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ABSTRACT: PURPOSE: Limited data on the outcomes of adults with active sepsis undergoing extracorporeal membrane oxygenation (ECMO) exist. MATERIALS AND METHODS: We analyzed our prospective database for adults undergoing their first ECMO from 2001 to 2009. Patients with preexisting sepsis had newly emerging or uncontrolled infections precipitating refractory respiratory and/or circulatory failure within 7 days preceding ECMO. Propensity score matching was performed to equalize potential prognostic factors between patients with and patients without sepsis. RESULTS: Of the 514 adults receiving their first ECMO, 108 with preexisting sepsis were matched with 108 without sepsis by propensity score. Overall survival to discharge did not differ between those with (28.7%) and those without sepsis (37.0%; P = .192). When venovenous ECMO and venoarterial ECMO were considered separately, survival tended to be worse for septic patients on venoarterial ECMO (24.4%) compared with nonseptic adults on venoarterial ECMO (34.9%; P = .147). After adjustments for age, stroke, acute myocarditis, inter-extracorporeal cardiopulmonary resuscitation, and post-ECMO renal and neurologic deficits by multivariate analysis, the increased risk of mortality persisted for septic adults receiving venoarterial ECMO (hazard ratio, 2.54; 95% confidence intervals, 1.75-3.70; P < .01). Patients on venovenous ECMO had similar outcomes regardless of preexisting sepsis. CONCLUSIONS: Preexisting sepsis is not a contraindication for ECMO. However, venoarterial ECMO should be used with caution, given active sepsis.
Journal of critical care 03/2013; · 2.13 Impact Factor
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ABSTRACT: BACKGROUND: Increasing the dosage of daptomycin may be advantageous in severe infection by enhancing bactericidal activity and pharmacodynamics. However, clinical data on using daptomycin at doses above 6 mg/kg in Asian population are limited. METHODS: A retrospective observational cohort study of all hospitalized adult patients treated with daptomycin (> 6 mg/kg) for at least 72 hours was performed in Taiwan. RESULTS: A total of 67 patients (40 males) with a median age of 57 years received a median dose of 7.61 mg/kg (range, 6.03-11.53 mg/kg) of daptomycin for a median duration of 14 days (range, 3--53 days). Forty-one patients (61.2%) were in intensive care units (ICU). Sites of infections included complicated skin and soft tissue infections (n= 16), catheter-related bacteremia (n= 16), endocarditis (n= 11), primary bacteremia (n= 10), osteomyelitis and septic arthritis (n=9), and miscellaneous (n= 5). The median Pitt bacteremia score among the 54 (80.6%) patients with bacteremia was 4. The most common pathogen was methicillin-resistant Staphylococcus aureus (n=38). Fifty-nine patients (88.1%) were treated with daptomycin after glycopepetide use. Overall, 52 (77.6%) patients achieved clinical success. The all-cause mortality rate at 28 day was 35.8%. In multivariate analysis, the significant predictors of in-hospital mortality in 54 bacteremic patients were malignancies (P = 0.01) and ICU stay (P = 0.02). Adverse effects of daptomycin were generally well-tolerated, leading to discontinuation in 3 patients. Daptomycin-related creatine phosphokinase (CPK) elevations were observed in 4 patients, and all received doses > 8 mg/kg. CONCLUSIONS: Treatment with high dose daptomycin as salvage therapy was generally effective and safe in Taiwan. CPK level elevations were more frequent in patients with dose > 8 mg/kg.
BMC Infectious Diseases 02/2013; 13(1):66. · 3.12 Impact Factor
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ABSTRACT: Evaluation and feedback of hand hygiene (HH) compliance are important elements of the WHO multimodal strategy for hospital infection control. Overt observation is recommended, but it may be confounded by Hawthorne effect. Covert observation offers the opportunity to decrease observer bias. In this study we conducted a one year hospital-wide HH promotion program that included medical students (MS) as covert observers.
HH compliance for the five WHO indications was determined by trained and validated observers. The overt observers consisted of eleven infection control nurses (ICNs) and two unit HH ambassadors (UAs) in each of 83 wards. The covert observers consisted of nine MS during their rotating clinical clerkships. Feedback was provided to department heads and staff each quarter.
