[A study of the effectiveness of nucleos(t)ide analogues in the treatment of HBeAg- positive chronic hepatitis B with normal alanine aminotransferase and high level of HBV DNA]

Objective: To investigate the effectiveness of nucleos(t)ide analogues in the treatment of HBeAg-positive chronic hepatitis B with normal alanine aminotransferase and high level of HBV DNA. Methods: Treatment-naïve chronic hepatitis B patients who were followed up at the Center of Infectious Diseases, West China Hospital of Sichuan University from January 2019 to January 2020 were selected as subjects. Demographic characteristics, the results of laboratory examination before treatment and one year after treatment were retrospectively collected. Patients were divided into tenofovir dipivoxil (TDF) and propofol fumurate tenofovir (TAF) treatment group according to different types of medication. The changes of serum HBV DNA level, HBeAg serological conversion and HBsAg quantitative level were analyzed and compared between the two groups. Results: A total of 38 cases were enrolled. Among them, there were 16 and 22 cases in the TDF and TAF group, respectively. There was no statistically significant difference in demographic characteristics, baseline HBV DNA levels and HBsAg quantitative levels between the two groups. Virological response was achieved in 60.5% (23/38) of patients after one year of antiviral therapy. Serum HBV DNA levels below the lower limit of detection [68.2% (15/22) vs. 50.0% (8/16), P=0.258] and higher HBeAg seroconversion rate [18.2%] (4/22) vs. 6.3% (1/16), P=0.374] was obtained in TAF than TDF group; however, there was no statistically significant differences between the two. Serum HBsAg quantitative level was significantly reduced with TDF and TAF treatment. In addition, alanine aminotransferase elevation was reduced in TAF than TDF treated group. Multivariate logistic regression analysis showed that patient age was an independent predictor of a virological response to antiviral therapy. Conclusion: HBeAg-positive CHB patients with normal alanine aminotransferase, and high HBV DNA level can obtain better curative effect after TDF and TAF treatment.

A compact electron beam ion trap in support of high-temperature plasma diagnostics based on conduction-cooled superconducting coils

Spectroscopic diagnostics of future fusion reactor plasmas require information on impurity line emissions, especially for relevant high-Z metal elements (e.g., tungsten). These materials will be widely used as plasma facing components for their high heat tolerance and low sputtering yield. Based on an electron beam ion trap, a compact impurity spectra platform is developed to mimic the high-temperature environment of a fusion reactor. The proposed platform can deliver a focused e-beam at energies over 30 keV using a confining magnetic field of ∼1.0 T generated by two superconducting coils (NbTi). Cooled by a closed-loop cryocooler, the coils can avoid the usage of a complicated cryogenic system involving the handling of liquid helium. For spectroscopic studies of highly charged ions, a spherically curved crystal spectrometer is proposed to measure a wavelength range around 2-4 Å covering the typical wavelength range expected to be emitted by metal ions in a fusion plasma. This paper reports the design and development progress of the platform.

Development and preliminary test of a space-resolved vacuum-ultraviolet spectroscopy in EAST

The impurity radiation from the divertor region of the EAST tokamak is dominantly in the wavelength range of vacuum ultraviolet (VUV) due to the elevated edge electron temperature. A space-resolved VUV spectroscopy is developed to measure impurity radiation in the divertor region. An eagle-type VUV spectrometer with a focal length of 1 m is adopted in this system, equipped with a spherical grating and a charged-coupled device (CCD) detector. The performance of the VUV spectrometer is preliminarily tested on a synchrotron radiation facility. The wavelength calibration is conducted near 65 nm. It is found that the wavelength range observed by the CCD detector is about 11.07 nm around the central wavelength of about 65 nm. With a linear dispersion of 0.0053 nm/pixel, it is possible to measure the ion temperature lower than 20 eV at the edge region by analyzing the Doppler broadening of a carbon line. These test results show that the performance of the VUV spectrometer is capable of measuring divertor radiation and analyzing the ion temperature of edge impurity ions.

[The 487th case: prominent eyes, headache, blurred vision]

One 51 years old man was admitted to the rheumatology department with a history of prominent eyes, headache and blurred vision for half year. The main manifestations included retrobulbar inflammatory pseudotumor and retroperitoneal fibrosis. He was initially diagnosed as granulomatosis with polyangiitis. Prednisone and cyclophosphamide were administrated and effective. New mass of dura mater and osteosclerosis presented during follow up. Finally Erdheim Chester disease(ECD) was diagnosed by biopsy and pathological examination. Vemurafenib, a v-raf murine sarcoma viral oncogenes homolog B1 (BRAF) inhibitor, 480 mg was given twice a day. The patient's condition is stable and still in follow-up. Although ECD is a rare histiocytosis, clinicians should pay attention to its manifestations and differential diagnoses.

Development of wavelength calibration techniques for high-resolution x-ray imaging crystal spectrometers on the EAST tokamak

Newly developed large-area pixelated two-dimensional detector and two-crystal assemblies were deployed for the first time on tokamaks to enable time-resolved Bragg-diffracted x-ray imaging with good framing rate and water-cooling capabilities for in-vacuum long-pulse operations. High-quality helium-like (He-like) and hydrogen-like (H-like) argon spectra have been observed simultaneously for the first time on a single detector for a wide range of plasma parameters to infer both ion temperature and rotation profiles and support studies on spontaneous rotation, impurity transport, and RF physics. Since tokamak plasmas rotate in both the poloidal (θ) and toroidal (ϕ) directions, a reliable wavelength calibration is needed to account for the correct Doppler shift as well as to compute the spectrometer's instrumental function. Ly_α lines emitted from Cd x-ray tubes are proposed to be used as "markers" to provide an in situ calibration of the EAST's X-ray imaging crystal spectrometer systems measuring He- and H-like argon spectra. The first lab test indicated that the X-ray tube can excite strong Ly_α lines at 15 kV voltage and 1 mA current when the crystal is shined for 10 min. Other indirect calibration methods using locked-mode discharge scenarios were also studied as complementary methods.

Upgrade of X-ray crystal spectrometer for high temperature measurement using neon-like xenon lines on EAST

A two-crystal X-ray spectrometer system has been implemented in the EAST tokamak to simultaneously diagnose high- and low-temperature plasmas using He- and H-like argon spectra. But for future fusion devices like ITER and Chinese Fusion Engineering Test Reactor (CFETR), argon ions become fully stripped in the core and the intensity of the H-like lines will be significantly at high temperatures (T_e > 5 keV). With increasing auxiliary heating power on EAST, the core plasma temperature could also reach 5 keV and higher. In such conditions, the use of a xenon puff becomes an appropriate choice for both ion-temperature and flow-velocity measurements. A new two-crystal system using a quartz 110 crystal (2d = 4.913 Å) to view He-like argon lines and a quartz 011 crystal (2d = 6.686 Å) to view Ne-like xenon spectra has been deployed on a poloidal X-ray crystal spectrometer. While the He-like argon spectra will be used to measure the plasma temperature in the edge plasma region, the Ne-like xenon spectra will be used for measurement in the hot core. The new crystal arrangement allows a wide temperature measurement ranging from 0.5 to 10 keV or even higher, being the first tests for burning plasmas like ITER and CFETR. The preliminary result of lab-tests, Ne-like xenon lines measurement will be presented.

