Oropharyngeal yeast colonization in HIV-infected outpatients in southern Taiwan: CD4 count, efavirenz therapy and intravenous drug use matter.

To understand the status of oropharyngeal yeast colonization in human immunodeficiency virus (HIV) -infected outpatients in the era of highly active antiretroviral therapy (HAART), we conducted a prospective, cross-sectional study from October 2009 to January 2010 at a medical centre in southern Taiwan. Fungal cultures of the oropharyngeal swabs were performed on 327 enrolled patients. At enrolment, 258 (79%) patients had been receiving HAART, and 42 (12.8%), 73 (22.3%) and 212 (64.8%) patients had CD4 cell counts ≤200, 201-350, and >350 cells/mm(3) , respectively. Oral yeast colonization was detected in 193 (59%) patients, among whom 157 (81.3%), 25 (13.0%), and 11 (5.7%) were colonized by a single, two and more than two species, respectively. Multivariate analysis showed that receipt of efavirenz-containing regiments and CD4 cell counts >200 cells/mm(3) were associated with lower risks of oral yeast colonization, while intravenous drug users were at a higher risk. Among the 241 isolates recovered, Candida albicans accounted for 69.7%, followed by C. dubliniensis (9.5%), C. glabrata (8.3%), C. tropicalis (3.3%), C. intermedia (2.1%), C. parapsilosis (1.7%), and 11 other species (5.4%). Overall, 230 (95.4%), 236 (97.9%) and 240 (99.6%) isolates were susceptible to fluconazole, voriconazole and amphotericin B, respectively. In conclusion, colonization by C. dubliniensis has emerged in recent years. In addition to a CD4 cell count ≤200 cells/mm(3) , which is a known risk factor for oropharyngeal yeast colonization in HIV-infected patients that was identified in our previous studies, two risk factors, non-receipt of efavirenz-based combinations and intravenous drug use, were first identified in the present study. Fluconazole remained effective in vitro against the yeasts colonizing the oropharynx in this population.

Intention to comply with post-exposure management among nurses exposed to blood and body fluids in Taiwan: application of the theory of planned behaviour.

Nurses are at significant risk from occupationally acquired bloodborne virus infections following a needlestick and sharps injury. This study aimed to apply the theory of planned behaviour (TPB) to predict nurses' intention to comply with occupational post-exposure management. A cross-sectional survey was applied to select registered nurses who worked in human immunodeficiency virus (HIV)-designated hospitals. An anonymous, self-administered questionnaire based on the TPB was distributed to 1630 nurses and 1134 (69.5%) questionnaires were returned. From these, a total of 802 nurses (71%) reported blood and body fluid exposure incidents during 2003-2005 and this group was used for analysis. Only 44.6% of the 121 exposed nurses who were prescribed post-exposure prophylaxis (PEP) by infectious disease doctors returned to the clinic for interim monitoring, and only 56.6% of exposed nurses confirmed their final serology status. Structural equation modelling was used to test the TPB indicating perceived behavioural control (the perception of the difficulty or ease of PEP management, ß=0.58), subjective norm (the perception of social pressure to adhere to PEP, ß=0.15), and attitudes (ß=0.12) were significant direct effects on nurses' intention to comply with post-exposure management. The hypothesised model test indicated that the model fitted with the expected relationships and directions of theoretical constructs [χ(2) (14, N=802)=23.14, P=0.057, GFI=0.987, RMSEA=0.039]. The TPB model constructs accounted for 54% of the variance in nurses' intention to comply with post-exposure management. The TPB is an appropriate model for predicting nurses' intention to comply with post-exposure management. Healthcare facilities should have policies to decrease the inconvenience of follow-up to encourage nurses to comply with post-exposure management.

Suboptimal therapy and clinical management of gonorrhoea in an area with high-level antimicrobial resistance.