Of the 23,333 HH observations 76.0% were by MS, 5.3% by ICNs and 18.7% by UAs. The annual compliance rates were MS 44.1%, ICNs 74.4% and UAs 94.1%; P<0.001. The MS found significantly lower annual compliance rates for 4/5 HH indications compared to ICNs and UAs; P<0.05. The ICNs reported significantly improvement from the first to the fourth quarter; P<0.001. This was associated with feedback from the MS of very poor compliance by nurses during the first quarter.
Based on these findings we recommend a two-pronged approach to HH programs. The role of ICNs and UAs is to educate, serve as role models, establish, sustain good HH practices and provide direct feedback. The role of the covert observers is to measure compliance and provide independent feedback.
PLoS ONE 01/2013; 8(1):e53746. · 4.09 Impact Factor
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Yi-Ju Tseng,
Jung-Hsuan Wu,
Hui-Chi Lin,
Hsiang-Ju Chiu,
Bo-Chiang Huang,
Rung-Ji Shang,
Ming-Yuan Chen,
Wei-Hsin Chen,
Huai-Te Chen,
Feipei Lai, Yee-Chun Chen
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ABSTRACT: Healthcare-associated infections (HAIs) are a major patient safety issue. These adverse events add to the burden of resource use, promote resistance to antibiotics, and contribute to patient deaths and disability. A rule-based HAI classification and surveillance system was developed for automatic integration, analysis, and interpretation of HAIs and related pathogens. Rule-based classification system was design and implement to facilitate healthcare-associated bloodstream infection (HABSI) surveillance. Electronic medical records from a 2200-bed teaching hospital in Taiwan were classified according to predefined criteria of HABSI. The detailed information in each HABSI was presented systematically to support infection control personnel decision. The accuracy of HABSI classification was 0.94, and the square of the sample correlation coefficient was 0.99.
Studies in health technology and informatics 01/2013; 186:145-9.
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Chien-Yuan Chen,
Aristine Cheng,
Shang-Yi Huang,
Wang-Huei Sheng,
Jia-Hau Liu,
Bo-Sheng Ko,
Ming Yao,
Wen-Chien Chou,
Hui-Chi Lin, Yee-Chun Chen,
Woei Tsay,
Jih-Luh Tang,
Shan-Chwen Chang,
Hwei-Fang Tien
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ABSTRACT: Perianal infection is a common problem for patients with acute leukemia. However, neutropenia and bleeding tendency are relatively contraindicated to surgical intervention. The epidemiology, microbiology, clinical manifestations and outcomes of perianal infection in leukemic patients are also rarely discussed.
The medical records of 1102 adult patients with acute leukemia at a tertiary medical center in Taiwan between 2001 and 2010 were retrospectively reviewed and analyzed.
The prevalence of perianal infection was 6.7% (74 of 1102) in adult patients with acute leukemia. Twenty-three (31%) of the 74 patients had recurrent episodes of perianal infections. Patients with acute myeloid leukemia had higher recurrent rates than acute lymphoblastic leukemia patients (p = 0.028). More than half (n = 61, 53%) of the perianal infections were caused by gram-negative bacilli, followed by gram-positive cocci (n = 36, 31%), anaerobes (n = 18, 15%) and Candida (n = 1, 1%) from pus culture. Eighteen patients experienced bacteremia (n = 24) or candidemia (n = 1). Overall 41 (68%) of 60 patients had polymicrobial infection. Escherichia coli (25%) was the most common micro-organism isolated, followed by Enterococcus species (22%), Klebsiella pneumoniae (13%), and Bacteroides species (11%). Twenty-five (34%) of 74 patients received surgical intervention. Acute leukemia patients with surgically managed anal fistulas tended to have fewer recurrences (p = 0.067). Four (5%) patients died within 30 days after diagnosis of perianal infection. Univariate analysis of 30-day survival revealed the elderly (≧ 65 years) (p = 0.015) and patients with shock (p<0.001) had worse outcome. Multivariate analysis showed septic shock to be the independent predictive factor of 30-day crude mortality of perianal infections (p = 0.016).