Risk factors and outcome of levofloxacin-resistant Elizabethkingia meningoseptica bacteraemia in adult patients in Taiwan

Elizabethkingia meningoseptica is an emerging nosocomial pathogen associated with high mortality and inherently resistant to many antimicrobial agents. Levofloxacin has been considered as a therapeutic agent based on in vitro susceptibility. We aim to investigate the risk factors and outcomes for levofloxacin-resistant E. meningoseptica bacteraemia. Adult patients with E. meningoseptica bacteraemia were identified retrospectively in a medical centre in Taiwan from January 2011 to July 2015. These strains were identified by the Vitek2 automated system or matrix-assisted laser desorption-ionization time-of-flight mass spectrometry. We compared clinical features and outcomes of patients with levofloxacin-resistant (MIC >2 μg/mL) and levofloxacin-susceptible (MIC ≤2 μg/mL) E. meningoseptica bacteraemia. A total of 93 patients were identified, including 51 (54.8%) with levofloxacin-resistant E. meningoseptica bacteraemia. The APACHE II score (OR, 1.08; 95% CI, 1.02-1.14; p = 0.008) was the only independent risk factor for levofloxacin-resistant E. meningoseptica bacteraemia. The 14-day mortality for patients with levofloxacin-resistant E. meningoseptica bacteraemia (attributable mortality: 30.7%) was significantly higher than that for patients with the levofloxacin-susceptible strain (56.9% versus 26.2%, p = 0.003). In the multivariate analysis of risk factors for mortality, appropriate definite antibiotic use was the only factor associated with 14-day survival (OR, 0.11; 95% CI, 0.02-0.55, p = 0.007). The levofloxacin-resistant strain was borderline significantly associated with mortality (OR, 3.09; 95% CI, 0.88-10.91, p = 0.079). The early identification of levofloxacin resistance in E. meningoseptica isolates is important to tackle this multi-drug resistance pathogen.

[An analysis of clinical characteristics of twelve cases of mesenteric panniculitis]

Objective: Mesenteric panniculitis is an idiopathic, uncommon disease involving the adipose tissue of mesentery. The etiology, diagnosis and treatment are still unnoticed. We thus reported a case series to improve the understanding of this rare disorder. Methods: We retrospectively analyzed the clinical data of 12 patients with mesenteric panniculitis including manifestation, diagnosis, treatment and prognosis. Results: We found a male predominance (M∶F 3∶1) with the median age of 58 years old at diagnosis. The most common symptom was abdominal pain (9/12), followed by abdominal distension (3/12) and weight loss (3/12). Physical examination was unremarkable in the majority of patients (8/12). C reactive protein (9/12) and erythrocyte sedimentation rate (10/12) were normal in majority of patients. CT findings were of much diagnostic value. All patients had small intestinal mesentery involvement and multi-nodular appearance with increased fat density. Pseudo-capsule sign (8/12) and fat halo sign (6/12) were common. Pathological diagnosis was obtained in 4 cases showing fat tissue inflammation with local necrosis and fibrosis. Six cases all received prednisone, 2 with combined cyclophosphamide, 1 with azathioprine, 1 with tripterygium wilfordii. Short-term clinical response was achieved in all cases, but two patients relapsed. Conclusions: Mesenteric panniculitis occurs predominantly in middle-aged and elderly. Abdominal pain is the leading symptom. Inflammatory markers are often normal while computed tomography is the most important diagnostic tool. Surgery combined with cortical steroid and immunosuppressant agents is effective.

Measurement of helium-like and hydrogen-like argon spectra using double-crystal X-ray spectrometers on EAST

A two-crystal assembly was deployed on the tangential X-ray crystal spectrometer to measure both helium-like and hydrogen-like spectra on EAST. High-quality helium-like and hydrogen-like spectra were observed simultaneously for the first time on one detector for a wide range of plasma parameters. Profiles of line-integrated core ion temperatures inferred from two spectra were consistent. Since tungsten was adopted as the upper divertor material, one tungsten line (W XLIV at 4.017 Å) on the short-wavelength side of the Lyman-α line (Lα1) was identified for typical USN discharges, which was diffracted by a He-like crystal (2d = 4.913 Å). Another possible Fe XXV line (1.85 Å) was observed to be located on the long-wavelength side of resonance line (w), which was diffracted from a H-like crystal (2d = 4.5622 Å) on the second order. Be-like argon lines were also observable that fill the detector space between the He-like and H-like spectra.

Risk factors and outcome for colistin-resistant Acinetobacter nosocomialis bacteraemia in patients without previous colistin exposure

The clinical characteristics of patients with colistin-resistant Acinetobacter baumannii bacteraemia have been documented, but those of patients with bacteraemia caused by other Acinetobacter species remain unknown. Previous exposure to colistin has been shown to be associated with the emergence of colistin resistance, but may be not the only predisposing factor. In the current study, we highlight the risk and outcome of patients without previous exposure to colistin who acquired colistin-resistant Acinetobacter nosocomialis (ColRAN) bacteraemia. This 11-year single-centre retrospective study analysed 58 patients with ColRAN bacteraemia and 213 patients with colistin-susceptible A. nosocomialis (ColSAN) bacteraemia. Antimicrobial susceptibilities were determined with an agar dilution method. The clonal relationship of ColRAN isolates was determined with pulsed-field gel electrophoresis. A conjugation mating-out assay was conducted to delineate the potential transfer of colistin resistance genes. Multivariable analysis was performed to evaluate the risk factors for ColRAN bacteraemia. Chronic obstructive pulmonary disease (COPD) was independently associated with ColRAN bacteraemia (OR 3.04; 95% CI 1.45-6.37; p 0.003). Patients with ColRAN bacteraemia had higher APACHE II scores, but the two groups showed no significant differences in 14-day mortality (10.3% vs. 10.3%) or 28-day mortality (15.5% vs. 15.0%). ColRAN isolates had greater resistance than ColSAN isolates to all antimicrobial agents except for ciprofloxacin (0% vs. 6.6%). There were 16 different ColRAN pulsotypes, and two major clones were found. Colistin resistance did not transfer to colistin-susceptible A. baumannii or A. nosocomialis. These results show that COPD is an independent risk factor for acquisition of ColRAN bacteraemia. The mortality rates were similar between patients with ColRAN and ColSAN bacteraemia.

