium at a university hospital in Taiwan, 2002–2015: Fluctuation of genetic populations and emergence of a new structure type of the Tn1546-like element

Background/purposes

Vancomycin resistance increased significantly to 31.3% among Enterococcus faecium in 2006 and remained high thereafter at a university hospital in Taiwan. A longitudinal study was retrospectively conducted to characterize these vancomycin-resistant E. faecium (VRE-fm).

Evolution of the antibiotic resistance of Streptococcus pneumoniae from 1997 to 2004 at Hôtel-Dieu de France, a university hospital in Lebanon

Various rates of Streptococcus pneumoniae with diminished susceptibility to Penicillin G (PNSP) are reported worldwide, while resistance to cefotaxime and ceftriaxone is actually increasing among S. pneumoniae. The aim of this survey was to determine the evolution of the susceptibility and resistance of S. pneumoniae at our hospital, throughout the years 1997-2004. 582 S. pneumoniae strains, isolated from different patients with pulmonary disease, otitis media, bacteremia and/or meningitis have been observed. MIC to benzylpenicillin (P), ampicillin (AMP) and ceftriaxone (CRO) were determined by E-TEST. Susceptibility to erythromycin (ERY), cotrimoxazole (SXT), tetracycline (TE) and rifampicin (RA) were determined by agar diffusion. All tests were interpreted according to CA-SFM guidelines. The percentage of PNSP varied between 49.6 and 69%. S. pneumoniae with reduced susceptibility to benzylpenicillin had stable rates, while fully resistant S. pneumoniae decreased significantly. Resistance to ampicillin varied alongside with penicillin with a decrease of fully resistant S. pneumoniae. Strains intermediate to ceftriaxone also decreased significantly while those fully resistant were not detected, except for 1999 (1 strain). The resistance (I+R) to SXT and TE remained stable with small variations, but resistance to ERY increased up to 43% of isolated strains in 2004. Resistance to LVX and RA was absent, with unexpected levels for RA (1 and 5%) in 2002 and 2003.     

Suicide by charcoal burning in Taiwan, 1995–2006

BackgroundWe sought to identify risk factors and trends that might underlie the greatly increased incidence of charcoal-burning suicide in Taiwan and to learn whether the increasing accessibility of a single suicide method can increase overall suicide rates.MethodsData from a national mortality register for subjects who committed suicide during 2001 to 2006 and who were 15 years old or older when they died was analyzed. A review of available evidence and comparisons with historical cases were also performed.ResultsFrom 1995 to 2006, 68% of suicides in Taiwan involved males, and suicide rates for men increased from 9.5 to 26.7 per 100,000 population; suicide rates for women rose from 5.6 to 11.7 per 100,000 population. The sex ratio (M:F) increased from 1.69:1 to 2.28:1. The greatest increase in suicide rates occurred among those 25–44 years of age. The incidence of charcoal-burning suicide was 0.22 per 100,000 in 1999 but reached 6.48 per 100,000 in 2006. Age, gender, marital status, and year of committing suicide were significant predictors for suicide by charcoal burning. This single suicide method accounted for 33.5% of suicide deaths in Taiwan in 2006.LimitationsThe number of suicides by charcoal burning may be under- or overestimated, and life events of the suicide subjects were not analyzed.ConclusionsRomanticizing suicide by charcoal burning by the media and cultural influences may have contributed to the increased suicides. Prohibiting sale of charcoal in convenience stores, enforcing media guidelines, and setting up carbon monoxide detectors may help prevent suicide by charcoal burning.     

Molecular epidemiology of extended-spectrum β-lactamase-producing Klebsiella pneumoniae strains in a university hospital in Tunis,Tunisia, 1999–2005

During a period of 6 years and 5 months (January 1999 to May 2005), 103 extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae isolates, each from an individual patient or site, were collected at Mongi Slim University Hospital Centre, Tunis, Tunisia. The objectives of our work were the characterization of the bla genes encoding ESBLs, the investigation of clonal diversity of strains, and identification of the transmission modes of the resistance genes. We carried out detection by PCR and sequencing of the bla_SHV, bla_CTX-M and bla_TEM genes, transferability studies, plasmid replicon typing, and analysis by multilocus sequence typing (MLST) on selected isolates. Forty-seven isolates were found to be producers of CTX-M-type ESBLs, of which 43 were CTX-M-15, two CTX-M-14 and two CTX-M-27. Fifty-eight isolates were producers of SHV-12, and three were producers of SHV-2a. More than one ESBL was detected in seven isolates, as five produced both CTX-M-15 and SHV-12, and two produced both CTX-M-27 and SHV-12. By a PCR-based replicon typing method, the plasmids carrying the bla_SHV-2a or bla_CTX-M-15 genes were assigned to IncFII or, more rarely, to IncL/M types. Of 12 plasmids carrying the bla_SHV-12 gene, only one could be typed: it was positive for the H12 replicon. The MLST results showed large genetic background diversity in the SHV-12-producing isolates and dissemination of specific clones of the CTX-M-15-producing isolates within the same ward and among wards, and suggested endemicity with horizontal dissemination of the bla_CTX-M-15 and the bla_SHV-12 genes.     