The choice of antimicrobial agents for the treatment of gonorrhoea is critical in areas where the prevalence of drug resistance is high. This study aimed to evaluate the antibiotic treatment of gonorrhoea in endemic areas. During 1999-2004, all Neisseria gonorrhoeae infections (n = 90) were evaluated. Patients' medical records and antibiotic treatment regimens were retrospectively reviewed if their isolates were viable (n = 65). In vitro antimicrobial susceptibility of N. gonorrhoeae isolates was performed. Urethritis (89%) and pelvic inflammatory disease (42%) were the most common presentations among men (n = 53) and women (n = 12), respectively. Of 54 patients with uncomplicated N. gonorrhoeae infection, 32 of them received appropriate antibiotics, including cefuroxime (n = 20), ceftriaxone (n = 10), ciprofloxacin (n = 1) and azithromycin (n = 1) during follow-ups. Among 65 patients, 53.8% were notified to the health authority. Check-ups of other sexually transmitted diseases were carried out in only 46% of patients. Not all isolates were susceptible to penicillin, 96.9% were resistant to tetracycline and 86% were resistant to ciprofloxacin. Ceftriaxone, cefixime, spectinomycin and azithromycin were active in vitro against all isolates. In conclusion, It is crucial to develop treatment guidelines according to regional antimicrobial resistances and educational programmes to improve clinical care for genital gonococcal diseases.

Sporadic and outbreak cases of melioidosis in southern Taiwan: clinical features and antimicrobial susceptibility.

BACKGROUND: Melioidosis has been well known to be endemic in Thailand and Northern Australia, and was reported sporadically in Taiwan before 2005. METHODS: We retrospectively analyzed 58 patients with melioidosis in southern Taiwan from 2000 to 2005, including 40 clustered and 18 sporadic cases, for clinical characteristics and antimicrobial susceptibility. RESULTS: Fifty-one (88%) cases were found during the rainy season, and there was a significant correlation between the average monthly rainfalls and the case number (r = 0.37; p = 0.001). Diabetes mellitus was the most common underlying disease (35 cases, 60%). The majority (52 cases, 90%) had never traveled abroad before illness, indicating indigenous acquisition of Burkholderia pseudomallei. In comparison, clustered cases were older, less often had underlying diabetes mellitus and had a shorter duration of clinical symptoms before admission than sporadic cases. Acute form of melioidosis predominated, and shock at admission was independently associated with a grave prognosis. Overall, 22% of 58 patients died in hospitals. Ceftazidime, imipenem, meropenem, amoxicillin/clavulanic acid, co-trimoxazole, and doxycycline, as previously recommended, were the potentially therapeutic choices. The role of piperacillin/ tazobactam for melioidosis remains undefined. CONCLUSIONS: Melioidosis can occur sporadically or in a cluster in diabetic patients during rainy seasons in Taiwan.

Risky behaviors for HIV infection among male incarcerated injection drug users in Taiwan: a case-control study.

Taiwan has experiencing an outbreak of HIV infection among injection drug users (IDUs) since 2003. A case-control study was conducted to determine the behavioral characteristics associated with HIV infection among IDUs. The study identified 120 inmates with HIV infection and 121 matched HIV-negative controls from prisons. Data were collected by face-to-face interviews. The study found 48.1% of IDUs shared needles, less than a half of IDUs reported sexual intercourse before incarceration and only 19.7% used condoms. The multivariate logistic regression analysis, adjusted for years of heroin injection, found that HIV infection was independently associated with the use of a used needle or syringe at the latest injection (odds ratio [OR], 8.2; 95% confidence interval [CI], 3.3-20.2, p<0.001), having HIV-infected relatives or friends (OR, 5.7; 95%CI, 2.5-13.2, p<0.001) and sharing containers with others (OR, 3.3; 95%CI, 1.2-8.8, p=0.02). Our findings highlight the importance of needle exchange programs along with HIV-prevention education.

Amoebiasis among patrons visiting gay saunas in Taiwan.

