Hwee-Kheng Lim’s research while affiliated with Mackay Memorial Hospital and other places

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Publications (9)


A dangerous cause of airway obstruction: Deep neck infection
  • Article
  • Full-text available

March 2021

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441 Reads

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7 Citations

Signa Vitae

Hwee-Kheng Lim

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Jinn-Ming Wang

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Sho-Ting Hung

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[...]

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Zhenbao Zhou

Abstract Deep neck infection (DNI) is an infection in the fascial spaces of the neck. Complications of DNI, including mediastinitis, internal jugular vein thrombosis, and upper airway obstruction, are severe and potentially life threatening. Therefore, early identification and accurate management of DNI are essential. We review the anatomy of the deep spaces of the neck to determine the route of DNI spread so that emergency doctors, physicians, and otorhinolaryngologists can quickly recognize the development of lethal complications of DNI, such as asphyxia from airway obstruction.

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Scrub Typhus: Seven-Year Experience and Literature Review

September 2018

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39 Reads

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5 Citations

Journal of Acute Medicine

Background: Scrub typhus, an emerging rickettsial disease caused by Orientia tsutsugamushi, is a clinically important endemic disease on Taiwan. Methods: From January 1, 2007, to December 31, 2013, 156 patients diagnosed with scrub typhus were admitted to Taitung MacKay Memorial Hospital. Demographic data, clinical features, laboratory results, and outcomes of patients were retrospectively analyzed. Results: Among 156 cases, 150 survived (96%) and six died (4%). There were 111 males (71%) and 45 females (29%) with a mean age of 47.8 years. The most common clinical features were fever (100%), general malaise (77%), chill (74%), headache (59%), and eschar (55%). No seasonal pattern was observed, with peaks in November and January. The average time to defervescence after appropriate antibiotics for the 150 surviving patients was 2.45 days. The significant risk factors were a delay of initial appropriate antibiotics use within 24 hrs, increased C-reactive protein (CRP), and liver cirrhosis. Conclusion: Scrub typhus, a growing and emerging disease, is considered in the differential diagnosis of fever of unknown origin, and its diagnosis may be missed if it is not considered owing to its nonspecific clinical presentation. It is important to have a high index of suspicion and to increase awareness in endemic areas. Prompt diagnosis and early treatment with appropriate antibiotics are vital.


Table 4 -Summary of baseline characteristics by outcome. 
Table 5 -Univariate and multivariate logistic regression models for the event of death. 
Necrotizing fasciitis: Eight-year experience and literature review

November 2013

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142 Reads

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155 Citations

The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases

To describe clinical, laboratory, microbiological features, and outcomes of necrotizing fasciitis. From January 1, 2004 to December 31, 2011, 115 patients (79 males, 36 females) diagnosed with necrotizing fasciitis were admitted to Mackay Memorial Hospital in Taitung. Demographic data, clinical features, location of infection, type of comorbidities, microbiology and laboratory results, and outcomes of patients were retrospectively analyzed. Among 115 cases, 91 survived (79.1%) and 24 died (20.9%). There were 67 males (73.6%) and 24 females (26.4%) with a median age of 54 years (inter-quartile ranges, 44.0-68.0 years) in the survival group; and 12 males (50%) and 12 females (50%) with a median age of 61 years (inter-quartile ranges, 55.5-71.5 years) in the non-surviving group. The most common symptoms were local swelling/erythema, fever, pain/tenderness in 92 (80%), 87 (76%) and 84 (73%) patients, respectively. The most common comorbidies were liver cirrhosis in 54 patients (47%) and diabetes mellitus in 45 patients (39%). A single organism was identified in 70 patients (61%), multiple pathogens were isolated in 20 patients (17%), and no microorganism was identified in 30 patients (26%). The significant risk factors were gender, hospital length of stay, and albumin level. Necrotizing fasciitis, although not common, can cause notable rates of morbidity and mortality. It is important to have a high index of suspicion and increase awareness in view of the paucity of specific cutaneous findings early in the course of the disease. Prompt diagnosis and early operative debridement with adequate antibiotics are vital.


