Mortality predictors of Pneumocystis jirovecii pneumonia in human immunodeficiency virus-infected patients at presentation: Experience in a tertiary care hospital of northern Taiwan.

BACKGROUND: Pneumocystis jirovecii pneumonia (PJP) remains the leading cause of opportunistic infections and deaths among human immunodeficiency virus (HIV)-infected patients. We would like to identify the predictors of mortality of these patients at initial presentation, and assist clinicians to aware the patients in risk of mortality earlier. METHODS: From 1997 to 2009, adults with HIV infection and a discharge diagnosis of PJP at Mackay Memorial Hospital were included in this retrospective study. Patients' demographic data and laboratory data were analyzed by reviewing the medical records. RESULTS: Eighty-five patients were included in this study. The overall mortality rate was 37.7%. Univariate analysis revealed several host factors significantly related to mortality, including age, systolic blood pressure, diastolic blood pressure, partial pressure of oxygen in arterial blood (PaO(2)), percentage of lymphocyte, percentage of CD4 lymphocyte, CD4 counts, serum total protein, serum albumin, and blood urea nitrogen. Multivariate analysis identified three independent predictors associated with mortality, i.e. systolic blood pressure ≤110 mmHg [adjusted odds ratio (AOR) 3.88; 95% confidence interval (CI) 1.17-12.83; p = 0.03], PaO(2) at room air ≤60 mmHg (AOR 4.97; 95% CI 1.34-18.23; p = 0.01), and lymphocytes ≤10% (AOR 8.19; 95% CI 1.48-45.36; p = 0.02). With these predictors, we can stratify patients into three groups with increasing risks for mortality, ≤one predictor (mortality rate 14%), any two predictors (47%), and three predictors (75%). CONCLUSIONS: HIV-infected patients with PJP can be clinically stratified by three prognostic variables identified by multivariate analysis. Early recognition of patients in higher risk can assist clinicians to prevent rapid deterioration and seek for better outcomes.

Aerosolized colistin for the treatment of multidrug-resistant Acinetobacter baumannii pneumonia: experience in a tertiary care hospital in northern Taiwan.

BACKGROUND/PURPOSE: Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) Acinetobacter baumannii in critically ill patients presents an emerging challenge to clinicians. Administration of aerosolized colistin as an adjunctive therapy is one therapeutic option mentioned in limited evidence-based studies. This study aimed to evaluate the effectiveness of adjunctive aerosolized colistin treatment for VAP due to MDR pathogens. METHODS: We retrospectively reviewed the medical records of patients who had received aerosolized colistin for treatment of VAP due to MDR A. baumannii in our hospital from August to December 2008. RESULTS: Forty-five patients were enrolled in our study. The mean age was 71 +/- 15 years. The mean Acute Physiological and Chronic Health Evaluation II (APACHE II) scores on the day of intensive care unit admission and on the first day of aerosolized colistin administration were 22.5 +/- 6.7 and 18.9 +/- 5.7, respectively. The mean duration of intensive care unit stay was 34 +/- 16 days. The mean daily dosage of aerosolized colistin was 4.29 +/- 0.82 million IU, and the mean duration of administration was 10.29 days. Seventeen patients (37.8%) had a favorable microbiological outcome and 26 (57.8%) showed a clinical response. Mortality due to all causes was 42.2%. No adverse effects related to inhaled colistin were recorded. CONCLUSION: Aerosolized colistin may be considered as an adjunct to intravenous treatments in patients with VAP due to colistin-susceptible MDR A. baumannii in critically ill patients.

Fournier's gangrene: ten-year experience in a medical center in northern Taiwan.

BACKGROUND AND PURPOSE: Fournier's gangrene is a life-threatening infection. The mortality is still high despite the rapid advancement of modern intensive care and surgical technique. In this study, we present our institution's recent experience with a large series of patients with Fournier's gangrene. METHODS: A retrospective chart review was performed including 44 consecutive patients with Fournier's gangrene over a 10-year period. RESULTS: The 44 cases comprised 39 males and 5 females, with a mean age of 55.5 years. The mean duration of hospitalization was 27.9 days. Overall mortality was 22.7%. Diabetes mellitus, hypertension, chronic liver disease, liver cirrhosis and chronic renal insufficiency were the 5 leading predisposing factors. Liver cirrhosis was highly related to mortality (p=0.009). The etiologic origin of the gangrene was colorectal, urological and dermatological in 52.3%, 25.0%, and 11.4% of patients, respectively. The most common isolated pathogens were Escherichia coli, Bacteroides fragilis, Klebsiella pneumoniae, Enterococcus spp., and Proteus mirabilis. There were a total of 74 debridements. Other related surgical procedures were reconstruction surgery (n = 18), colostomy (2), cystostomy (1), vasectomy (1), orchiectomy (1) and penectomy (1). Major complications of Fournier's gangrene, including respiratory failure, renal failure, septic shock, hepatic failure and disseminated intravascular coagulopathy, were significantly to mortality (p<0.05). CONCLUSIONS: Early diagnosis, intensive medical care (aggressive resuscitation and broad-spectrum antibiotics), and prompt and repeated surgical intervention are the mainstays of treatment. Liver cirrhosis in particular is a poor prognostic factor. Reconstructive surgery should also be a consideration once the acute condition has improved. Patients with comorbid condition, serious infection, and major complications should be treated carefully and aggressively.