Upgrades of imaging x-ray crystal spectrometers for high-resolution and high-temperature plasma diagnostics on EAST

Upgrade of the imaging X-ray crystal spectrometers continues in order to fulfill the high-performance diagnostics requirements on EAST. For the tangential spectrometer, a new large pixelated two-dimensional detector was deployed on tokamaks for time-resolved X-ray imaging. This vacuum-compatible detector has an area of 83.8 × 325.3 mm(2), a framing rate over 150 Hz, and water-cooling capability for long-pulse discharges. To effectively extend the temperature limit, a double-crystal assembly was designed to replace the previous single crystals for He-like argon line measurement. The tangential spectrometer employed two crystal slices attached to a common substrate and part of He- and H-like Ar spectra could be recorded on the same detector when crystals were chosen to have similar Bragg angles. This setup cannot only extend the measurable Te up to 10 keV in the core region, but also extend the spatial coverage since He-like argon ions will be present in the outer plasma region. Similarly, crystal slices for He-like iron and argon spectra were adopted on the poloidal spectrometer. Wavelength calibration for absolute rotation velocity measurement will be studied using cadmium characteristic L-shell X-ray lines excited by plasma radiation. A Cd foil is placed before the crystal and can be inserted and retracted for in situ wavelength calibration. The Geant4 code was used to estimate X-ray fluorescence yield and optimize the thickness of the foil.

Magnetic topology changes induced by lower hybrid waves and their profound effect on edge-localized modes in the EAST tokamak

Strong mitigation of edge-localized modes has been observed on Experimental Advanced Superconducting Tokamak, when lower hybrid waves (LHWs) are applied to H-mode plasmas with ion cyclotron resonant heating. This has been demonstrated to be due to the formation of helical current filaments flowing along field lines in the scrape-off layer induced by LHW. This leads to the splitting of the outer divertor strike points during LHWs similar to previous observations with resonant magnetic perturbations. The change in the magnetic topology has been qualitatively modeled by considering helical current filaments in a field-line-tracing code.

Extracorporeal membrane oxygenation as treatment for acute respiratory failure and subsequent pneumothorax caused by Pneumocystis jirovecii pneumonia in a kidney transplant recipient

Acute respiratory failure (ARF) accompanied by pneumothorax caused by Pneumocystis jirovecii pneumonia (PJP) is often fatal. We present our experience using extracorporeal membrane oxygenation as treatment for ARF and subsequent pneumothorax caused by PJP in a kidney transplant recipient.

Changes in the incidence of candidaemia during 2000-2008 in a tertiary medical centre in northern Taiwan

Candidaemia is associated with high mortality and high healthcare costs. The incidence of candidaemia in Taiwan rose markedly during the period 1980-2000. We conducted this hospital-based surveillance study in order to explore the secular trend in incidence of candidaemia during the period 2000 to 2008. In our study, Candida spp. were the fourth most common cause of bloodstream infections, with a 30-day crude mortality rate of 36.7%. Candida albicans was the most common species identified, although mortality rate did not differ significantly among species. The incidence of candidaemia began to decrease in 2004. Risk factors related to higher mortality included longer hospital stay before onset of candidaemia, liver cirrhosis, malignancy, end-stage renal disease requiring renal dialysis, dependence on mechanical ventilation and urinary catheterisation.

Clinical characteristics of Group G streptococcal bacteremia in Taiwan

The results of this retrospective study showed that Group G streptococcal bacteremia was an acute febrile disease with low mortality. Most patients were > 60 y old but there was a strong association between age < 60 y and malignancy. Cases clustered in summer and the most common port of entry was the skin.

Comparative study of ceftibuten and cefixime in the treatment of complicated urinary tract infections

Between August 1996 and May 1998, a total of 62 patients who had complicated urinary tract infections treated at the Taipei Veterans General Hospital were enrolled into this study. This prospective, randomized, open-labeled trial aimed at comparing the efficacy and safety of ceftibuten and cefixime, prescribed each at a dose of 200 mg twice daily, in treating complicated urinary tract infection. Seventeen patients were later excluded from the analysis because of resistant pathogens (7 patients), uncomplicated urinary tract infection (6), initial culture negative for bacteria (3), and infective endocarditis (1). The remaining 45 patients were categorized into ceftibuten (n=23; mean age, 71.3 years) and cefixime (n=22; mean age, 62.8 years) treatment groups. No significant difference in demographic data and clinical characteristics was found between the 2 groups. The clinical efficacy rate (78.3% vs 77.3%, p=0.9) and bacteriological eradication rate (52.2% vs 63.6%, p=0.08) were similar between the ceftibuten and the cefixime group. Adverse effects caused by ceftibuten treatment included diarrhea and slight elevation of the serum level of liver transaminase in 2 (6.5%) patients. Those caused by cefixime treatment included slight elevation of serum level of liver transaminase in 2 (6.5%) patients and skin rash in 1 (3.2%) patient. All of these adverse effects resolved quickly after the regimen had been completed, and no patient discontinued the regimen because of the adverse effects. The results suggest that oral administration of ceftibuten 200 mg twice daily is as effective and safe as oral administration of cefixime 200 mg twice daily in the treatment of complicated urinary tract infections.

Maternal zinc deficiency impairs brain nestin expression in prenatal and postnatal mice

Effects of maternal dietary zinc deficiency on prenatal and postnatal brain development were investigated in ICR strain mice. From d 1 of pregnancy (E0) until postnatal d 20 (P20), maternal mice were fed experimental diets that contained 1 mg Zn/kg/day (severe zinc deficient, SZD), 5 mg Zn/kg/day (marginal zinc deficient, MZD), 30 mg Zn/kg/day (zinc adequately supplied, ZA) or 100 mg Zn/kg/day (zinc supplemented, ZS and pair-fed, PF). Brains of offspring from these dietary groups were examined at various developmental stages for expression of nestin, an intermediate filament protein found in neural stem cells and young neurons. Immunocytochemistry showed nestin expression in neural tube 10.5 d post citrus (dpc) as well as in the cerebral cortex and neural tube from 10.5 dpc to postnatal d 10 (P10). Nestin immunoreactivities in both brain and neural tube of those zinc-supplemented control groups (ZA, ZS, PF) were stronger than those in zinc-deficient groups (SZD and MZD). Western blot analysis confirmed that nestin levels in pooled brain extracts from each of the zinc-supplemented groups (ZA, ZS, PF) were much higher than those from the zinc-deficient groups (SZD and MZD) from 10.5 dpc to P10. Immunostaining and Western blots showed no detectable nestin in any of the experimental and control group brains after P20. These observations of an association between maternal zinc deficiency and decreased nestin protein levels in brains of offspring suggest that zinc deficiency suppresses development of neural stem cells, an effect which may lead to neuroanatomical and behavioral abnormalities in adults.

Investigation of an outbreak caused by methicillin-resistant Staphylococcus aureus in a cardiovascular surgery unit by ribotyping, randomly amplifed polymorphic DNA and pulsed-field gel electrophoresis

An outbreak caused by rapid spread of methicillin-resistant Staphylococcus aureus (MRSA) in an intensive care unit for cardiovascular surgery was investigated by phenotypic and genotypic methods. Fourteen isolates were collected during a 2-month period from clinical and environmental specimens in the unit recently re-opened after reconstruction. The isolates were tested for antibiotic susceptibility patterns and genotyped by automated ribotyping, randomly amplified polymorphic DNA-PCR (RAPD) analysis and pulsed-field gel electrophoresis (PFGE). Automated ribotyping applying EcoRI digestion proved to be of no value in separating the isolates. In contrast, PFGE grouped the isolates into four clusters different from the reference strain. These results fully correlated with the antibiograms. Twelve of the isolates were grouped into two clonally related clusters. RAPD analyses grouped the isolates into five clusters. Except for two isolates of one patient, which had different RAPD patterns, PFGE and RAPD analyses presented very similar results. The results verified the usefulness of PFGE in studies of MRSA epidemics. A combination of these two methods reduces the time to identification of an outbreak and increases the accuracy in detection of intraspecies differences.

