Syphilis and neurosyphilis in human immunodeficiency virus-infected patients: a retrospective study at a teaching hospital in Taiwan.

BACKGROUND AND PURPOSE: Some studies have reported that the risk factors for neurosyphilis in patients with human immunodeficiency virus (HIV) and syphilis co-infection, include CD4 cell counts ≤350cells/µL and rapid plasma reagin (RPR) titer ≥1:32. However, neurosyphils can develop even in patients with CD4 cell counts >350cells/µL or RPR titer <1:32. In this study, we evaluated the outcome of syphilis to treatment in HIV-infected patients, and analysed the predictors of neurosyphilis in this population. METHODS: We retrospectively reviewed medical records of HIV-infected patients with syphilis who visited the China Medical University Hospital between January 2000 and December 2009. Neurosyphilis was defined by white blood cell (WBC) counts >20cells/µL in the cerebrospinal fluid (CSF) sample or elevated Venereal Disease Research Laboratory (VDRL) titers of the CSF samples. Treatment failure was defined as less than 4-fold decrease in the serum RPR titer at or beyond 12 months post-treatment in case of early syphilis, and, at or beyond 24 months in case of late syphilis. RESULTS: One hundred and twenty-one HIV-infected patients (average age, 32 years) with syphilis were included in this study. Of 63 patients who had follow-up of serologic responses, 30 (47.6%) failed to respond to treatment. CD4 cell counts ≤200cells/µL was the indicator for treatment failure (P=.029). Lumbar puncture was performed in 65 patients, and 14 patients were diagnosed with neurosyphilis. At the time of lumbar puncture, 31 and 19 of the 65 patients showed CD4 cell counts of >350cells/µL and RPR of <1:32, respectively. An HIV viral load (VL) ≥10000copies/mL was found to be associated with the development of neurosyphilis (P=.016). CONCLUSION: In HIV-infected patients with syphilis, RPR titer should be evaluated more frequently when CD4 count ≤200cell/µL is associated with treatment failure. Lumbar puncture for the diagnosis of neurosyphilis should be considered in patients with HIV and syphilis co-infection, even in patients with CD4 cell counts >350cells/µL, and particularly when the HIV VL ≥10000copies/mL.

Different presentations and outcomes between HIV-infected and HIV-uninfected patients with Cryptococcal meningitis.

BACKGROUND AND PURPOSE: Cryptococcus species are the most common causative agents of fungal meningitis. Different populations may show different clinical manifestations and outcomes. In this retrospective study, we investigated these differences in patients with and without HIV infection. METHODS: From 1995 to 2009, we collected data from HIV-infected or HIV-uninfected patients aged 18 years or over who had cryptococcal meningitis (CM) in a medical center in Taiwan. We reviewed and analyzed their demographic data, clinical manifestations, therapeutic strategies and outcomes. RESULTS: Among the 72 patients with CM, 19 HIV-infected patients were predominantly younger males, and all of them had AIDS status when CM was diagnosed. In contrast, the 53 HIV-uninfected patients were mostly older males with underlying diseases. The time from initial symptoms to diagnosis was shorter in HIV-infected patients (median 10 vs. 18 days, p = 0.048). The HIV-infected patients presented with less pleocytosis (p = 0.003) and lower protein levels in the cerebrospinal fluid (CSF), but a higher proportion had positive results for cryptococci in the CSF (90% vs. 60%, p = 0.02) and blood (53% vs. 21%, p = 0.009) cultures. Surgical drains and repeated lumbar punctures for the management of increased intracranial pressure were performed in 47% of the HIV-infected patients and 38% of the HIV-uninfected patients. A lower mortality rate was observed in the HIV-infected patients (p = 0.038). On multivariate analysis, initial CD4 count ≤20/mm(3) was an indicator of death or relapse in HIV-infected patients. In the HIV-uninfected group, the initial high cryptococcal antigen titer in the CSF (≥1:512) and hydrocephalus were related to unsatisfactory outcomes. CONCLUSION: In addition to well-known differences, we found a lower mortality in HIV-infected patients than in HIV-uninfected patients. Cryptococci and inflammation in the central nervous system may play important roles in the pathogenesis of CM. Low intensity of inflammation and effective surgical CSF drains for increased intracranial pressure and cryptococci removal may contribute to lower mortality in HIV-infected patients.