AIMS: This study aimed to assess the prevalence of amoebiasis among patrons visiting gay saunas in Taiwan. METHODS: A cross-sectional survey was conducted using questionnaire interview and indirect hemagglutination assays and specific Entamoeba histolytica antigen assays of blood and rectal swab specimens, respectively, among patrons visiting 10 gay saunas between September 2006 and December 2006. RESULTS: During the three-month study period, 208 blood and 120 rectal swab specimens were tested for E. histolytica infection. Amoebiasis was detected among 3.8% and 3.3% of the patrons by serologies and antigen assays, respectively. During the latest sexual encounter, more than 70% of the patrons had oral-anogenital sex, and only 20% used condoms during oral-anogenital contact. CONCLUSION: Our findings suggest that there is a potential risk of E. histolytica transmission among the patrons visiting gay saunas who do not practise safe sex consistently in Taiwan.

Community-acquired Klebsiella pneumoniae complicated skin and soft-tissue infections of extremities: emphasis on cirrhotic patients and gas formation.

BACKGROUND: Klebsiella pneumoniae was rarely reported to cause complicated skin and soft tissue infections (cSSTIs). Our study was to delineate clinical characteristics and outcome of cSSTIs involving extremities caused by K. pneumoniae. PATIENTS AND METHODS: Adult patients aged 16 years or more with community-acquired cSSTIs, which involved the extremities and were caused by four common aerobic pathogens at a medical center in southern Taiwan during a 54-month period, were reviewed. RESULTS: Of 76 cases enrolled, Staphylococcus aureus was the most common pathogen (52 cases, 68%), followed by K. pneumoniae (16, 21%), beta-hemolytic streptococci (5, 7%), and Escherichia coli (3, 4%). Forty-six (61%) had underlying conditions, and diabetes mellitus was most common among K. pneumoniae and non-K. pneumoniae groups (63% and 45%, respectively). Compared to patients with cSSTIs caused by other bacteria, those with K. pneumoniae cSSTIs were predominantly male, more often had liver cirrhosis, malignant neoplasm and alcoholism. In addition, they were more likely to have fever, shock, bacteremia, gas formation, pyomyositis, metastatic infections, as well as longer durations of hospitalization. Using multivariate analysis, liver cirrhosis (adjusted odds ratio [aOR] 12.5, 95% confidence interval [CI] 2.0-79.1, p = 0.007) and male gender (aOR 11.5, 95% CI 1.1-116.8, p = 0.039) were significantly associated with K. pneumoniae cSSTIs. CONCLUSIONS: We highlight the role of K. pneumoniae in Taiwanese patients with cSSTIs involving extremities, and its potential for gas and pus formation, and metastatic infections. Empiric antimicrobial coverage of K. pneumoniae and close monitoring of metastatic infections are mandatory for patients with risk factors.

Camellia japonica suppresses immunoglobulin E-mediated allergic response by the inhibition of Syk kinase activation in mast cells.

BACKGROUND: Novel approaches are being explored to develop new therapies for various allergic diseases. Complementary and alternative medicines are considered to be promising avenues for the development of such new therapies. OBJECTIVES: To investigate the effect of many Korean plants on the IgE-mediated allergic response in mast cells and in vivo, and its mechanism of action. MATERIALS AND METHODS: The anti-allergic activity was tested by evaluating effects on degranulation of mast cells in culture and passive cutaneous anaphylaxis (PCA) in vivo. Its mechanism of action was investigated by immunoblotting analysis, immunoprecipitation, RT-PCR, and other molecular biological approaches in mast cells. RESULTS: We screened approximately 100 natural plant extracts collected in Korea for in vitro anti-allergic activity. The leaf extract of Camellia japonica (LECJ) exhibited the most potent effect on degranulation in antigen-stimulated rodent and human mast cells. LECJ reversibly inhibited degranulation in a dose-dependent manner, with IC(50) values of approximately 50 microg/mL for the mast cells, and it also suppressed the expression and secretion of TNF-alpha and IL-4 in rat basophilic leukaemia-2H3 mast cells. In agreement with its in vitro activity, LECJ significantly inhibited mast cell-mediated PCA in an animal model. LECJ inhibited activating phosphorylation of tyrosine Y371 on Syk kinase, indicating that LECJ inhibits the activity of Src-family kinases in mast cells. In the in vitro kinase assay, LECJ directly inhibited Lyn kinase, the major Src-family kinase in the cells. It also suppressed Akt and MAP kinases, which are critical for the production of various pro-inflammatory cytokines in mast cells. In high-performance liquid chromatography analysis, quercetin-3-beta-D-glucoside and eugenol were identified as the major active components. CONCLUSION: The present results strongly suggest that the anti-allergic activity of LECJ is mediated through inhibiting degranulation and allergic cytokine secretion by inhibition of Src-family kinase in mast cells and it may be useful for the treatment of mast cell-related immediate and delayed allergic diseases.