Table 4 . Summary of baseline characteristics by outcome (survival or death)
Table 5. Univariate and multivariate logistic regression models for the event of death. 
Aeromonas hydrophila Infection: 6-Year Experience and Literature Review

January 2010

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512 Reads

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1 Citation

Background: While uncommon, Aeromonas hydrophila bacteremia can be fatal. Method: From January 1, 2003 to December 31, 2008, 48 patients (39 males, 9 females) diagnosed with A. hydrophila bacteremia were admitted to Mackay Memorial Hospital in Taitung. Patient demographic data, clinical features, laboratory data, and outcomes were retrospectively analyzed. Result: Of the 48 cases of A. hydrophila bacteremia, 36 were monomicrobial and 12 were polymicrobial infections. The most common symptoms were fever (43/48, 90%), jaundice (28/48, 58%), and abdomen pain (25/48, 52%). Underlying diseases included liver cirrhosis (27/48, 56%), and malignancy (7/48, 15%). In vitro, A. hydrophila was generally susceptible to gentamycin (100%), quinolones (98%), chloramphenicol (98%), cefuroxime (94%), and cefotaxime (94%) and resistant to ampicillin (98%). A. hydrophila bacteremia usually occurred in patients with liver cirrhosis or malignancy and heralded a poor prognosis. The overall crude fatality rate was (15/48, 31%). Anemia, leukocytosis, and impaired renal function were independent significant risk factors of death. Conclusion: A. hydrophila, although not common, can cause notable rates of morbidity and mortality among immunocompetent and immunocompromised persons. It is important to have a high index of suspicion and increase awareness of A. hydrophila infection at initial presentation. Prompt diagnosis and early treatment with adequate antibiotics are vital.


High prevalence rate of multidrug resistance among nosocomial pathogens in the respiratory care center of a tertiary hospital

October 2009

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132 Reads

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10 Citations

Journal of Microbiology Immunology and Infection

There is an increasing need for respiratory care centers (RCCs) for patients who require prolonged mechanical ventilation after intensive care unit (ICU) stay. Nosocomial infections occur at a high rate in ICUs, but there have been few studies of nosocomial infections in RCCs in Taiwan. The infection rates, sources, and pathogens of nosocomial infections in the RCC of a tertiary hospital were retrospectively analyzed from January 2001 to December 2002. Nosocomial infections were defined in accordance with the recommendations of the Centers for Disease Control in the United States. There were 398 nosocomial infections in 265 patients (1.5 episodes for each patient). The incidence density of nosocomial infection was 27.3%. The mean age +/- standard deviation of patients was 74.5 +/- 12.8 years. The mean duration of infection from the day of patient transfer to the RCC was 13 days (range, 2-78 days). Urinary tract infection was most common (53.8%), followed by bloodstream infection (31.2%), skin and soft tissue infection (6.0%), and lower respiratory tract infection (5.5%). 481 strains of microorganisms were isolated, 12.8% of which were Staphylococcus aureus (all methicillin-resistant), 11.1% were Klebsiella pneumoniae (69.1% of which were the extended spectrum beta-lactamase [ESBL] phenotype), and 10.6% were Escherichia coli (31.4% of which were the ESBL phenotype). The infection incidence density in the RCC was similar to previous findings for ICUs during the same period. However, there were differences in the distribution of sites and pathogens. Multiple drug resistance rates were high.


Emphysematous pyelonephritisTwelve years’ experience at a medical center

July 2009

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10 Reads

Objective. The mortality rate among patients with emphysematous pyelonephritis (EPN) is high and the best therapy has long been debated. Material and methods. Between January 1993 and December 2004, 26 patients diagnosed with EPN were treated at our hospital. Historical, demographic and laboratory data were obtained from medical records for analysis. Results. The mean age of the patients was 58.7±12.7 years. All patients had diabetes, and women outnumbered men (23:3). The clinical findings were non-specific. A plain abdominal X-ray was diagnostic in only 9/26 patients (36%), ultrasonography was accurate in 13 (50%) and CT was diagnostic in all cases. Eighteen patients survived, including all five treated with open drainage and three out of four treated with percutaneous drainage (although one of these later required nephrectomy), and eight died. Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome, obesity and smoking were significant predictors of death. Conclusions. Early diagnosis by means of CT and CT-guided percutaneous drainage (which is better than ultrasonography-guided drainage) or open drainage, along with antibiotic treatment, may be a reasonable alternative to nephrectomy for this high morbidity condition.