Eight years experience in treatment of prosthetic joint infections at a teaching hospital in Central Taiwan.

BACKGROUND/PURPOSE: Prosthetic joint infection (PJI) has become an important issue in the management of patients who receive prostheses. We compared the clinical outcomes of PJIs caused by Gram-negative bacteria (GN PJIs) and Gram-positive bacteria (GP PJIs). METHODS: Patients with culture-proven PJIs admitted to China Medical University Hospital between March 2001 and March 2009 were included in this retrospective study. RESULTS: Fifty-nine patients were diagnosed with PJI during the study period. Nineteen patients had GN PJIs (mean age: 68 years) and 40 had GP PJIs (mean age: 61 years). The most common comorbid condition was diabetes mellitus (23.7%) and the most common presentation was joint pain (79.7%). Staphylococcus aureus was the most common pathogen, whereas Klebsiella pneumoniae was the most common Gram-negative pathogen. The GN PJI group included more cases of hematogenous infection (36.8% vs. 20%; p < 0.001), showed a shorter interval between onset of infection symptoms and surgical intervention (median: 8 days vs. 21 days; p = 0.04), and required longer medical treatment (median: 259 days vs. 161 days; p = 0.04). In comparison with patients whose prostheses were eventually removed, patients whose prostheses were not removed had a shorter interval between onset of infection symptoms and surgical intervention (median: 6 days vs. 90 days; p = 0.004 and median: 6 days vs. 44 days; p = 0.04) in the GP PJI and GN PJI groups, respectively. CONCLUSION: GN PJI was less common than GP PJI, but GN PJI was more complicated and required longer treatment. Prospective randomized clinical studies are needed to investigate whether prosthesis implantation should be reserved if the patient undergoes early surgical intervention for PJI.

Abdominal tuberculosis in adult: 10-year experience in a teaching hospital in central Taiwan.

BACKGROUND/PURPOSE: Tuberculosis (TB) is an important communicable disease worldwide. The clinical presentation of abdominal TB often mimics various gastrointestinal disorders and may delay accurate diagnosis. In this study, we conducted a 10-year retrospective study to investigate the clinical manifestations, treatment responses and outcomes of abdominal TB. METHODS: This retrospective study recruited patients presenting between January 1998 and December 2007; all patients ≥ 18 years of age with a diagnosis of abdominal TB were enrolled. Patient charts were thoroughly reviewed and clinical specimens were processed in the laboratory using the BBL MycoPrep System and BACTEC MGIT 960 Mycobacterial Detection System. Mycobacterium tuberculosis complex was confirmed by acid fast stain and the BD ProbeTec ET System. RESULTS: During the study period, 34 patients were diagnosed with abdominal TB. The mean age was 55+18 years. Fourteen patients (41%) had no risk factors; however, 20 patients (59%) had at least one risk factor. Abdominal pain (94.1%), abdominal fullness (91.2%), anorexia (88.2%) and ascites (76.5%) were the most common presenting symptoms. The peritoneum (88%) was the most commonly involved site. Patients with risk factors such as liver cirrhosis, end-stage renal disease and diabetes mellitus had a higher positive rate of acid-fast stain and mycobacterial culture from abdominal specimens (p = 0.02 and 0.05, respectively). The crude mortality rate was 9% and the attributed mortality rate was 3%. CONCLUSION: In an endemic area like Taiwan, regardless of whether a patient has risk factors for TB, abdominal TB should be seriously considered as a differential diagnosis when a patient presents with gastrointestinal symptoms and unexplained ascites.

Molecular epidemiology of community-acquired methicillin-resistant Staphylococcus aureus bacteremia in a teaching hospital.