Perianal infections were common and had high recurrence rate in adult patients with acute leukemia. Empirical broad-spectrum antibiotics with anaerobic coverage should be considered. Shock independently predicted 30-day crude mortality. Surgical intervention for perianal infection remains challenging in patients with acute leukemia.
PLoS ONE 01/2013; 8(4):e60624. · 4.09 Impact Factor
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ABSTRACT: BACKGROUND: The incidence of candidemia varied between hospitals and different study periods. Few, if any, studies provide the reasons. This hospital-based population study aimed to describe and compare the patient population hospitalized in 2002 and 2010 and determine the disease-specific incidences of candidemia and evaluate the impact of time to initiate antifungal therapy on 30-day mortality. PATIENTS AND METHODS: All patients hospitalized at a 2300-bed teaching hospital in Taiwan in 2002 and 2010 were analyzed for the distribution of age, sex, and type of underlying diseases (maximum of six diagnoses). All patients with blood isolates that were collected in 2002 and 2010 and yielded Candida species were included for analysis of the demographic and clinical characteristics, distribution of Candida species, length of hospital stay before candidemia, stay in the intensive care units at onset of candidemia, time of initiating systemic antifungal agent, antifungal regimen, and 30-day crude mortality. RESULTS: In 2010, the hospitalized patients were older (p < 0.001), had a higher Charlson comorbidity index (p < 0.001), and more underlying disease/status, including chronic pulmonary diseases, moderate-to-severe renal diseases, leukemia, lymphoma, and gastrointestinal malignancies (p < 0.001) than those seen in 2002. Multivariate analysis identified the following host factors were associated with the occurrence of candidemia in 2010: neonate (adjust odds ratio [OR], 3.67), 45-64 year (OR, 2.18) and the elderly (OR 2.64), compared with young adult (20-44 year); patients with moderate-to-severe renal diseases (OR, 8.08), leukemia (OR, 4.58) and lymphoma (OR 3.98) and gastrointestinal malignancies (OR 2.80). The incidence density of candidemia was 0.34 and 0.41 per 1000 patient-days in 2002 and 2010, respectively (p = 0.04). The majority of characteristics of patients with candidemia and disease-specific incidences of candidemia did not differ between 2002 and 2010. Despite more patients in 2010 receiving antifungal therapy on the same day or 1 day after onset (27.5% vs. 41.2%, respectively, p = 0.002), the 30-day mortality remained high (45.9% in 2002 and 44.4% in 2010). Moreover, time to initiate antifungal therapy had no impact on 30-day mortality. CONCLUSION: This hospital-based population study demonstrated that the incidence density of candidemia was high and increased in 2010 compared with 2002, which was at least in part due to the increase in the proportion of patients at a higher risk of candidemia. Although antifungal therapy was initiated earlier in 2010, the 30-day mortality remained high.
Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi 10/2012; · 0.99 Impact Factor
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ABSTRACT: This prospective study aimed to describe the clinical features, as well as outcomes, of adult patients with influenza of different severity, and to determine the predictors for development of complications.
From December 2006 to March 2009, four types of diagnostic tests were given to both in- and outpatients with influenza-like illness (ILI). Confirmed cases were categorized into three groups (uncomplicated, moderately complicated, and severely complicated) for analysis using a proportional odds logistic regression model.
A total of 206 laboratory-confirmed cases of influenza were identified out of 360 enrolled patients with ILI. Among 30 patients (14.6%) classified as complicated cases due to development of pneumonia (n=28) and viral encephalopathy (n=2), 16 were hospitalized in general wards (moderately complicated) and 14 required admission to intensive care units (severely complicated). Complicated patients were less likely to have classic symptoms of ILI than uncomplicated patients. By multivariate analysis, the presence of coronary artery disease, systemic corticosteroid use, impaired renal function and delayed hospital visit were independently associated with development of complications.
Our study results may help clinicians to identify patients at high risk for complicated influenza, to provide timely antiviral therapy and optimal clinical care.