Emphysematous pyelonephritis

February 2007

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33 Reads

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42 Citations

Scandinavian Journal of Urology and Nephrology

The mortality rate among patients with emphysematous pyelonephritis (EPN) is high and the best therapy has long been debated. Between January 1993 and December 2004, 26 patients diagnosed with EPN were treated at our hospital. Historical, demographic and laboratory data were obtained from medical records for analysis. The mean age of the patients was 58.7+/-12.7 years. All patients had diabetes, and women outnumbered men (23:3). The clinical findings were non-specific. A plain abdominal X-ray was diagnostic in only 9/26 patients (36%), ultrasonography was accurate in 13 (50%) and CT was diagnostic in all cases. Eighteen patients survived, including all five treated with open drainage and three out of four treated with percutaneous drainage (although one of these later required nephrectomy), and eight died. Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome, obesity and smoking were significant predictors of death. Early diagnosis by means of CT and CT-guided percutaneous drainage (which is better than ultrasonography-guided drainage) or open drainage, along with antibiotic treatment, may be a reasonable alternative to nephrectomy for this high morbidity condition.


Treatment of pan-drug resistant Acinetobacter baumannii

February 2005

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1,012 Reads

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52 Citations

Scandinavian Journal of Infectious Diseases

The objective of this study was to investigate the role of sulbactam in the treatment of pan-drug resistant Acinetobacter baumannii (PDRAB). We studied 89 patients with PDRAB infection treated with different antibiotic regimens. Group A (n = 39) were treated with carbapenem with sulbactam and group B (n = 30) with second and third generation cephalosporins, antipseudomonas penicillins, or fluoroquinolones with aminoglycosides. We also studied the MICs for 48 PDRAB strains by using antimicrobial agents with and without sulbactam. The clinical outcomes of the 2 groups did not differ significantly, either in terms of resolution of infection (25/59, 42% in group A vs 12/30, 40% in group B) or survival (35/59, 59% vs 17/30, 57%). However, the MICs indicated that 16 of the 48 strains were sensitive to imipenem/sulbactam, compared with only 2 of the 48 to imipenem alone. The addition of sulbactam thus reversed the response in 30% (14/46) of strains initially resistant or only intermediate sensitive to imipenem. The MICs for meropenem/sulbactam were in the sensitive range for 8 of 48 strains compared to only 3 of the meropenem alone, indicating an 11% (5/45) reversal rate when sulbactam was added to meropenem. For the 38 isolates initially resistant to both carbapenems alone, imipenem/sulbactam reversed the resistance in 16% (6/38), while meropenem/sulbactam did so in only 3% (1/38). Thus, the carbapenem-sulbactam combinations did not clearly improve clinical outcome, but they did demonstrate lower MICs for the PDRAB strains tested. It may be that aggressive, early treatment of A. baumannii infections with these agents might prevent the emergence of PDRAB strains.


Severe acute respiratory syndrome in a medical center in Taipei

October 2003

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43 Reads

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6 Citations

Journal of Microbiology Immunology and Infection

From April 18 to May 31, 2003, 46 patients with probable severe acute respiratory syndrome were admitted to the negative-pressure isolation rooms of Mackay Memorial Hospital in Taipei, Taiwan. Their demographic, clinical, laboratory, and radiologic characteristics and clinical outcomes were analyzed. There were 15 males and 31 females, in this cohort, 13 of whom were healthcare workers. The latter included 6 hospital staff and 7 medical personnel transferred from other hospitals. The most common symptoms were fever (100%, 46/46), cough (72%, 33/46), shortness of breath (46%, 21/46), and diarrhea (39%, 18/46). Other common findings were lymphopenia (57%, 26/46), thrombocytopenia (39%, 18/46), elevated lactate dehydrogenase (63%, 29/46), and elevated creatine kinase (24%, 11/46). A total of 7 patients (15%) required mechanical ventilation, and 8 (17%) died. Advanced age was an independent significant risk factor for death. Fever followed by rapidly progressive respiratory compromise led to significant morbidity and mortality in this cohort.

