Factors associated with severity and mortality in patients with confirmed leptospirosis at a regional hospital in northern Taiwan.

BACKGROUND/PURPOSE: The clinical, epidemiological, and laboratory factors associated with disease severity and mortality from confirmed leptospirosis patients in Taiwan are not well known. This retrospective study examined patients with suspected leptospirosis admitted to En-Chu-Kong Hospital, a regional teaching hospital in northern Taiwan. METHODS: From January 2002 to July 2014, 733 suspected cases were reported to the National Reference Laboratory, 57 of which were identified as laboratory and clinical confirmed. We analyzed the clinical, epidemiological, and laboratory factors associated with disease severity and mortality in 57 cases. RESULTS: The mean age was 59.1 ± 18.2 years, 74% were male, and 49% had occupational contact with soil. The major complications were pulmonary involvement (54%), shock (44%), ventilator support (32%), jaundice (32%), hemorrhage (30%), acute kidney injury (30%), meningitis (11%) and myocarditis (2%). Leptospira santarosai serova Shermani was present in 42 (74%) patients and 37 (58%) patients had severe leptospirosis. Sixteen (28%) patients had concomitant infections, including nine patients with bloodstream infection. The only independent predictor for severe leptospirosis was shock (OR 14.8, 95% CI 2.97-73.59). Eleven patients died (19%). Acute respiratory distress syndrome with severe pulmonary hemorrhage syndrome (6 patients) was present in 55% of the fatal cases. The factors independently related to mortality were prior steroid use (OR 20.2, 95% CI 1.9-217.5) and hemorrhage (OR 71.2, 95% CI 4.9 - >999.9). CONCLUSION: These results indicate that shock is a predictor of severe leptospirosis, and prior steroid use and hemorrhage are predictors of death from leptospirosis.

Clinical characteristics, microbiology, and outcomes for patients with lung and disseminated nocardiosis in a tertiary hospital.

BACKGROUND/PURPOSE: Nocardia are ubiquitous in the environment worldwide and cause a variety of infections. Clinical manifestations and outcomes of nocardiosis can vary with different populations, host immunity, and presentations. The purpose of this study was to analyze the differences in clinical characteristics, antimicrobial susceptibility, and outcomes for patients with skin, lung, and disseminated nocardiosis. METHODS: We conducted a retrospective survey of culture-proven nocardial infections in 81 patients with invasive nocardiosis over an 18-year period at the National Taiwan University Hospital. The clinical syndromes included skin infections (n = 44), localized pulmonary infections (n = 24), and disseminated infections (n = 13). RESULTS: Disseminated nocardiosis included lung and brain involvement (7 patients), brain and skin involvement (2 patients), localized brain abscess (1 patient), lung involvement with bacteremia (1 patient), lymphadenitis (1 patient), and liver cirrhosis with spontaneous nocardial peritonitis (1 patient). Eleven (14%) of all patients died due to nocardiosis. In comparison with those with skin infections, patients with lung and disseminated nocardiosis tended to have chronic lung disease, malignancy, concomitant bacteremia, were often misdiagnosed as having tuberculosis, were receiving immunosuppressive treatments, and demonstrated an increased mortality. Nocardia strains isolated from patients with lung infections or disseminated infections tended to have lower in vitro antimicrobial susceptibility than those isolated from skin infections [cefotaxime: 67% (lung) vs. 86% (skin); trimethoprim/sulfamethoxazole: 75% (disseminated) vs. 97% (skin)]. CONCLUSION: These results highlight the protean disease manifestations and antimicrobial susceptibility of Nocardia and indicate the need to address the option of combined antimicrobial therapy for lung and disseminated nocardiosis.

Hepatosplenic actinomycosis in an immunocompetent patient.

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.

Antimicrobial resistance of rapidly growing mycobacteria in western Taiwan: SMART program 2002.