Journal of the Formosan Medical Association 07/2012; 111(7):364-9. · 1.13 Impact Factor
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ABSTRACT: PURPOSE: The aim of this study was to assess the performance of 3 different influenza-like illness (ILI) case definitions, adopted by the European (European-CDC), USA (USA-CDC), and Taiwan Centers for Disease Prevention and Control (Taiwan-CDC), as screening tools for influenza during the 2009 H1N1 pandemic. METHODS: From August 15 to 30, 2009, all emergency department patients with clinical symptoms or at epidemiologic risk for influenza were enrolled in an observational cohort study. Influenza diagnosis was established by positive rapid influenza diagnostic test or virus isolation. Sensitivity, specificity, positive predictive value, and negative predictive value of the European-, USA, and Taiwan-CDC ILI case definitions for screening were determined. RESULTS: A total of 870 patients were screened during the study period. Rapid influenza diagnostic test was positive in 315 patients, 273 (85.6%) of whom had fever duration less than 72 hours. Virus isolation identified 4 more patients with influenza A initially negative by rapid influenza diagnostic test. The mean (SD) age of these 319 patients was 24.3 (18.1) years. Of the 870 screened patients, 670 (77.0%), 476 (54.7%), and 325 (37.4%) met the European-, USA-, and Taiwan-CDC ILI case definition, respectively. Screening sensitivity was 95%, 77.7%, and 57.7% and specificity was 33.4%, 58.6%, and 74.4%, respectively. Differences in sensitivity and specificity between any 2 of the 3 groups were statistically significant (P < .05). CONCLUSION: First-line physicians should recognize the advantage and limitation of different ILI case definitions in influenza screening, especially confronted by pandemic or highly pathogenic avian influenza in the future.
The American journal of emergency medicine 05/2012; · 1.54 Impact Factor
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ABSTRACT: Vancomycin-resistant enterococci (VRE), particularly vancomycin-resistant Enterococcus faecium (VREfm), have emerged among the leading pathogens causing hospital-acquired infections worldwide. We aimed to examine whether there were newly introduced clones contributing to this increase and to assess the risk factors for mortality in patients with VREfm bacteraemia.
Between 2003 and 2010, all medical records of adult patients diagnosed with VREfm bacteraemia at a university hospital in Taiwan were reviewed. Antibiotic susceptibility, genotyping and multilocus sequence typing of the VREfm isolates were performed.
During the study period, the prevalence of non-duplicated blood VRE isolates increased significantly from 3.9% in 2003 to 18.9% in 2010 (P < 0.0001). One-hundred-and-forty-nine patients with VREfm bacteraemia were noted and 102 isolates of VREfm were available for microbiological characterization. All isolates were susceptible to daptomycin and linezolid. Sequence type (ST) 18 and ST414 were the two predominant emerging STs from 2009 to 2010, accounting for 29.7% and 25.0% of all isolates, respectively. Patients who received immunosuppressives, had a high Charlson comorbidity index or experienced septic shock had a significantly higher 14 day mortality rate. Patients who had bacteraemia caused by ST414 isolates and received appropriate antibiotics had a lower 14 day mortality rate.
The prevalence of the VRE that caused bacteraemia increased from 2003 to 2010. This increase might be attributed to the clonal spread of VREfm belonging to ST18 and ST414. The all-cause 14 day mortality rate was lower in patients with bacteraemia due to VREfm isolates that belonged to ST414.
Journal of Antimicrobial Chemotherapy 05/2012; 67(9):2243-9. · 5.07 Impact Factor
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ABSTRACT: Hepatosplenic abscess caused by Actinomyces is rare and often misdiagnosed as malignancy. Herein, we report a case of hepatosplenic actinomycosis in a 37-year-old immunocompetent man with a 2-month clinical history of intermittent fever and upper left abdominal pain. Physical examination revealed a mildly ill-appearing man with a low-grade fever (38°C) and upper left quadrant abdominal tenderness. Abdominal sonographic examination showed the presence of a 6.3 cm × 6.5 cm heterogeneous abscess with a hypoechoic center and honeycomb appearance in an enlarged spleen (8 cm × 5 cm). Computerized tomography of the abdomen revealed a multiloculated splenic lesion, and laparotomy showed multiple hepatic nodules and a splenic abscess. Histopathological examination of the biopsy revealed filamentous branching bacilli and sulfur granules in the hepatosplenic abscess. The patient successfully underwent splenectomy accompanied by intravenous and oral penicillin treatment. Proper and prompt diagnosis of hepatosplenic actinomycosis is important because the therapeutic plan and prognosis of this pathogen are quite different from other microorganisms and malignancies.