Risk factors of catheter-related infections in total parenteral nutrition catheterization

BACKGROUND

The use of central venous catheter for administration of total parenteral nutrition (TPN) is a risk factor of catheter-related infections (CRIs) that are associated with increased morbidity and mortality, prolonged hospitalization, and increased medical costs. The purpose of this study is to evaluate the risk factors of CRIs in patients with administration of TPN.

METHODS

A total of 1134 patients receiving TPN between January, 1996 and December, 1998 were studied. The category of infection included definite catheter-related bloodstream infection (CR-BSI), probable CR-BSI, and insertion site infection. Statistical analysis of risk factors was performed.

RESULTS

A total of 131 episodes of CRI occurred, representing an infection rate of 11.46%. Ninety-three episodes (8.1%) had probable CR-BSI, 13 episodes (1.1%) had definite CR-BSI, and 25 episodes (2.2%) had insertion site infection. Duration of TPN infusion and frequency of catheter insertion showed statistically significant difference by logistic regression multivariate analysis. The isolated organisms were in sequence of coagulase-negative Staphylococci (19.4%), Staphylococcus aureus (17.2%) and Candida albicans (14.4%).

CONCLUSIONS

Risk factors influencing the occurrence of CRI in TPN administration were multifactorial; however, duration of TPN infusion and frequency of catheter insertion were the main factors in our study.

Analysis of sharp-edged medical-object injuries at a medical center in Taiwan

A total of 733 incidents by sharp-edged objects occurred among healthcare workers between 1995 and 1998. Injuries occurred most frequently among interns. The workplace location with the highest incidence of injury was the patient ward, and the object that most frequently inflicted injury was a needle. The most frequent work practice was recapping of syringes. One healthcare worker demonstrated seroconversion for hepatitis C.

Risk factors of deep sternal wound infections in coronary artery bypass graft surgery

BACKGROUND

Major infections of sternal wounds after coronary artery bypass graft surgery (CABG) occur infrequently, but when they do, they contribute substantial morbidity and mortality. We identified significant risk factors of deep sternal wound infection (DSWI) following CABG and hoped to plan prophylactic measures for high risk patients in order to reduce the incidence of infection.

METHODS

From 1996 to 1997, a total of 620 patients received CABG at a medical center in Taiwan. The surgical wound was examined every day. Wound infections were defined and classified according to Centers for Diseases Control (CDC) definitions. DSWI were defined as those involving the mediastinum, bone or cartilage, and infections beneath the subcutaneous tissue. Several risk factors were analyzed.

RESULTS

We identified 17 (2.7%) DSWI. Univariate analysis indicated that ASA scores, surgical risk index, surgeon, postoperative low cardiac output, re-operation for bleeding, re-wiring of sternum, length of postoperative stay in the intensive care unit, postoperative duration of mechanical ventilation, operation time, duration of cardiopulmonary bypass. Independent predictors by multivariate logistic regression analysis were re-operation for bleeding and operation time. A total of 16 organisms were isolated among 14 patients. Staphylococcus accounted for most isolates (93.8%) and the most of them were methicillin-resistant (80%).

CONCLUSIONS

Re-operation for bleeding and operation time were the independent predictors.

In vitro activity of quinupristin/dalfopristin against gram-positive bacteria Haemophilus influenzae and Branhamella catarrhalis in Taiwan

BACKGROUND

Over the past decade, resistance of Gram-positive cocci to common antibiotics has steadily increased. New antibacterial agents that are active against multidrug-resistant pathogens are urgently needed for the treatment of these pathogens. We conducted an in vitro study on the activity of quinupristin/dalfopristin and other antibiotics against common clinical isolates of the gram-positive cocci, Haemophilus influenzae and Branhamella catarrhalis.

METHODS

The agar dilution method described by the National Committee for Clinical Laboratory Standards was used to determine the minimum inhibitory concentrations (MICs) of bacterial isolates from clinical specimens obtained from patients in a medical center.

RESULTS

All Staphylococcus aureus isolates were inhibited by quinupristin/dalfopristin (< or = 2 micrograms/ml). The MIC90s were 1 mg/ml for both methicillin-sensitive and -resistant S aureus. Quinupristin/dalfopristin inhibited streptococci at a concentration of 1 microgram/ml or less. The MIC90s were 1 microgram/ml for Streptococcus pneumoniae, S pyogenes and viridans streptococci. Ampicillin-resistant Enterococcus faecium was inhibited by quinupristin/dalfopristin at 0.5 to 4 micrograms/ml, with an MIC90 of 1 microgram/ml. H influenzae was inhibited by quinupristin/dalfopristin at 0.25 to 8 micrograms/ml, with an MIC90 of 4 micrograms/ml. B catarrhalis was inhibited by quinupristin/dalfopristin at 0.25 to 1 microgram/ml, with an MIC90 of 1 microgram/ml.

CONCLUSIONS

We found that quinupristin/dalfopristin showed good in vitro activity against staphylococci, streptococci and B catarrhalis but less in vitro activity against H influenzae.

In vitro activity of quinupristin/dalfopristin and other antibiotics against ampicillin-resistant enterococcus faecium

BACKGROUND

Enterococcus faecium constitutes approximately 10% of clinical isolates of enterococci and is noted for its antimicrobial resistance. In particular, E faecium is commonly resistant to ampicillin. The optimal treatment for severe infections caused by these multi-resistant organisms has yet to be determined.

METHODS

Enterococci tested were isolated from blood, pleural fluid and cerebrospinal fluid. Ampicillin-resistant Enterococcus faecium (AREF) was identified using the API Rapid Strep Kit system. A total of 58 isolates of AREF were enrolled in this study. Ten different antibiotics were tested, including Synercid (quinupristin/dalfopristin), teicoplanin, vancomycin, ampicillin, trimethoprim/sulfamethoxazole (TMP/SMX), ciprofloxacin, gentamicin, chloramphenicol, rifampicin and tetracycline. The agar dilution method described by the National Committee for Clinical Laboratory Standards was used to determine the minimum inhibitory concentrations (MICs) of the antibiotics tested.

