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We investigated the prevalence of latent tuberculosis infection (LTBI) among the residents in seven long-term care facilities (LTCFs) located in different regions of Taiwan and compared the performance of two interferon gamma release assays, i.e., QuantiFERON-TB Gold In-Tube (QFT-GIT) and QuantiFERON-TB Gold Plus (QFT-Plus) for screening LTBI. We also assessed the diagnostic performance against a composite reference standard (subjects with persistent-positive, transient-positive, and negative results from QFTs during reproducibility analysis were classified as definite, possible, and not LTBI, respectively). Two hundred forty-four residents were enrolled, and 229 subjects were included in the analysis. The median age was 80 years (range, 60 to 102 years old), and 117 (51.1%) were male. Among them, 66 (28.8%) and 74 (32.3%) subjects had positive results from QFT-GIT and QFT-Plus, respectively, and the results for 215 (93.9%) subjects showed agreement. Using the composite reference standard, 66 (28.8%), 11 (4.8%), and 152 (66.4%) were classified as definite, possible, and not LTBI, respectively. For definite LTBI, the sensitivity, specificity, positive predictive value, and negative predictive value of QFT-GIT were 89.4%, 95.7%, 89.4%, and 95.7%, respectively, and those for QFT-Plus were 100.0%, 95.1%, 89.2%, and 100.0%, respectively. The sensitivity of QFT-GIT decreased gradually with patient age. Compared to QFT-GIT, QFT-Plus displayed significantly higher sensitivity (100.0% versus 89.4%, P = 0.013) and similar specificity (95.1% versus 95.7%). In conclusion, a high prevalence of LTBI was found among elders in LTCFs in Taiwan. The new QFT-Plus test demonstrated a higher sensitivity than QFT-GIT in the older adults in LTCFs.

We evaluated whether the Bruker Biotyper matrix-associated laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) system provides accurate species-level identifications of 147 isolates of aerobically growing Gram-positive rods (GPRs). The bacterial isolates included Nocardia ( n = 74), Listeria ( n = 39), Kocuria ( n = 15), Rhodococcus ( n = 10), Gordonia ( n = 7), and Tsukamurella ( n = 2) species, which had all been identified by conventional methods, molecular methods, or both. In total, 89.7% of Listeria monocytogenes , 80% of Rhodococcus species, 26.7% of Kocuria species, and 14.9% of Nocardia species ( n = 11, all N. nova and N. otitidiscaviarum ) were correctly identified to the species level (score values, ≥2.0). A clustering analysis of spectra generated by the Bruker Biotyper identified six clusters of Nocardia species, i.e., cluster 1 ( N. cyriacigeorgica ), cluster 2 ( N. brasiliensis ), cluster 3 ( N. farcinica ), cluster 4 ( N. puris ), cluster 5 ( N. asiatica ), and cluster 6 ( N. beijingensis ), based on the six peaks generated by ClinProTools with the genetic algorithm, i.e., m/z 2,774.477 (cluster 1), m/z 5,389.792 (cluster 2), m/z 6,505.720 (cluster 3), m/z 5,428.795 (cluster 4), m/z 6,525.326 (cluster 5), and m/z 16,085.216 (cluster 6). Two clusters of L. monocytogenes spectra were also found according to the five peaks, i.e., m/z 5,594.85, m/z 6,184.39, and m/z 11,187.31, for cluster 1 (serotype 1/2a) and m/z 5,601.21 and m/z 11,199.33 for cluster 2 (serotypes 1/2b and 4b). The Bruker Biotyper system was unable to accurately identify Nocardia (except for N. nova and N. otitidiscaviarum ), Tsukamurella , or Gordonia species. Continuous expansion of the MALDI-TOF MS databases to include more GPRs is necessary.

Among 217 Aeromonas isolates identified by sequencing analysis of their rpoB genes, the accuracy rates of identification of A. dhakensis , A. hydrophila , A. veronii , and A. caviae were 96.7%, 90.0%, 96.7%, and 100.0%, respectively, by the cluster analysis of spectra generated by matrix-assisted laser desorption ionization–time of flight mass spectrometry.