Journal of the Formosan Medical Association 04/2012; 111(4):228-31. · 1.13 Impact Factor
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ABSTRACT: The emergence and spread of multidrug-resistant organisms (MDROs) are causing a global crisis. Combating antimicrobial resistance requires prevention of transmission of resistant organisms and improved use of antimicrobials.
To develop a Web-based information system for automatic integration, analysis, and interpretation of the antimicrobial susceptibility of all clinical isolates that incorporates rule-based classification and cluster analysis of MDROs and implements control chart analysis to facilitate outbreak detection.
Electronic microbiological data from a 2200-bed teaching hospital in Taiwan were classified according to predefined criteria of MDROs. The numbers of organisms, patients, and incident patients in each MDRO pattern were presented graphically to describe spatial and time information in a Web-based user interface. Hierarchical clustering with 7 upper control limits (UCL) was used to detect suspicious outbreaks. The system's performance in outbreak detection was evaluated based on vancomycin-resistant enterococcal outbreaks determined by a hospital-wide prospective active surveillance database compiled by infection control personnel.
The optimal UCL for MDRO outbreak detection was the upper 90% confidence interval (CI) using germ criterion with clustering (area under ROC curve (AUC) 0.93, 95% CI 0.91 to 0.95), upper 85% CI using patient criterion (AUC 0.87, 95% CI 0.80 to 0.93), and one standard deviation using incident patient criterion (AUC 0.84, 95% CI 0.75 to 0.92). The performance indicators of each UCL were statistically significantly higher with clustering than those without clustering in germ criterion (P < .001), patient criterion (P = .04), and incident patient criterion (P < .001).
This system automatically identifies MDROs and accurately detects suspicious outbreaks of MDROs based on the antimicrobial susceptibility of all clinical isolates.
Journal of Medical Internet Research 01/2012; 14(5):e131. · 4.41 Impact Factor
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ABSTRACT: The prevalence of vancomycin-resistant enterococci (VRE) colonization or infection in the hospital setting has increased globally. Many previous studies had analysed the risk factors for acquiring VRE, based on cross-sectional studies or prevalent cases. However, the actual incidence of and risk factors for VRE remain unclear. The present study was conducted in order to clarify the incidence of and risk factors for VRE in the intensive care unit (ICU). From 1(st) April 2008 to 31(st) March 2009, all patients admitted to a surgical ICU (SICU) were put on active surveillance for VRE. The surveillance cultures, obtained by rectal swab, were taken on admission, weekly while staying in the SICU, and on discharge from the SICU. A total of 871 patients were screened. Among them, 34 were found to carry VRE before their admission to the SICU, and 47 acquired VRE during their stay in the SICU, five of whom developed VRE infections. The incidence of newly acquired VRE during ICU stay was 21.9 per 1000 patient-days (95% confidence interval [CI], 16.4-29.1). Using multivariate analysis by logistic regression, we found that the length of ICU stay was an independent risk factor for new acquisition of VRE. In contrast, patients with prior exposure to first-generation cephalosporin were significantly less likely to acquire VRE. Strategies to reduce the duration of ICU stay and prudent usage of broad-spectrum antibiotics are the keys to controlling VRE transmission.
PLoS ONE 01/2012; 7(10):e47297. · 4.09 Impact Factor
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ABSTRACT: The incidence of Clostridium difficile-associated diarrhea (CDAD) is increasing worldwide. Spread of an epidemic hypervirulent strain in southern Taiwan was associated with poor outcome. This prospective study evaluates the incidence and clinical manifestation of CDAD following a hospital-wide hand hygiene promotion program in a 2,200-bed teaching hospital in northern Taiwan.