RESULTS

Teicoplanin showed the best in vitro activity. Its MIC ranged from 0.25 to 2 micrograms/ml with an MIC90 of 1 microgram/ml. The MIC of vancomycin was 0.5-128 micrograms/ml with an MIC90 of 2 micrograms/ml. Three strains were vancomycin resistant, and they were the VanB phenotype. The MIC of quinupristin/dalfopristin was 0.5 to 8 micrograms/ml with an MIC90 of 2 micrograms/ml. Chloramphenicol and tetracycline showed moderate susceptibility. AREF showed high resistance to other antibiotics tested, including ciprofloxacin, gentamicin, TMP/SMX and rifampicin. High-level gentamicin resistance (MIC > 1,000 micrograms/ml) was found in 78% of AREF tested.

CONCLUSIONS

Teicoplanin showed the best in vitro activity against AREF. Clinical studies are necessary to confirm the efficacy of quinupristin/dalfopristin in vivo.

[Effect of dietary zinc on microtubule-associated protein 2 expression in the brain of mice]

Zinc deficiency could result in reduction of microtubule polymerization, which may cause impairment of brain development and function. The relationship between zinc deficiency and microtubules polymerization is still unclear. In this paper, microtubule-associated protein 2 (MAP2) expression in the brain was examined in order to explore the mechanism of zinc regulated microtubule polymerization. 80 pregnant ICR mice, randomized into 5 groups, were fed with experimental diets of different zinc levels (from 1 to 100 mg/kg) during pregnancy and lactation. The MAP2 expression in the brain of offsprings was examined by Western blot assays. The results showed that MAP2, including MAP2a, MAP2b and MAP2c, were expressed in brain from embryonic day 15, but not found on embryonic day 10. The high molecular weight of MAP2a and MAP2b expressed continuously from embryonic day 15 to postnatal day 70 (adult). While the low molecular weight of MAP2c was down-regulated from embryonic day 15 to non-existing on postnatal day 70. The expression of MAP2 in cerebrum and cerebellum kept closely at the positive dependence with dietary zinc level. The order of the levels of expression of MAP2 of the various groups administrated with different amounts of zinc is as follows: 1 mg/kg < 5 mg/kg < 30 mg/kg < 100 mg/kg. The above results suggest that zinc deficiency may inhibit the MAP2 expression, while zinc supplement exerts much improvement. The lowered level of MAP2 expression is one of important mechanisms underlying impairments of microtubule polymerization, as a result of zinc deficiency.

A comparative study of cefepime versus ceftazidime as empiric therapy of febrile episodes in neutropenic patients

An open-label, randomized comparative study was conducted to evaluate the efficacy and safety of cefepime (2.0 g q. 8 h) and ceftazidime (2.0 g q. 8 h) in the empiric therapy of febrile neutropenic patients. A total of 45 eligible febrile episodes were randomized (1:1) to be treated with the study regimen. Nineteen febrile episodes treated with cefepime and 22 febrile episodes treated with ceftazidime were evaluable for efficacy. The two groups were comparable in terms of age, sex, height, weight, underlying neoplasm, number of pretherapy neutrophil, duration of neutropenia and types of infections. The overall therapeutic success rate of the cefepime group (53%) was comparable to the ceftazidime group (50%). It did not differ significantly (95% confidence interval: -0.28 to 0. 34, p = 0.85). Eighty-eight percent of pathogens in each group were bacteriologically eradicated. The safety profile was similar in both groups. No patients in either group discontinued the therapy because of adverse events. None (0%) of the cefepime patients and 2 (9%) of the ceftazidime patients died of infection. The results of this study suggest that cefepime is an effective and safe agent in the empiric therapy of febrile episodes in neutropenic patients.

In vitro activities of macrolides against gram-positive aerobes, Haemophilus influenzae, Moraxella catarrhalis and Bacteroides fragilis in Taiwan

BACKGROUND

New macrolides with improved pharmacokinetic characteristics have been developed and introduced for clinical use in Taiwan. In order to understand the antibacterial activities of these new macrolides, we tested their in vitro activities against common pathogenic bacteria.

METHODS

Minimum inhibitory concentrations (MICs) of azithromycin, clarithromycin, dirithromycin, erythromycin and roxithromycin for clinical isolates collected from six teaching hospitals in Taiwan were determined by the agar dilution method. The tested bacteria included methicillin-sensitive and -resistant coagulase-negative staphylococci, methicillin-sensitive and -resistant Staphylococcus aureus, viridans streptococci, Streptococcus pneumoniae, Streptococcus pyogenes, Enterococcus spp, Corynebacterium spp, Haemophilus influenzae, Moraxella catarrhalis and Bacteroides fragilis.

RESULTS

High MICs were detected against most of the bacteria tested except for H influenzae and M catarrhalis. The MIC90 for viridans streptococci, S pneumoniae, S pyogenes, Enterococcus spp, S aureus (both methicillin-sensitive and -resistant), coagulase-negative staphylococci (both methicillin-sensitive and -resistant), Coryne-bacterium spp, and B fragilis were all at least 128 micrograms/ml. Wide ranges of MICs were demonstrated.

CONCLUSIONS

Most bacteria tested were highly resistant to macrolides. This result is a warning for clinicians that rational use of antibiotics, including macrolides, is mandatory.

Flavobacterium meningosepticum bacteremia: an analysis of 16 cases

BACKGROUND

Flavobacterium meningosepticum is an uncommon pathogen causing nosocomial pneumonia and meningitis in newborns. It is usually resistant to antimicrobial agents used to treat gram-negative bacilli. While the pathogen often results in high mortality and serious sequelae in newborns, it is also found to cause to disease in adults. Therefore, it is necessary to know the full spectrum of the infection in adults and to identify effective antimicrobial agents.

METHOD

Microbiology logbooks were reviewed for F meningosepticum isolated from January, 1992, to March, 1996. The medical records of these patients were reviewed. Special attention was paid to clinical manifestations, underlying diseases, risk factors, treatments, and prognosis. Twenty-four antimicrobial agents were tested using antimicrobial susceptibility tests.

RESULTS

Eighteen isolates of F meningosepticum were identified from 16 patients. There were 10 men and six women, with a mean age of 63.7 years. The clinical features of infection included fever (> or = 38 degrees C) in 13 patients, chills in seven, shortness of breath in four, rales or rhonchi in four, shock in three and flank pain in two. All except one patient survived without sequelae. Fifteen patients contracted F meningosepticum from nosocomial sources. Of them, seven were suspected to have acquired the pathogen from diagnostic or therapeutic procedures. Bacteremia occurred in these patients within a mean period of 2.2 days. The other eight patients suffered nosocomial bacteremia within a mean period of 33.4 days after admission. The suspected infection route was not identified in only one patient. The organism was resistant to penicillins, cephalosporins, aztreonam, imipenem, aminoglycosides and macrolides. Testing with lomefloxacin, ciprofloxacin and ofloxacin yielded 72.2%, 83.3% and 94.4% susceptibility rates, respectively. Rifampin (61.1%) and trimethoprim-sulfamethoxazole (TMP-SMX) (88.9%) were effective. Vancomycin and minocycline were 100% effective.

CONCLUSIONS

F meningosepticum is an opportunistic pathogen of low virulence and rarely causes serious infections in adults. Reducing the use of unnecessary residual devices and invasive procedures may help reduce the incidence of infection. Therapeutic options include vancomycin, TMP-SMX, minocycline, rifampin or fluoroquinolones.

