Scrub Typhus: Seven-Year Experience and Literature Review.

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.

Necrotizing fasciitis: eight-year experience and literature review

OBJECTIVES: To describe clinical, laboratory, microbiological features, and outcomes of necrotizing fasciitis. METHODS: 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. RESULTS: 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. DISCUSSION: 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. .

Necrotizing fasciitis: eight-year experience and literature review.

OBJECTIVES: To describe clinical, laboratory, microbiological features, and outcomes of necrotizing fasciitis. METHODS: 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. RESULTS: 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. DISCUSSION: 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.

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

BACKGROUND AND PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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 pyelonephritis.

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.

Treatment of pan-drug resistant Acinetobacter baumannii.

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.

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.