We determined the groESL sequences of three species of nutritionally variant streptococci ( Abiotrophia defectiva , Granulicatella adiacens , and Granulicatella elegans ) and three Gemella species ( Gemella morbillorum , Gemella haemolysans , and Gemella sanguinis ). The nucleotide sequence similarities between the groES and groEL genes of the above genera were 41.7 to 85.9% and 63.7 to 84.3%, respectively. The intraspecies similarities of groESL sequences for the isolates of Abiotrophia and Granulicatella species were 94.4 to 97.8% for groES and 94.0 to 98.2% for groEL . For Ge. morbillorum and Ge. sanguinis , all strains showed the same groESL spacer length (8 bp), and sequence identities within species were >97.8% for groES and >96.1% for groEL . However, higher intraspecies heterogeneity was observed in Ge. haemolysans . Phylogenetic analysis of groEL sequences separated the 6 isolates of Ge. haemolysans into two subgroups. Among these isolates, three isolates with the same groESL spacer region length (45 bp) clustered together but were distant from the ATCC reference strain (with a spacer length of 8 bp). The remaining three isolates, with a spacer length of 50 or 8 bp, clustered together. Although 16S rRNA gene sequence analysis did not provide enough discrimination for the 6 Ge. haemolysans isolates, rpoB gene sequence analysis supported the subgrouping. Based on the obtained groESL sequences, we developed a multiplex PCR that enables simple, rapid, and accurate identification of Abiotrophia , Granulicatella , and Gemella at the genus level. This assay would be helpful for identifying these fastidious and slow-growing organisms in clinical laboratories.

We describe the development of nonsusceptibility to daptomycin and vancomycin during treatment for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia associated with infective endocarditis and probable septic thrombophlebitis in a uremic patient. MRSA bacteremia persisted during glycopeptide and subsequent daptomycin treatment but cleared after 5 days' treatment with linezolid and fusidic acid.

The performance of the DR. MTBC PCR-based assay and the BD ProbeTec ET Mycobacterium tuberculosis Complex Direct Detection (DTB) assay for the direct detection of Mycobacterium tuberculosis was evaluated using 1,066 consecutive clinical respiratory samples collected from 494 patients who did not have old cases of pulmonary tuberculosis and were not receiving antituberculosis treatment at National Taiwan University Hospital from January to February 2005. The results of both assays were compared to the “gold standard” of combined culture results and clinical diagnosis. The overall sensitivity and specificity of the DR. MTBC Screen assay were 56.6% and 98.9%, respectively, and of the DTB assay were 63.2% and 98.4%, respectively. The positive and negative predictive values for the DR. MTBC Screen assay were 84.5% and 95.4%, respectively, and for the DTB assay were 81.7% and 96.0%, respectively. The DR. MTBC Screen assay produced 11 false-positive results for 11 patients, including three samples yielding non- M. tuberculosis mycobacteria (one each for M. abscessus , a mixture of M. abscessus and M. chelonae , and unidentified non-tuberculosis mycobacteria). The DTB assay produced 15 false-positive results for 13 patients, including five samples from four patients yielding non-tuberculosis mycobacteria (two for M. abscessus , one for a mixture of M. abscessus and M. chelonae , and two for unidentified non-tuberculosis mycobacteria). This study demonstrated that the DR. MTBC Screen assay has a similar diagnostic value but fewer false-positive results than the DTB assay for respiratory specimens.

We determined the groESL sequences ( groES , groEL , and the intergenic spacer) of 10 clinically relevant Enterococcus species and evaluated the feasibility of identifying Enterococcus species on the basis of these sequences. Seven common clinical Enterococcus species, E. faecalis , E. faecium , E. casseliflavus , E. gallinarum , E. avium , E. raffinosus , and E. hirae , and three less common Enterococcus species, E. cecorum , E. durans , and E. mundtii , were examined in this study. We found that the groES genes of these enterococcal species are identical in length (285 nucleotides) and contain an unusual putative start codon, GTG. The lengths and sequences of the intergenic regions (spacers between the groES and groEL genes) are quite variable (17 to 57 bp in length) among Enterococcus species but are conserved in strains within each species, with only a few exceptions. Considerable variation of groES or groEL sequences was also observed. The evolutionary trees of groES or groEL sequences revealed similarities among Enterococcus species. However, the overall intraspecies variation of groES was less than that of groEL . The high interspecies variation and low intraspecies variation indicate that the groES and spacer sequences are more useful than groEL for identification of clinically relevant Enterococcus species. The sequences of these two genetic traits, groES and spacer, can be determined by a single PCR and direct sequencing and may provide important information for the differentiation of closely related species of Enterococcus .