Prevalence of nosocomial respiratory tract infections in the surgical intensive care units of a medical center

BACKGROUND

The intensive care unit (ICU) is one of the most common locations in the hospital for the development of nosocomial respiratory tract infections (RTIs). The purpose of this study was to better understand and compare the rate of nosocomial RTIs, their distribution and the frequency of infective organisms in three different adult surgical ICUs at a medical center in Taiwan.

METHODS

This retrospective study covered the period from 1991 to 1996, and targeted patients who had acquired nosocomial RTIs more than 72 hours after admission to the surgical, cardiovascular surgical, or neurosurgical ICU. Infection control nurses made routine weekly rounds to the units and conducted comprehensive patient-based surveys. Data collected were subjected to descriptive and deductive statistical analyses.

RESULTS

A total of 277 episodes of nosocomial RTIs were encountered (3.8 episodes per 1,000 patient-days of hospitalization). Neurosurgical ICU patients had the highest infection rate (4.8%) (p < 0.01). The median length of hospital stay of patients acquiring nosocomial RTIs was 61 days; the infection occurred 19 days (median) after admission to the ICU and the length of postinfection stay was 38 days (median). Pneumonia accounted for 91.3% of these infections. The overall mortality rate was 42.6%, with the surgical ICU having the highest mortality rate (61.5%), which was significantly higher compared with the other two ICUs studied. The majority of patients with nosocomial RTIs had medical catheters or devices in place. A total of 297 isolates were cultured from 277 infected patients. Pseudomonas aeruginosa was the predominant organism isolated (29.6%), followed by Staphylococcus aureus (26.6%), of which 88.2% were methicillin-resistant S aureus (MRSA).

CONCLUSIONS

The rate of nosocomial RTIs was significantly higher in neurosurgical ICU patients; the majority of infected patients had medical catheters or devices in place. S aureus played an increasingly important role as a nosocomial pathogen; hence, control of MRSA should be the focus of infection control policies.

Activity of cefepime compared with other antibiotics against gram-positive bacteria and cefuroxime-resistant gram-negative bacteria

BACKGROUND

Cefepime is a new, parenteral, fourth-generation antibiotic that is stable in the presence of Bush group 1 beta-lactamases. In vitro activity of cefepime, cefuroxime, ceftazidime, ciprofloxacin and imipenem against Gram-positive cocci and cefuroxime-resistant Gram-negative bacilli was studied.

METHODS

The agar dilution method described by the US National Committee for Clinical Laboratory Standards was used to determine the minimum inhibitory concentrations of antibiotics tested. These included cefepime, cefuroxime, ceftazidime, ciprofloxacin and imipenem. The tested clinical isolates included Gram-positive cocci (methicillin-sensitive coagulase-negative staphylococci, methicillin-resistant coagulase-negative staphylococci, methicillin-sensitive Staphylococcus aureus, methicillin-resistant S aureus, Streptococcus pyogenes, viridans streptococci, Streptococcus pneumoniae, group D enterococci) and cefuroxime-resistant Gram-negative bacilli (Escherichia coli, Klebsiella pneumoniae, Acinetobacter spp, Pseudomonas aeruginosa, Enterobacter cloacae, Serratia marcescens, Burkholderia cepacia and Xanthomonas maltophilia).

RESULTS

The activity of cefepime against most Gram-negative bacilli other than B cepacia and X maltophilia is better than that of ceftazidime. However, cefepime is less active against these Gram-negative bacilli than ciprofloxacin and imipenem. The activity of cefepime against B cepacia and X maltophilia is less than that of ceftazidime or ciprofloxacin. Among Gram-positive cocci, cefepime was active against most isolates of methicillin-sensitive staphylococci, S pyogenes, viridans streptococci and S pneumoniae. However, cefepime has poor activity against methicillin-resistant S aureus and enterococci.

CONCLUSIONS

Due to its extended spectrum of activity, cefepime has potential use as suitable empiric monotherapy for the treatment of a variety of community- and hospital-acquired infections.

Bacteremia in patients with hematologic malignancies

The decision regarding the appropriate empirical antibiotic therapy for bacteremia in patients with hematologic malignancies must be individualized in each institution, by taking into account variations in the patterns of microbial isolates and their resistance profiles. Microbial isolates and antibiotic resistance patterns must be taken into account at each hospital. A shift from bacteremia due to infections caused by predominantly gram-negative organisms to predominantly gram-positive organisms in patients with hematologic malignancies has been noted in reports from other countries. We investigated bacterial isolates and their antibiotic sensitivities in patients with hematologic malignancies in the Veterans General Hospital-Taipei. A total of 185 episodes of bacteremia in 140 patients with hematologic malignancies were recorded during the period from 1995 to 1996. Unlike foreign reports, our investigation shows that gram-negative organisms still predominate, accounting for 72.7% of isolates, followed by gram-positive organisms, accounting for 26.3% of isolates, and anaerobes, accounting for 1% of isolates. Escherichia coli was the most commonly isolated organism, accounting for 23.9% of isolates, followed by Klebsiella pneumoniae (18.5%), Pseudomonas aeruginosa (12.2%), Enterobacter cloacae (7.3%), and methicillin-resistant Staphylococcus aureus (7.3%). A high mortality rate was observed in gram-negative bacteremia: 31% for E. coli, 26% for K. pneumoniae, 24% for P. aeruginosa, and 33% for E. cloacae. If methicillin-resistant S. aureus bacteremia occurred, mortality was high (47%). The antibiotic sensitivity profiles of the four most common gram-negative isolates (E. coli, K. pneumoniae, P. aeruginosa, and E. cloacae) indicated that, in our hospital, amikacin with either cefoperazone, ceftazidime, ciprofloxacin, or imipenem, would be an ideal combination for empirical therapy for bacteremia in patients with hematologic malignancies.

The DnaJ family of protein chaperones in Trypanosoma cruzi

We have molecularly cloned four members of the DnaJ (heat shock protein 40) family of protein chaperones of the protozoan parasite Trypanosoma cruzi--tcj1, tcj2, tcj3 and tcj4. While all the proteins contain defining J domains at their N-termini, only tcj2, tcj3 and tcj4 contain glycine/phenylalanine-rich and zinc finger domains common to many other DnaJ homologues. Furthermore, tcj2 and tcj4 contain C-terminal CaaX motifs, substrates for prenyl modifications, suggesting that they are associated with cellular membranes. tcj1 is a divergent member of the family, containing neither glycine/phenylalanine-rich nor zinc finger domains. All the T. cruzi DnaJ genes are single copy, in contrast to other T. cruzi heat shock genes, which are arranged in multicopy direct tandem arrays. Among the tcj mRNAs, only tcj2 is heat inducible, which may result from posttranscriptional regulation involving a sequence found in the 3' untranslated regions of all heat-inducible T. cruzi mRNAs described to date. Further study of this important family of protein chaperones will aid our understanding of the protein folding and assembly processes in protozoans.