Citations (8)


... Our research findings are consistent with previous studies, which have reported that patients with neck abscesses and diabetes tend to have longer hospital stays [11,12]. During the treatment process of neck abscesses, impaired immune function in patients with diabetes may increase the difficulty of infection control, requiring a longer time to manage the C drug sensitivity analysis of Staphylococcus aureus; D intersection of antibiotics sensitive to three pathogenic bacteria infection. ...

Reference:

Microbiological analysis and antibiotic selection strategy in neck abscesses among patients with diabetes mellitus
A dangerous cause of airway obstruction: Deep neck infection

Signa Vitae

... Understanding this unique presentation is crucial for early diagnosis and effective management, given the potential for severe morbidity and mortality associated with scrub typhus-induced ARDS. 5 Case report A 18-year-old student hailing from Wardha, India, with recent travel history to Amravati, was urgently brought to Acharya Vinoba Bhave Hospital. She presented with a triad of fever accompanied by chills and rigors 3 to 4 episodes, recurring over the past week. ...

Scrub Typhus: Seven-Year Experience and Literature Review
  • Citing Article
  • September 2018

Journal of Acute Medicine

... Necrotizing soft tissue infections (NSTIs) rank among the most challenging and deadly infections, destroying skin, subcutaneous tissue, and fascia while presenting signs of systemic toxicity [1,2]. NSTIs are most commonly observed in the extremities but infrequently in the neck [3][4][5]. In this regard, the neck poses a specific danger due to its complex anatomy involving vital vascular, neural, and respiratory components. ...

Necrotizing fasciitis: Eight-year experience and literature review

The Brazilian journal of infectious diseases: an official publication of the Brazilian Society of Infectious Diseases

... Fever was also one of the most common clinical manifestations and it was noted in 90% of the patients. 9 In term of basic laboratory investigations, leukocytosis and increased C-reactive protein level were among the common findings. 5,6 Aeromonas hydrophila are gram-negative, non-spore forming facultative anaerobic rods bacteria which usually produced beta hemolytic colonies on blood agar. ...

Aeromonas hydrophila Infection: 6-Year Experience and Literature Review

... Further analysis of the distribution of ESBL-producing isolates in different ICUs showed that the most significant increase occurred in medical ICUs, with a peak prevalence rate of 35.9% in 2006 for E. coli (Shu et al., 2010). In a respiratory care center, one retrospective analysis in a tertiary care center from January 2001 to December 2002 reported that the ESBL phenotype was found in 31.4% of E. coli (Lee C. M. et al., 2009). In the respiratory care ward involving patients who required prolonged or long-term mechanical ventilation, Lin et al. reported that the prevalence of ESBLproducing isolates of E. coli was 39.5% (Lin et al., 2013). ...

High prevalence rate of multidrug resistance among nosocomial pathogens in the respiratory care center of a tertiary hospital
  • Citing Article
  • October 2009

Journal of Microbiology Immunology and Infection

... Other authors obtained similar results. Increased age, 6,13,21 Comorbidities" is defined as the presence of existing chronic illnesses that were diagnosed prior to admission. These include asthma, chronic obstructive lung disease, diabetes mellitus, ischaemic heart disease, hypertension, cardiac failure, chronic or end-stage renal failure, liver impairment, and cerebral vascular disease. ...

Severe acute respiratory syndrome in a medical center in Taipei
  • Citing Article
  • October 2003

Journal of Microbiology Immunology and Infection

... MDR refers to strains that exhibit resistance to more than three or more antimicrobial drug classes, while extensively drug resistant (XDR) strains display resistance to all but two drug classes (Leski et al, 2013). Pan-drug resistance (PDR) indicates resistance to all drug classes including carbapenems, colistin, and other polymyxins (Lee et al, 2005). ...

Treatment of pan-drug resistant Acinetobacter baumannii

Scandinavian Journal of Infectious Diseases

... The management of emphysematous pyelonephritis encompasses both surgical and medical approaches. Medical interventions include percutaneous drainage, addressing hemodynamic and electrolyte imbalances, managing glycemic disorders, and implementing antibiotic therapy [5]. Surgical options vary from drainage of the excretory tract to percutaneous or surgical drainage of renal spaces, nephrectomy, and potentially cystectomy in severe cases involving necrotic cystitis [4]. ...

Emphysematous pyelonephritis
  • Citing Article
  • February 2007

Scandinavian Journal of Urology and Nephrology