The performance of a nested PCR-based assay (the RAPID BAP-MTB; AsiaGen, Taichung, Taiwan) and the BD ProbeTec ET (DTB) system (Becton Dickinson, Sparks, Md.) for detection of Mycobacterium tuberculosis was evaluated with 600 consecutive clinical samples. These samples, including 552 respiratory specimens and 48 nonrespiratory specimens, were collected from 333 patients treated at National Taiwan University Hospital from September to October 2003. The results of both assays were compared to the gold standard of combined culture results and clinical diagnosis. The overall sensitivity and specificity of the RAPID BAP-MTB assay for respiratory specimens were 66.7% and 97.2%, respectively, and for the DTB assay they were 56.7% and 95.3%, respectively. The positive and negative predictive values for the RAPID BAP-MTB were 74.1% and 96.0%, respectively, and for the DTB assay they were 59.6% and 94.7%, respectively. For smear-negative samples, the sensitivity of the RAPID BAP-MTB and DTB assays was 57.1% and 40.5%, respectively. The RAPID BAP-MTB assay produced 14 false-positive results in 14 samples, including one of the six samples yielding Mycobacterium abscessus , one of the six samples yielding Mycobacterium avium intracellulare , one sample from a patient with a history of pulmonary tuberculosis with complete treatment, and three samples from three patients with a previous diagnosis of tuberculosis who were under treatment at the time of specimen collection. Among the 48 nonrespiratory specimens, the RAPID BAP-MTB assay was positive in one biopsy sample from a patient with lumbar tuberculous spondylitis and one pus sample from a patient with tuberculous cervical lymphadenopathy. Our results showed that the RAPID BAP-MTB assay is better than the DTB assay for both respiratory specimens and nonrespiratory specimens. The overall time for processing this assay is only 5 h. In addition, its diagnostic accuracy in smear-negative samples is as high as in smear-positive samples.

From December 2002 to February 2003, 15 isolates of pandrug-resistant unidentified Acinetobacter species were recovered from seven patients treated on different wards or intensive care units. Both 16S-23S rRNA intergenic spacer PCR-restriction fragment length polymorphism profiles and sequence analysis of these isolates identified them as Acinetobacter baumannii . This pandrug-resistant A. baumannii strain with an unusual phenotype could persist in humans for long periods and was widely disseminated throughout the hospital.

We applied a set of commonly used universal primers (primers RW01 and DG74) to amplify partial fragments of 16S ribosomal DNA for bacterial identification and found an unexpected amplicon (547 bp), in addition to the expected 362-bp product, in samples containing Bacteroides thetaiotaomicron . It was demonstrated that the internal sequence (508 bp, excluding the primers) of the 547-bp amplicon was identical to the genomic sequence from nucleotide positions 165800 to 166307 of B. thetaiotaomicron type strain VPI-5482 by a BLAST search of the sequences in the GenBank database. The existence of this unexpected yet specific amplicon strongly indicated the presence of B. thetaiotaomicron in the sample, and it was found that it could be used to discriminate B. thetaiotaomicron from closely related species. Another set of PCR primers specific for B. thetaiotaomicron was developed on the basis of the sequence of this 547-bp genomic fragment. Both PCR-based assays showed the same sensitivity (88%) and specificity (100%).

We describe two patients with otologic infections caused by Mycobacterium massiliense ( M. abscessus subsp. bolletti ) which were identified using erm (41) PCR, 23S rRNA, and rpoB gene sequence analysis. They were middle-aged adults with underlying otologic diseases and were treated successfully with clarithromycin-based combination regimens for 3 and 9 months, respectively.

We describe 16 patients with bacteremia caused by Eggerthella lenta ( n = 7), Paraeggerthella hongkongensis ( n = 3), Eubacterium limosum ( n = 4), Eubacterium callanderi ( n = 1), and concomitant Eubacterium limosum / Eggerthella lenta ( n = 1). Nine (56%) patients had polymicrobial bacteremia. The overall 60-day mortality rate was 19%, and all deaths occurred in patients with E. lenta bacteremia.

The full-length sequences of the groESL genes (also known as cpn10/60 ) of Streptococcus anginosus , Streptococcus constellatus , Streptococcus gordonii , and Streptococcus sanguis and the near full-length sequence of the groESL genes of Streptococcus intermedius , Streptococcus bovis , Streptococcus mitis , Streptococcus mutans , Streptococcus oralis , and Streptococcus salivarius were determined. The lengths of the groES genes from the 10 species listed above ranged from 282 to 288 bp, and the full-length sequences of groEL determined for 4 species ( S. anginosus , S. constellatus , S. gordonii , and S. sanguis ) revealed that each was 1,623 bp. The intergenic region (spacer) between the groES and groEL genes varies in size (15 to 111 bp) and sequence between species. The variation of the groES sequences among the species tested was greater (62.1 to 95.1% nucleotide sequence identities) than that of the groEL sequences (77.2 to 95.2% nucleotide sequence identities). Phylogenetic analysis of the groES and groEL genes yielded evolutionary trees similar to the tree constructed by use of the 16S rRNA gene. The intraspecies variation of the spacer was minimal for clinical isolates of some species. The groESL sequence data provide an additional parameter for identification of viridans group streptococcal species.