Infections in febrile granulocytopenic patients: clinical features and pathogens

From 1990 to 1994, we prospectively evaluated patients with cancer or aplastic anemia who had granulocyte counts of less than 500/mm3 and fever, in order to study infections in febrile granulocytopenic patients in Taiwan. A total of 100 episodes in 95 patients were evaluated. Aerobic Gram-negative bacilli were responsible for 72.5% of the 80 organisms identified in the infections. Escherichia coli was the most common isolate, accounting for 46.5% of Gram-negative bacilli. Pseudomonas aeruginosa and Klebsiella spp caused 24.1% and 18.9% of these infections, respectively. Aerobic Gram-positive cocci were responsible for 12.5% of the 80 organisms identified in the infections. Fungal infections were responsible for 8.8% of isolates. Septicemia, predominantly due to Gram-negative bacilli, accounted for 39 episodes. Infection sites included the respiratory tract, urinary tract, skin and soft tissue, oral cavity, intestines, anus and ear canal. Identification of the pathogens and their clinical features is important in the immediate treatment of such infections.

Invasive group G streptococcal infections: a review of 37 cases

BACKGROUND

Beta-hemolytic streptococci group A, B, and D which cause many diseases have been well studied. Infection caused by group G Streptococcus has increased in clinical significance, and thus is attracting more physicians attention. This retrospective analysis reports clinical experience with such infections at the Veterans General Hospital-Taipei.

METHODS

Medical records of invasive group G streptococcal isolates from March 1991 to April 1994 were reviewed. Thirty-seven cases were included.

RESULTS

There were 33 males and 4 females with a mean age of 67.4. Major underlying diseases included diabetes (24.3%), cardiovascular diseases (21.6%), malignancy (21.6%), bone or joint diseases (18.9%) and cirrhosis of the liver (13.5%). Only 8.1% cases had no underlying disease. The most common portal of entry was the skin (64.9%). There was a wide spectrum of clinical manifestations, including cellulitis (32.4%), arthritis or osteomyelitis (16.2%), endocarditis (8.1%), meningitis (8.1%), peritonitis (8.1%), empyema (5.4%) and primary bacteremia (27%). All of these isolates were susceptible to penicillin, oxacillin, cefazolin, clindamycin and vancomycin. Ten patients died, and five of these expired from group G streptococcal infections.

CONCLUSIONS

Group G Streptococcus is a low virulent microorganism. Clinical improvement after therapy is fast. Poor response to antibiotics should prompt investigation of the underlying diseases or undrained foci of infection.

Scrub typhus complicating acute respiratory distress syndrome: a report of two cases

Scrub typhus is a zoonotic disease, caused by Rickettsia tsutsugamushi, in which humans are accidental hosts. Although it is an acute febrile illness, severe complications of this disease are very rare since the introduction of specific antibiotic therapy. The authors report two cases of scrub typhus complicating acute respiratory distress syndrome. The first case progressed to multiple organ failure, and the patient expired. In the second case, the patient recovered and was discharged. These two cases were proved to be scrub typhus by their travel history or their having lived in endemic area, clinical manifestations, an eschar and indirect immunofluorescent antibody test. For a good prognosis, early diagnosis and early treatment of this disease are important.

Enterococcal meningitis: analysis of twelve cases

From 1986 to 1993, 12 cases of enterococcal meningitis were identified at the Veterans General Hospital, Taipei. Most of the cases were caused by Enterococcus faecalis and three cases were mixed bacterial meningitis. There were six adult and six pediatric patients. Among the adult patients, four had undergone neurosurgical procedures before onset of meningitis and the other two had severe chronic underlying diseases. In contrast, all six pediatric patients had underlying central nervous system (CNS) pathology such as meningomyelocele or hydrocephalus. Placement of CNS devices was the most important predisposing factor of enterococcal meningitis in this study series. Direct microbial invasion via CNS devices or neural tube defects was considered the most likely portal of entry in most patients. Only one patient had primary meningitis, and one other had an enterococcal infection outside the CNS. The overall mortality rate was 25%. None of the pediatric patients died. Underlying conditions were considered the most important factor influencing the prognosis of these patients.

A randomized comparative study on the safety and efficacy of clarithromycin and erythromycin in treating community-acquired pneumonia

BACKGROUND

Clarithromycin, a new macrolide, has distinct microbiological and pharmacokinetic advantages compared with erythromycin. This study was designed to compare the safety and efficacy of clarithromycin and erythromycin in the treatment of community-acquired pneumonia.

METHODS

Forty adult patients, diagnosed with community-acquired pneumonia, were randomly arranged to received either clarithromycin 250 mg twice daily (20 patients) or erythromycin 500 mg four times daily (20 patients), over a period of 14 days each.

RESULTS

There were no statistically significant differences between the two groups in terms of clinical cure (65% for clarithromycin, 65% for erythromycin), clinical success (clinical cure and improvement: 95% for clarithromycin, 90% for erythromycin) and radiological response (95% for clarithromycin, 90% for erythromycin). However, adverse effects, mainly gastrointestinal, were significantly higher among patients treated with erythromycin than among patients treated with clarithromycion (p < 0.05).

CONCLUSIONS

These results demonstrate that clarithromycin 250 mg twice daily is at least as effective as erythromycin 500 mg four times daily for the treatment of community-acquired pneumonia, and is much better tolerated.

Serological evaluation for tuberculosis by antigen 60 IgG ELISA test

BACKGROUND

Tuberculosis remains a significant global health problem, especially among developing countries. It unfortunately results in high morbidity and mortality rates. This disease is also prevalent to a large extent in Taiwan. The traditional tuberculous tests, including the acid-fast smear and culture, have a limited activity in regard to extrapulmonary or smear-negative tuberculosis. A new testing is necessary to improve diagnosis of this disease.

METHODS

An enzyme-linked immunosorbent assay (ELISA) test for detection of serum IgG antibodies, based on Antigen 60, was applied to 146 subjects including 68 non-tuberculous cases and 78 tuberculous cases. A titer of less than 200 serounits was considered negative, and one of 200 or more serounits was thought positive.

RESULTS

In the healthy group, which included 5 newborns, 5 children and 20 healthy adults, 6.1% (2/30) showed positive results. Of the 15 hospital attendants, 60% (9/15) also displayed positive results. Nine of 17 cases (52.9%) with non-tuberculous pulmonary diseases had positive results. Among 6 cases with other diseases, the results were all negative. The false positive rate in non-tuberculous group was 29.4% (20/68). In 10 cases with inactive pulmonary tuberculosis, 30% (3/10) showed positive results. In 50 with active pulmonary tuberculosis, 88% (44/50) generated positive results. Effectual results were obtained in 66.7% (8/12) of the cases with extrapulmonary tuberculosis. Including 6 cases with mixed pulmonary and extrapulmonary tuberculosis, 83.3% (5/6) proved positive results. The positive rate in active tuberculous group was 83.8% (57/68).

CONCLUSIONS

The ELISA test, for detection of IgG antibody with Antigen 60, is helpful in improving the diagnosis of tuberculosis, especially in extrapulmonary tuberculosis.