From June 1, 2010 to October 31, 2010, a predefined protocol was used to actively survey CDAD at 11 high-risk units. Stool samples of patients with antibiotic-associated diarrhea (AAD) were submitted for stool culture and toxin A/B assay using a combined enzyme immunoassay. CDAD was diagnosed by a positive toxin assay.
The incidence of CDAD was 0.45/1000 patient-days and was highest in medical intensive care units (7.9/1000 patient-days), followed by hemato-oncology wards, and infectious disease wards. Occurrence of CDAD was associated with ≥3 stool pus cells per high power field (p = 0.018), prior use of metronidazole (p = 0.029), high usage of beta-lactamase stable penicillins (p = 0.046), and anaerobe-active antibiotics (p = 0.029). No attributable mortality was found. The incidence of CDAD was lower than that previously observed (1.0/1000 patient-days in 2003, p < 0.001).
This study showed a lower incidence of CDAD and absence of attributable mortality. The impact of hand hygiene promotion and other infection control measures on decreasing incidence of CDAD warrants further elucidation.
Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi 12/2011; 45(4):287-95. · 0.99 Impact Factor
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ABSTRACT: Diseases caused by Mycobacterium tuberculosis (TB) among adult patients with hematological malignancies have rarely been investigated.
Adult patients with hematological malignancies at National Taiwan University Hospital between 1996 and 2009 were retrospectively reviewed. Patients with positive serology for HIV were excluded. TB disease is diagnosed by positive culture(s) in the presence of compatible symptoms and signs. The demographics, laboratory and, microbiological features, were analyzed in the context of clinical outcomes.
Fifty-three of 2984 patients (1.78%) were diagnosed with TB disease. The estimated incidence was 120 per 100,000 adult patients with hematological malignancies. Patients with acute myeloid leukemia had a significantly higher incidence of TB disease than other subtypes of hematological malignancies (2.87% vs. 1.21%, p = 0.002, odds ratio, 2.40; 95% confidence interval, 1.39-4.41). Thirty-eight patients (72%) with non-disseminated pulmonary TB disease presented typically with mediastinal lymphadenopathy (53%), pleural effusion (47%) and fibrocalcific lesions (43%) on chest imaging. The 15 (28%) patients with extra-pulmonary disease had lower rates of defervescence within 72 h of empirical antimicrobial therapy (13% vs 45%, p = 0.03) and a higher 30-day in-hospital mortality (20% vs. 0%, p = 0.004) compared to those with disease confined to the lungs.
TB disease is not uncommon among patients with hematological malignancies in Taiwan. Patients who received a diagnosis of extra-pulmonary TB suffered higher mortality than those with pulmonary TB alone. Clinicians should consider TB in the differential diagnoses of prolonged fever in patients with hematological malignancies, particularly in regions of high endemicity.
BMC Infectious Diseases 11/2011; 11:324. · 3.12 Impact Factor
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ABSTRACT: Recent studies have demonstrated that rapid influenza diagnostic tests (RIDTs) have a relatively low sensitivity in detecting severe cases of pandemic H1N1 2009 influenza virus (pH1N1) infection. We hypothesized that viral load in upper respiratory specimens obtained on presentation may not be correlated with disease severity.
We conducted a prospective study to compare patterns of viral shedding using nasopharyngeal swab specimens, according to the number of days of post-symptom onset and post-antiviral therapy, between patients with and without complications.
From July 15, 2009 through July 23, 2010, we collected and processed a total of 141 nasopharyngeal swab specimens from 64 inpatients and outpatients with laboratory-confirmed pH1N1 infection. These included 46 patients without any complications (uncomplicated group) and 18 patients who required hospital admission (complicated group). The mean initial viral load was higher in the uncomplicated group than in the complicated group (3·4 ± 1·6 log(10) copies/μl versus 1·9 ± 1·7, P = 0·02). However, prolonged viral shedding was only detected in the complicated group (44% by day 7 of antiviral therapy). By multivariate analysis, we found that age (OR, 1·1; 95% CI, 1·0-1·1) and initial nasopharyngeal viral load (OR, 0·5; 95% CI, 0·3-0·8) were significant factors associated with complications.