Differences in HIV disclosure by modes of transmission in Taiwanese families.

HIV serostatus disclosure is a crucial decision, and often perceived as a double-edged sword for people living with HIV. This study was intended to determine the extent of disclosure according to interpersonal relationships, compare the characteristics of disclosure by modes of HIV transmission, and to describe perceived consequences after disclosure to Taiwanese families. Data were collected by in-depth interviews and chart reviews at HIV primary care clinics in a university hospital in southern Taiwan from 2004 to 2005. Of 105 male participants interviewed, 76 (72.4%) had disclosed their HIV status to at least one person, including 62% to an immediate family member and 21% to friends. The HIV disclosure rates were different in three groups divided by modes of transmission, 36% in men having sex with men (MSM), 34% in heterosexuals, and 21% in injection drug users (IDUs). MSM were more likely than heterosexual men or male IDUs to disclose their HIV status directly to friends immediately after leaning of their HIV diagnosis. Heterosexual men and male injection drug users often disclosed to their immediate families a few days after obtaining an HIV diagnosis. Perceived consequences after disclosure included: increased substantial support from family, assistance with medical and healthcare, encouragement of living positively with HIV, being rejected, treated as contagion, and condemnation. Disclosure of HIV-positive status in a family-oriented Taiwanese society is a complex process and different by the modes of transmission.

Extraintestinal focal infections in adults with nontyphoid Salmonella bacteraemia: predisposing factors and clinical outcome.

BACKGROUND: Nontyphoid Salmonella (NTS) isolates lead to not only self-limited, acute gastrointestinal infections, but also bacteraemia with or without extraintestinal focal infections (EFIs). The risk factors associated with EFIs in adults with NTS bacteraemia were not clearly elucidated. METHODS: In a medical center in southern Taiwan, patients aged > or = 18 years with NTS bacteraemia between January 1999 and June 2005 were included for analysis. RESULTS: Of 129 patients, 51 (39.5%) were complicated with EFIs. The most common EFI was mycotic aneurysm, followed by pleuropulmonary infections and spinal osteomyelitis. Compared to patients with primary bacteraemia, those with EFIs had higher leucocyte counts (P = 0.004) and higher serum levels of C-reactive protein (P < 0.0001). The development of EFIs was associated with a higher mortality, more severe septic manifestations, longer hospital stays and duration of antimicrobial therapy. Univariate analysis revealed that diabetes mellitus (P = 0.02), hypertension (P = 0.02) and chronic lung disease (P = 0.006) were significantly associated with EFIs. However, patients with malignancy (P = 0.01) and immunosuppressive therapy (P = 0.03) were less likely to develop EFIs. On the basis of multivariate analysis, an independent factor for the occurrence of EFIs was age [adjusted odds ratio (aOR) 1.05; 95% confidence interval (CI) 1.02-1.07; P < 0.0001], whilst malignancy was negatively associated with EFIs (aOR 0.16; 95% CI 0.14-0.78; P = 0.01). CONCLUSION: Amongst patients with NTS bacteraemia, EFIs often occurred in the aged, and were associated with a higher mortality and morbidity. Recognition of specific host factors is essential for identification of EFIs which often demand early surgical interventions and prolonged antimicrobial therapy.

Clinical implications of hypermucoviscosity phenotype in Klebsiella pneumoniae isolates: association with invasive syndrome in patients with community-acquired bacteraemia.