[Clinical efficacy of cefmetazole in intraabdominal infection]

A number of different organisms can be isolated from intraabdominal infection. The most common are aerobic Gram-negative bacilli. Anaerobes are not unusual. From June 1989 to January 1990, Cefmetazole was administered to 23 patients with intraabdominal infection at Veterans General Hospital-Taipei. There were six patients with spontaneous bacterial peritonitis, five biliary tract infection, five liver abscesses, five with pelvic inflammatory disease, one acute ruptured appendicitis and another intraabdominal abscess. In addition, ten patients had sepsis. Clinical response was satisfactory in 21 (91.3%) of 23 patients, and the microbiological eradication rate was 90% (36/40). One patient with Streptococcus and Bacteroides oralis liver abscess relapsed after organism eradication. Therapy failed in a case with Pseudomonas aeruginosa and Bacteroides fragilis infection. This study showed Cefmetazole to be an effective and safe antibiotic for treatment of intraabdominal infection.

Gram-negative bacillary meningitis in adults: a recent six-year experience

Thirty-eight cases of Gram-negative bacillary meningitis in adults have been identified over the past six years at the Veterans General Hospital, Taipei. Twenty cases were associated with head trauma and/or neurosurgery, while 18 cases occurred spontaneously. The overall mortality was 58%. Within the spontaneous meningitis group, 13 cases (72%) were due to Klebsiella pneumoniae, 11 cases (61%) were associated with bacteremia and eight cases (44%) with diabetes mellitus. In spite of the administration of third-generation cephalosporins, most cases of spontaneous meningitis (15 patients, 83%) died soon after diagnosis. In contrast, the clinical course for the postneurosurgical patients was more benign. Only seven patients (35%) died during the course of therapy. Common causative agents in postneurosurgical patients included Pseudomonas aeruginosa, Acinetobacter baumannii, and Escherichia coli. External cerebrospinal fluid drainage devices were thought to be the most important predisposing factor in Gram-negative bacillary meningitis in the postneurosurgical patients. Factors that adversely influenced the mortality of Gram-negative bacillary meningitis included the presence of bacteremia, shock, deep coma and a high initial cerebrospinal fluid leukocyte count.

Xanthomonas maltophilia bacteremia: an analysis of 32 cases

Thirty-two cases of Xanthomonas maltophilia bacteremia have been identified over the last two years at the Veterans General Hospital, Taipei. Among them, 27 cases (84%) were due to hospital-acquired infections, and 14 cases (44%) were polymicrobial bacteremia. One case was confirmed as prosthetic valve endocarditis and one case was complicated by recurrent attacks of ecthyma gangrenosum. Most cases had severe debilitating conditions. Twelve cases (38%) had a malignancy, 19 cases (59%) were resident in the Intensive Care Unit and 16 cases (50%) had undergone major surgery. The main predisposing factors included central venous catheterization, endotracheal intubation or tracheostomy, prior antibiotic therapy and prolonged hospitalization. Moxalactam, chloramphenicol and trimethoprim-sulfamethoxazole were the most effective agents in vitro against X. maltophilia. Twenty-two cases (69%) died during hospitalization; 13 cases (41%) were directly attributed to septicemia. Factors that adversely influenced mortality included inappropriate antimicrobial therapy and prior antibiotic treatment. Of particular interest is the fact that none of the patients who did not receive appropriate antimicrobial therapy survived. Early diagnosis and appropriate antibiotic therapy are critical for improving the prognosis of X. maltophilia infection.

Cutaneous abscess caused by Nocardia brasiliensis: report of a case

We report a case of cutaneous Nocardia brasiliensis infection. The patient had received radiotherapy and anti-neoplastic chemotherapy for epidermoid carcinoma of the left sphenoid sinus with bone destruction. He developed fever and an ulcer on the dorsal medial surface of the left hand after an intravenous infusion of chemotherapeutic agents in the same site 3 days earlier. Needle aspiration of the abscess disclosed polymorphonuclear leukocytes, and a partially acid-fast, gram-positive filamentous branching organism. Cultures of the aspirate grew N. brasiliensis 1 week later. The patient was treated successfully with a regimen of parenteral ceftazidime and amikacin with definite improvement 1 week later. Therapy was continued for 1 more week, and then the patient was switched to oral trimethoprim-sulfamethoxazole for 3 months with no recurrence. The diagnosis, clinical manifestations, treatment and prognosis of cutaneous abscesses cause by N. brasiliensis are discussed.

Septicemia in adults: II. Factors in prognosis

Over the period of 2 months between October and November, 1987, 190 episodes of septicemia in adults were monitored at Veterans General Hospital-Taipei. The most common causative microorganisms were Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus. The most frequent sources of infection came from intra-abdominal (gastro-intestinal as well as hepato-biliary), urinary and respiratory tract. Its overall mortality was 34.7%. Factors associated with a higher mortality from septicemia were old age, rapidly fatal underlying disease, hospital acquired infection, hypothermia, hypotension/shock, high-risk source of infection (from respiratory tract, skin/soft tissue, surgical wound or other unknown source), high-risk microorganisms (Candida species, Ps. aeruginosa or K. Pneumoniae) and inappropriate antimicrobial therapy. Identification of these factors may help early correction of reversible factors and improve its prognosis.

Successful treatment of metastatic endophthalmitis. Case reports

Endophthalmitis is a well-recognized complication of intraocular surgery, penetrating ocular trauma and systemic infection. Metastatic bacterial endophthalmitis is rare. However, once it happens, the visual outcome is very poor. In order to prevent visual damage, early diagnosis and treatment is essential. Due to the blood-ocular barrier, intravitreal drug concentrations are low after systemic administration. Strong antibiotics with good penetration into the vitrous humor are needed to obtain adequate bactericidal concentrations. We report two cases with liver abscess complicated by septic events to the eye. One was uveitis, and the other was endophthalmitis. They were diagnosed early and were successfully treated with parenteral ceftriaxone and good vision was preserved.

A comparative study of ceftriaxone plus amikacin, ceftazidime plus amikacin and imipenem/cilastatin in the empiric therapy of febrile granulocytopenic cancer patients

In a prospective, randomized study we compared ceftriaxone (active ingredient of Rocephin) plus amikacin, ceftazidime plus amikacin and imipenem/cilastatin in the empiric therapy of febrile granulocytopenic (less than 500/mm3) patients with cancer or aplastic anemia. Of 27 evaluable episodes, 12 were treated with ceftriaxone plus amikacin, 5 with ceftazidime plus amikacin and 10 with imipenem/cilastatin. 56% were culture-positive. Septicemia was the most frequent site of infection and Escherichia coli was the most frequently isolated organism. The efficacy of the three regimens was comparable. One failure occurring in each treatment group was successfully treated with an alternative antibiotic regimen. A second failure in the first treatment group did not respond to the alternative treatment either. No major adverse effects occurred. This study demonstrates that the three regimens are excellent in the empiric therapy of febrile granulocytopenic patients.