Given that patients with severe pH1N1 infection may have relatively lower initial viral load in the upper respiratory tract, cautious interpretation of negative RIDT results is particularly warranted in this patient population.
Influenza and Other Respiratory Viruses 11/2011; 6(5):367-73. · 4.16 Impact Factor
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ABSTRACT: This study assessed the impact of ertapenem and other carbapenems on mortality in patients with monomicrobial extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) bacteremia.
This non-concurrent prospective study included adult patients with ESBL-EC bacteremia during a 2.5-year period at a 2200-bed teaching hospital. We used a multivariate logistic regression model and Cox's proportional hazards model including propensity score analysis to assess variables associated with 30-day mortality.
Of 71 patients who met the study criteria, nine died within 3 days. Among the 62 remaining patients who received definitive antimicrobial therapy, 13 died within 30 days. Male gender, ICU stay, solid tumor, and primary bacteremia were independent predictors of 30-day mortality, whereas definitive antimicrobial therapy using either ertapenem or imipenem/meropenem was protective (p<0.001 and p=0.002, respectively). Adjustment by propensity score found that ertapenem appeared to exhibit more favorable outcomes, but the difference fell short of statistical significance (hazard ratio 0.02, p=0.06). Inappropriate initial therapy was not a significant predictor of mortality.
ICU stay, but not initial choice of empirical antimicrobial therapy, was a major predictor of mortality. Using a carbapenem as definitive therapy was a protective factor for 30-day mortality. The choice of ertapenem is reasonable for less severely-ill patients who are at risk of ESBL-EC bacteremia and unlikely to have infection due to Pseudomonas aeruginosa.
International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases 11/2011; 16(1):e47-52. · 2.17 Impact Factor
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ABSTRACT: Despite general recommendation of short-course antibiotic prophylaxis, prolonged antibiotic use is still commonly reported in clinical settings. This study compared the efficacy of 1-day versus 3-day antibiotic prophylaxis in preventing surgical site infection (SSI) in patients undergoing coronary artery bypass graft (CABG).
This prospective, randomized control study was performed in a tertiary-care medical center from June 2002 to April 2004. Patients underwent non-emergency CABG and were randomized into two groups receiving either 1 day or 3 days cefazolin prophylaxis. The SSI rates were compared between the two groups.
During the study period, 231 patients were enrolled, 120 in the 1-day group and 111 in the 3-day group. Twenty-two episodes of SSI were observed within 1 month after operation: 13 (10.8%) in the 1-day group and nine (8.1%) in the 3-day group (odds ratio: 1.37; 95% confidence interval: 0.56-3.33; p = 0.48). By logistic regression analysis, 1-day prophylaxis with cefazolin was not associated with higher risk of SSI (adjusted odds ratio: 0.91; 95% confidence interval: 0.32-2.56; p = 0.85).
Antibiotic prophylaxis for 1 day in CABG surgery was associated with similar rates of postoperative infection compared with antibiotic prophylaxis of 3 days.
Journal of the Formosan Medical Association 10/2011; 110(10):619-26. · 1.13 Impact Factor
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ABSTRACT: Risk factors and outcomes in hematological patients who acquire invasive fungal sinusitis (IFS) are infrequently reported in the modern medical era.
A retrospective study of hospitalized patients with hematological disease was conducted at National Taiwan University Hospital between January 1995 and December 2009.
Clinical characteristics and outcomes with their associated radiographic and microbiological findings were analyzed. Forty-six patients with IFS and 64 patients with chronic non-invasive sinusitis were enrolled as comparsion. IFS developed more commonly in patients with acute myeloid leukemia (AML) and with prolonged neutropenia (absolute neutrophil count less than 500/mm³ for more than 10 days) (p < 0.001). Aspergillus flavus was the most common pathogen isolated (44%). Serum Aspergillus galactomannan antigen was elevated in seven of eleven patients (64%) with IFS caused by aspergillosis but negative for all three patients with mucormycosis. Bony erosion and extra-sinus infiltration was found in 15 of 46 (33%) patients on imaging. Overall, 19 of 46 patients (41.3%) died within 6 weeks. Patients with disease subtype of AML (p = 0.044; Odds Ratio [OR], 5.84; 95% confidence interval [95% CI], 1.02-30.56) and refractory leukemia status (p = 0.05; OR, 4.27; 95% CI, 1.003-18.15) had worse prognosis. Multivariate analysis identified surgical debridement as an independent good prognostic factor (p = 0.047) in patients with IFS.