BACKGROUND/PURPOSE: To understand the resistance patterns of rapidly growing mycobacteria (RGM) in Taiwan, antimicrobial resistance of clinical isolates was determined as part of the SMART (Surveillance from Multicenter Antimicrobial Resistance in Taiwan) program. METHODS: During the period from January 2002 to December 2003, clinical isolates were collected from eight hospitals located on the west side of Taiwan and one reference laboratory. Broth microdilution minimum inhibitory concentrations of 11 antimicrobial agents were determined for 312 clinical isolates of RGM, including the Mycobacterium fortuitum group (110 isolates), Mycobacterium abscessus group (168 isolates), and Mycobacterium chelonae group (34 isolates). RESULTS: Nearly all of the RGM were susceptible to amikacin and ofloxacin (= 90%) and resistant to doxycycline (less than 3% susceptible). Tobramycin showed similar in vitro activity against the M. fortuitum and M. chelonae (77%) groups, but was less active against the M. abscessus group (58%). Ciprofloxacin was active mainly against M. fortuitum (95%). Nearly all RGM were resistant to erythromycin and doxycycline. However, around half of the RGM isolates remained susceptible to minocycline (50-54%). Clarithromycin was active against the M. abscessus group (53% susceptible), with a high rate of resistance in the M. chelonae (38% susceptible) and M. fortuitum (15% susceptible) group. Cefoxitin was more active against the M. fortuitum group (65%) than the other two RGM (40-44%), and les than 40% of the RGM isolates remained susceptible to imipenem (21-38%). CONCLUSION: The resistance of RGM in Taiwan is not as high as previously reported (notably for tobramycin, ciprofloxacin and cefoxitin), but reduction in the susceptibility rates of clarithromycin and imipenem for the M. fortuitum and M. abscessus groups demonstrates the importance of in vitro susceptibility testing of clinically important isolates, as susceptibility may differ in different geographical areas, even regionally, and over time.

Brain abscess associated with multidrug-resistant Capnocytophaga ochracea infection.

Brain abscesses are occasionally associated with a dental source of infection. An unusual case of frontal lobe abscess in a nonimmunocompromised child infected with multidrug-resistant Capnocytophaga ochracea is described and confirms the pathogenic potential of this organism to cause human disease in the central nervous system.

Trichomonas empyema with respiratory failure.

Pulmonary trichomoniasis is rare, and few cases of trichomonas empyema have been reported in the literature. We describe a rare case of a non-immunocompromised 55-year-old man with Trichomonas empyema presenting with bilateral pleural effusion leading to respiratory failure. Examination of the pleural effusion showed numerous motile organisms by fresh wet preparation that were identified as Trichomonas species by Liu stain. The patient was successfully treated with metronidazole, ampicillin/clavunalate, fibrinolytic therapy, and thoracotomy decortication.

In vitro activities of 16 antimicrobial agents against clinical isolates of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae in two regional hospitals in Taiwan.

BACKGROUND AND PURPOSE: Infections due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EC and ESBL-KP) have become an important clinical problem. Local knowledge of antimicrobial susceptibilities of these organisms is important for implementation of effective hospital anti-infective policies. METHODS: We analyzed the activities of various antimicrobial agents against recent isolates of ESBL-EC and ESBL-KP from 2 regional hospitals using the agar dilution method to determine minimal inhibitory concentrations (MICs). A total of 80 strains of ESBL-EC and 101 strains of ESBL-KP collected during 2003 and 2004 were included in the study. RESULTS: The MICs of all carbapenems were relatively low, with almost all isolates being susceptible. In contrast, only 30.0% of ESBL-EC and 36.6% of ESBL-KP were susceptible to ciprofloxacin. Flomoxef and cefmetazole were the most active cephamycins (88.8% and 90.0% ESBL-EC and 93.1% and 87.1% ESBL-KP susceptible, respectively), followed by ceftibuten (85.0% and 80.2%) and cefoxitin (42.5% and 49.5%). A cefepime MIC < or = 8 mg/L was found in 77.5% of ESBL-EC and 73.3% of ESBL-KP isolates. The susceptible rates to amikacin and isepamicin were both 81.3% for ESBL-EC; 72.3% and 73.3% for ESBL-KP. Inter-hospital differences in susceptibilities were demonstrated for several antimicrobials. CONCLUSIONS: The inter-hospital variation of these data emphasizes the need for monitoring of antimicrobial susceptibility profiles at the individual hospital level and to establish rationales supporting policy for treating infections caused by ESBL-producing bacteria.