Clinical and microbiological characteristics of Nocardiosis including those caused by emerging Nocardia species in Taiwan, 1998–2008

The genus of Nocardia is rapidly expanding and the species distribution varies with different geographical locations. We retrospectively reviewed the laboratory records of the bacteriology laboratory at National Taiwan University Hospital from January 1998 to June 2008 to identify patients with nocardiosis. During the study period, 164 isolates of Nocardia spp. were identified from 134 patients but only 113 patients had Nocardia infection. Nocardia brasiliensis (n = 54) was the most common pathogen, followed by N. asteroides (n = 36), N. farcinica (n = 7), N. flavorosea (n = 4), N. otitidiscaviarum (n = 3), N. nova (n = 3), N. beijingensis (n = 2) and one each of N. puris, N. jinanensis and N. takedensis. The major types of infection were cutaneous infection (56.6%), pulmonary infection (33.6%) and disseminated infection (7.1%). Eighty-eight patients received sulfonamide-containing antibiotic and eight of 100 patients with available data on outcomes died during the episode of nocardiosis. In conclusion, the clinical and microbiological manifestations of Nocardiosis vary with the different Nocardia species. Accurate identification of the species is crucial to make the diagnosis.     

Using computed tomography colonography in patients at high risk of colorectal cancer – a prospective study in a university hospital in South America

OBJECTIVES:

The purpose of our study was to report the results of the implementation of computed tomography colonography in a university hospital setting serving a Brazilian population at high risk of colorectal cancer.

METHODS:

After creating a computed tomography colonography service in our institution, 85 patients at high risk of colorectal cancer underwent computed tomography colonography followed by a same-day optical colonoscopy from September 2010 to May 2012. The overall accuracy of computed tomography colonography in the detection of lesions ≥6 mm was compared to that of optical colonoscopy (direct comparison). All colonic segments were evaluated using quality imaging (amount of liquid and solid residual feces and luminal distension). To assess patient acceptance and preference, a questionnaire was completed before and after the computed tomography colonography and optical colonoscopy. Fisher''s exact test was used to measure the correlations between colonic distension, discomfort during the exam, exam preference and interpretation confidence.

RESULTS:

Thirteen carcinomas and twenty-two lesions ≥6 mm were characterized. The sensitivity, specificity and accuracy of computed tomography colonography were 100%, 98.2% and 98.6%, respectively. Computed tomography colonography was the preferred method of investigation for 85% of patients. The preparation was reported to cause only mild discomfort for 97.6% of patients. According to the questionnaires, there was no significant relationship between colonic distension and discomfort (p>0.05). Most patients (89%) achieved excellent bowel preparation. There was a statistically significant correlation between the confidence perceived in reading the computed tomography colonography and the quality of the preparation in each colonic segment (p≤0.001). The average effective radiation dose per exam was 7.8 mSv.

CONCLUSION:

It was possible to institute an efficient computed tomography colonography service at a university hospital that primarily assists patients from the public health system, with high accuracy, good acceptance and effective radiation doses. Our results seem to be comparable to other centers of excellence and fall within acceptable published guidelines, showing that a successful computed tomography colonography program can be reproduced in a South American population screened in a university hospital.     

In a disaster, what should medical technologists at a university hospital do? What do they have?

"Disaster medicine" involves "cases that cannot be supported by the normal medical service system of the hospital because many injuries have occurred by an explosion/chemical pollution/radioactive pollution or a pandemic caused deliberately as well as natural disasters". In "disaster medicine", university hospitals should become the base for advanced medical services and wide area transportation. Also, the clinical laboratory/medical technologists of the university hospital should offer high quality laboratory analysis. On the other hand, one of the advantages of a university hospital is an experimental medicine laboratory (integrated universities also have a Department of Science and Department of Engineering). Development of testing equipment to cover all the functions necessary for disaster medicine may be a possibility. A system to conduct simple testing is expected at the actual location of the emergency, and an identification system must be established. "Emergency medicine" and "disaster medicine" have different aspects, but the essence is the same, and medical technologists must have knowledge/techniques to report and interpret results quickly. Because a university hospital is the core of logistical support, daily training is important.     

Culture-positive invasive aspergillosis in a medical center in Taiwan, 2000–2009

We reviewed 776 patients who were culture positive for Aspergillus species at the hospital from 2000 to 2009. The isolates were collected for species identification by oligonucleotide hybridization and sequence analysis. A total of 96 cases of proven or probable IA were identified according to published criteria. The incidence of IA has increased significantly during the study period. Aspergillus fumigatus and A. flavus (41.7% each) were equally prevalent causative species. IA due to unusual species including A. nidulans (n=2), A. versicolor (n=2), and A. tubingensis (n=1) were also found. Among patients with IA, 55.2% had hematological disorder, 19.8% had underlying lung disorder, and 10.4% had autoimmune disease. The isolates species (P<0.001) and underlying disease (P<0.001) significantly affect the association of a positive culture with invasive disease. The overall mortality at three months was 62.5%, which remained stable throughout the study period. Multivariate analysis identified prior steroid use (P=0.007) as a significant risk factor for death, while surgery (P=0.030) and voriconazole (P=0.012) had protective effects. In conclusion, autoimmune disorders and underlying pulmonary diseases should also be considered as important predisposing factors of IA. Further emphasis on surgery and voriconazole in the management of IA might be beneficial.