BACKGROUND: Klebsiella pneumoniae, a Gram-negative bacillus usually forming glistening mucoid colonies with viscid consistency on the culture plate, is a common pathogen causing various clinical infection patterns. However, little is known about the clinical implications of this mucoid character. OBJECTIVE: The purposes of this study, therefore, were to investigate the frequency of hypermucoviscosity (HV) in bacteraemic isolates of K. pneumoniae, and determine the significance of any association between HV and various clinical manifestations. DESIGN: Retrospective observational study. PATIENTS: Patients diagnosed with K. pneumoniae bacteraemia at a community-based university hospital between June 1999 and June 2001 were enrolled in this analysis. MEASUREMENTS: Clinical data concerning comorbid diseases and infection patterns was collected. K. pneumoniae bacteraemic isolates were examined for the presence of HV using a modified string test. The clinical impact of HV and risk factors for the invasive syndrome were assessed using statistical analysis. Polymerase chain reaction (PCR) was performed to detect magA, a gene related to HV phenotype. RESULTS: Overall, 200 (64.9%) of the 308 cases of K. pneumoniae bacteraemia were community-acquired infections. Compared with hospital-acquired K. pneumoniae bacteraemia (HA-KpB), community-acquired K. pneumoniae bacteraemia (CA-KpB) was more likely to be monomicrobial in nature (83.5% vs. 64.8%; P < 0.001) and caused by HV strains (41.5% vs. 14.8%; P < 0.001). The prevalence rate of magA among HV phenotypical K. pneumoniae strains was 24.1%. Patients infected with HV-positive strains were more likely to have the distinctive invasive syndrome (i.e. liver abscess, meningitis, pleural empyaema or endophthalmitis) than those infected with HV-negative variants (37.3% vs. 6.8%; P < 0.001). Multivariate logistic regression analysis, adjusted for age, showed that HV phenotype in K. pneumoniae strains (OR 8.86; 95% CI, 3.70-21.25; P < 0.001) was positively associated with the development of the invasive syndrome in CA-KpB cases. CONCLUSIONS: The HV phenotype of K. pneumoniae bacteraemic isolates was associated with the development of a distinctive invasive syndrome. Identification of the HV phenotype should prompt clinicians to initiate aggressive investigations for invasive diseases.

Prevailing discourses among AIDS care professionals about childbearing by couples with HIV in Taiwan.

The aim of this study was to analyze the dynamics of ideology, power and language in the dominant discourses about childbearing by couples with HIV that were expressed by AIDS care professionals in Taiwan. Critical discourse analysis of the interview texts with 11 AIDS care professionals identified three prevailing discourses on childbearing by couples with HIV/AIDS: pro-children, conditional pro-choice and pro-rights. The pro-children and conditional pro-choice were the predominant discourses. The two discourses both medicalized childbearing among couples with HIV/AIDS by identifying medical authorities as the proper persons to decide which reproductive choices people with HIV/AIDS should make under what conditions. Even though the pro-rights discourse embodied an ideology of individualism, empowerment and autonomy, it was weak and relatively rare in the other two discourses.

Cancer symptom control: feasibility of a tailored, interactive computerized program for patients.

This study evaluated the feasibility of an innovative computerized symptom assessment tool, SymptomReport, and a computerized, tailored education tool, SymptomConsult, in a sample of 41 outpatients with cancer. After patients completed the computerized programs, an audiotaped telephone interview was conducted to assess patients' impressions. The study found that patients required less than 40 minutes on average to complete SymptomReport. The mean acceptability score was high 11 +/- 2. The 12 patients who completed SymptomConsult did so in an average of 20 minutes. The majority of participants indicated that the computer programs were easy, enjoyable, and informative tools. Initial formative research supports further study of these feasible computerized programs.

Detection of elevated serum beta-chemokine levels in seronegative Chinese individuals exposed to human immunodeficiency virus type 1.