BACKGROUND AND PURPOSE: Methicillin-resistant Staphylococcus aureus (MRSA) is a key nosocomial pathogen globally. Community-acquired MRSA (CA-MRSA) infections have become a growing problem in recent years. The purpose of this 4-year retrospective study was to analyze the molecular epidemiology and susceptibility pattern of isolates from adults (> or =18 years of age) with CA-MRSA bacteremia in northern Taiwan. METHODS: Molecular epidemiology of CA-MRSA isolates was analyzed by pulsed-field gel electrophoresis. Antimicrobial susceptibility was tested by the disk diffusion method and the minimal inhibitory concentration was determined by Etest. RESULTS: Thirty eight patients with CA-MRSA bacteremia were enrolled. Thirty one CA-MRSA isolates were available for further molecular typing and susceptibility testing. A total of 13 distinct genotypes were identified and 48.4% (15/31) of the isolates were found to belong to genotype A. Genotype A CA-MRSA isolates were closely associated with the nosocomial strains. All CA-MRSA isolates were multidrug resistant (19.4% susceptible to clindamycin and 25.8% to trimethoprim-sulfamethoxazole) and consistent susceptibility was only observed to glycopeptides, rifampin, and linezolid. CONCLUSIONS: This study demonstrated that although CA-MRSA genotypes were heterogeneous, the predominant genotype that was circulating in our community was genotype A. Also, the multidrug resistance of CA-MRSA might be connected to the spreading of nosocomial strains in the community.

Pseudomonas mendocina spondylodiscitis: a case report and literature review.

Pseudomonas mendocina is rarely recovered as a human pathogen. Only 2 human cases have been reported in the literature. Here, we report the third human case and possibly the first 1 to involve spinal infection caused by such an unusual bacterium.

Epidemiologic trends in nosocomial bacteremia in a neonatal intensive care unit.

The primary goal of this study was to analyze the epidemiologic features of nosocomial bloodstream infection (NBSI) in a neonatal intensive care unit over a 7-year period. All neonatal patients with NBSI treated from January 1997 to December 2003 were retrospectively analyzed. 232 NBSI episodes were diagnosed in 208 patients. The average NBSI patient-day rates were 4.69 and 2.59 per 1000 patient-days in 1997-1999 and 2000-2003, respectively. The average NBSI rates were 5.00 and 1.50 per 1000 patient days in neonates <1500 g and > or =1500 g, respectively. The proportion of Gram-positive organisms increased from 24% in 1997-2001 to 41% in 2002-2003, whereas the proportion of Gram-negative isolates decreased from 65% in 1997-2001 to 47% in 2002-2003. The implementation of measures for the prevention of nosocomial infection was associated with the reduction of NBSI rates. Low birth weight was demonstrated to be a significant risk factor for NBSI. The fact that Gram-positive organisms were isolated in increasing frequency may impact on the appropriate selection of empiric antimicrobial therapy for NBSI in the neonatal intensive care unit.

Monotherapy with meropenem versus combination therapy with ceftazidime plus amikacin as empirical therapy for neutropenic fever in children with malignancy.

Fifty-four pediatric cancer patients with a total of 100 febrile neutropenic episodes treated at China Medical College Hospital were randomized to receive meropenem or ceftazidime plus amikacin from January 2001 to April 2002. The characteristics of 76 assessable febrile episodes (39 with meropenem and 37 with ceftazidime plus amikacin) were compared between the 2 groups. The success rate with unmodified therapy was not significantly different between the meropenem group (72%) and the ceftazidime-plus-amikacin group (57%). The incidence of side effects was similar between the 2 groups and these side effects were reversible. Microbiologically documented infection, clinically documented infection, and unexplained fever accounted for 35%, 37%, and 28% of episodes, respectively. The clinical response rates in subgroups of documented infection and unexplained fever did not significantly differ between the 2 treatment groups. Meropenem was significantly more effective than ceftazidime plus amikacin in children at high risks of developing severe infection who had profound neutropenia (absolute neutrophil count [ANC] < 100/mm3), prolonged neutropenia (ANC < 500/mm3 lasting for > 10 days), or clinically deteriorating shock (p=0.045). As an empirical treatment, meropenem seems to be as effective and safe as ceftazidime plus amikacin for febrile episodes in children with cancer and neutropenia. Meropenem is more effective for pediatric cancer patients at the high risk of severe infection.