Patients of AML with prolonged neutropenia (> 10 days) had significantly higher risk of IFS. Early introduction of anti-fungal agent and aggressive surgical debridement potentially decrease morbidity and mortality in high risk patients with IFS.
BMC Infectious Diseases 09/2011; 11:250. · 3.12 Impact Factor
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ABSTRACT: Dysphagia increases the risk of pneumonia in stroke patients. This study aimed to evaluate bedside swallowing screening for prevention of stroke-associated pneumonia (SAP) in acute stroke patients admitted to the intensive care unit (ICU). Consecutive acute stroke patients admitted to the stroke ICU from May 2006 to March 2007 were included. Patients were excluded if they were intubated on the first day of admission or had a transient ischemic attack. A 3-Step Swallowing Screen was introduced since October 2006 and therefore patients were divided into pre-screen and post-screen groups. A binary logistic regression model was used to determine independent risk factors for SAP and in-hospital death. There were 74 and 102 patients included in the pre- and post-screen groups, respectively. Pneumonia was associated with higher National Institutes of Health Stroke Scale (NIHSS) score, older age, nasogastric and endotracheal tube placement. After adjusting for age, gender, NIHSS score and nasogastric and endotracheal tube insertion, dysphagia screening was associated with a borderline decrease in SAP in all stroke patients (odds ratio, 0.42; 95% CI, 0.18-1.00; p=0.05). However, dysphagia screening was not associated with reduction of in-hospital deaths. Systematic bedside swallowing screening is helpful for prevention of SAP in acute stroke patients admitted to the ICU.
Journal of the neurological sciences 07/2011; 306(1-2):38-41. · 2.32 Impact Factor
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ABSTRACT: Therapeutic options for the treatment of infections caused by carbapenem-resistant Acinetobacter baumannii (CRAB) are limited. In vitro activity of amikacin, ciprofloxacin, colistin (polymyxin E), ampicillin-sulbactam, and tigecycline alone and in combination with imipenem against CRAB and carbapenem-resistant Acinetobacter genospecies 3 and 13TU was investigated. Colistin (97% susceptible) and tigecycline (88% and 44% susceptible by US Food and Drug Administration [FDA] and European Committee on Antimicrobial Susceptibility Testing [EUCAST] breakpoints for Enterobacteriaceae, respectively) were the 2 most active agents against CRAB, followed by minocycline (66%), ampicillin/sulbactam (16%), and amikacin (13%). Compared with CRAB isolates, carbapenem-resistant Acinetobacter genospecies 3 and 13TU isolates had higher antimicrobial susceptible rates to ciprofloxacin (88%), amikacin (63%), tigecycline (100% by FDA breakpoint and 88% by EUCAST breakpoint for Enterobacteriaceae, respectively), minocycline (100%), and ampicillin/sulbactam (75%). For the 12 tested CRAB isolates, the checkerboard titration method demonstrated synergy between imipenem and colistin (42%), tigecycline (25%), amikacin (16%), and ampicillin/sulbactam (16%). Time-kill assays revealed antimicrobial synergism for imipenem in combination with colistin (75%), tigecycline (50%), ampicillin/sulbactam (42%), amikacin (42%), and ciprofloxacin (16%). However, antimicrobial synergism between imipenem and combined agents was not present among CRAB isolates with an imipenem MIC ≥ 32 mg/L. The combination of tigecycline and colistin showed good in vitro synergy for CRAB with high imipenem resistance. Our results demonstrate accurate identification of prevalent Acinetobacter species and highlight their different antimicrobial susceptibilities. This knowledge will enable clinicians to select appropriate regimens for treating these infections.
Diagnostic microbiology and infectious disease 07/2011; 70(3):380-6. · 2.45 Impact Factor