The mutations in the CCR5 coding region, such as CCR5Delta32 and CCR5m303, that suppress the transmission of human immunodeficiency virus (HIV) type 1 do not exist in Chinese people. However, 9 Chinese subjects in Taiwan with histories of multiple sexual exposures to HIV remained uninfected, suggesting that certain anti-HIV factors do indeed exist. Experiments were therefore designed to investigate the immune mechanism that protects this cohort against HIV infection. Peripheral blood samples from these 9 subjects and 7 healthy people who had not been exposed to HIV were obtained for the quantitation of the levels for beta-chemokines and interleukin 16 (IL-16) in serum samples or secreted by peripheral blood lymphocytes. Significantly higher serum levels for nearly all 3 beta-chemokines, regulation on activation, normal T cell-expressed and secreted, macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta (P<.05, P<.05, and P=.05, respectively), but not IL-16, were detected in the 9 HIV-uninfected subjects as compared with control subjects. The result suggests that among the host genes and cellular factors thus far identified, beta-chemokines are the major HIV-suppressive factors that protect Chinese people from infection with HIV.

Comparison of sexual behaviors between male homosexuals and male heterosexuals in Taiwan.

BACKGROUND: Homosexuality and sexual behavior have attracted great attention in the acquired immunodeficiency syndrome (AIDS) epidemic. This study primarily explores the risky behaviors and patterns of sexual behavior of male homosexuals in Taiwan. METHODS: Comparison study methodology was adopted. Ninety-two male homosexuals, as the study group, were recruited from gay bars and gay organizations, and 91 male heterosexuals, with similar ages and educational levels, were recruited as a control group for comparison. Semi-structured interviews were carried out and anonymous questionnaires were self-administered. RESULTS: (1) The mean age at the time of first sexual intercourse of the study group was younger than that of the control group. (2) The rate of having two or more sexual partners in the study group was significantly higher. (3) However, the rate of condom use during recent intercourse was higher in the control group than in the study group. (4) Sexual knowledge and attitudes toward sexuality in the study group were more open, but their sexual desires, as rated by the questionnaire, were more suppressed than those of the control group. (5) In terms of courtship, the study group was less constrained by the social values of marriage and tended to separate sex from love. CONCLUSION: Similar to western studies, our study found that the study group in Taiwan adopted more risky sexual behaviors. Each group had its particular sexual behavioral pattern and subculture of sexuality. However, a longitudinal follow-up study with ethnographic perspective is necessary for a more sophisticated understanding of the trends and changes of sexual behavior in homosexuals.

[Informational needs and information-seeking behaviors of recently diagnosed HIV seropositive gay man].

In recent years, substantial changes in doctor-patient relations and consumer oriented attitudes have occurred. Many patients need more information regarding their diagnosis and treatment for developing positive coping strategies to face their disease. This case report uses an informational needs theoretical framework to present the informational needs and information-seeking behaviors of a recently diagnosed HIV seropositive gay man. The data was collected through continuous contacts with the patient during October 1994 to January 1995. This report's findings indicated that need for information after diagnosis fall into eight categories of concern: process in hospitalization, physical symptoms related to HIV/AIDS, side effects of anti-viral drugs, death, insurance, future planning, self care and how to disclose to others. Information seeking behaviors included actively or passively gathering information, asking others' experience and counseling with caregiver. Non-judgmental and supportive attitudes were significant factors for reducing the effects of social stigmatization as an obstacle to the patient during the information seeking process.

[Concerns and nursing care of a family living with AIDS].

AIDS is not solely a medical issue but also has profound implications for family relationships. This case report using the concepts of family nursing and case management presents the concerns of a family living with AIDS. The data was collected through continuous contacts with a patient during December 1994 to August 1996. This report's findings indicate that the concerns of the family living with AIDS fall into seven categories: The reasons for HIV infection, how to meet the patient's sexual needs, suffering during health care seeking, the effectiveness and side-effects of anti-viral drugs, home care skills, the light of hope, death issues. Professional nurses should provide care to both the AIDS patient and the family members. Using social resources and cooperating with other health professionals can promote the quality of life for families living with AIDS.