We describe six patients with hospital-acquired bacteremia caused by Methylobacterium species, including M. radiotolerans ( n = 2), M. thiocyanatum ( n = 2), M. aminovorans ( n = 1), and M. lusitanum ( n = 1), which were confirmed to species level by 16S rRNA gene sequence analysis. Among these patients, five had catheter-related bacteremia and all had favorable outcomes.

Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) (Bruker Biotyper) was able to accurately identify 98.6% (142/144) of Acinetobacter baumannii isolates, 72.4% (63/87) of A. nosocomialis isolates, and 97.6% (41/42) of A. pittii isolates. All Acinetobacter junii , A. ursingii , A. johnsonii , and A. radioresistens isolates ( n = 28) could also be identified correctly by Bruker Biotyper.

Amplification of the partial Cpn60 (or GroEL) gene segment has been used for identification of many bacteria, including Enterococcus species. To obtain more sequence data from groESL genes of Enterococcus faecalis , the full-length sequence of the E. faecalis groESL genes containing groES (285 bp), spacer (57 bp), and groEL (1,626 bp) was determined. A database search of GenBank revealed that the deduced E. faecalis GroES and GroEL proteins show significant homology to the GroES and GroEL proteins of other bacteria. The GroEL ( groEL ) of E. faecalis had the highest identity with Streptococcus pneumoniae (81.8% amino acid sequence identity and 73.0% nucleotide sequence identity), followed by Lactococcus zeae , while GroES ( groES ) had 60.2% (64.6%) identity with Lactobacillus zeae and 58.5% (66.2%) identity with Lactococcus lactis , followed by 57.0% (65.5%) identity with Bacillus subtilis. Based on the groES sequence, an E. faecalis -specific PCR assay was developed, and this PCR assay was positive for all the E. faecalis strains tested. Dot blot hybridization using either groES or groEL as the probe distinguished E. faecalis clearly from other species, indicating that both genes can be used as suitable targets for E. faecalis identification. Moreover, broad-range PCR-restriction fragment length polymorphism of groESL was designed to differentiate eight commonly encountered Enterococcus species. The Enterococcus species of reference strains could be easily differentiated on the basis of restriction patterns produced by Hae III and Rsa I. The DNA-based assays developed in this study provide an alternative to currently used methods of identification for clinically important enterococcal species.

A total of 274 Streptococcus dysgalactiae subsp. equisimilis isolates was analyzed by emm typing and by determining the organization of their mgrC loci. Three of the most frequent emm types were stG485.0 (45/274, 16.4%), stG6.1 (43/274, 15.7%), and stC839.0 (32/274, 11.7%), in decreasing order. The cpdB -positive mgrC locus appears to be predominant in some emm types.

Bacteroides thetaiotaomicron is the second most frequently encountered species of the anaerobes isolated from clinical specimens. We developed a PCR-based assay for the rapid identification of B. thetaiotaomicron . Specific primers were based on shared amplicons of about 1.2 kb generated from B. thetaiotaomicron by randomly amplified polymorphic DNA. This 1.2-kb fragment was sequenced and then used to design a set of PCR amplification primers. This PCR generated an amplification product of 721 bp, which was unique to all 65 isolates of B. thetaiotaomicron tested. There was no amplification with isolates of other bacterial species. Restriction enzyme digestion of the amplification product and dot blot hybridization further verified the specificity of the assay. These results suggest that this PCR assay targets a nucleotide sequence that is strongly conserved in B. thetaiotaomicron . This simple and rapid PCR assay provides a rapid and accurate method for identification of B. thetaiotaomicron and shows promise for the detection of B. thetaiotaomicron in clinical samples.

Thirteen patients who had 16 episodes of bacteremia were observed between 1993 and 1997 in a pediatric oncology ward with a high background isolation rate of cefotaxime- or aztreonam-resistant gram-negative bacteria. Four blood isolates were Escherichia coli and 12 were Klebsiella pneumoniae , and these isolates harbored extended-spectrum β-lactamases (ESBLs). All episodes of bacteremia were nosocomial, all except one of the episodes occurred in neutropenic patients, and all patients were treated with piperacillin or ceftazidime with amikacin and cefazolin prior to the onset of bacteremia. Nine of 13 patients were receiving extended-spectrum β-lactam treatment when the bacteremias caused by ESBL producers occurred. Molecular studies revealed that four K. pneumoniae SHV-2-producing isolates from 1994 were of the same clone. Other ESBL producers, including six that carried both TEM-1 and SHV-5, five that carried SHV-5, and one that carried SHV-2 alone, were unrelated. In conclusion, SHV-5 was present in 11 of the 16 isolates and coexisted with TEM-1 in 6 isolates. Acquisition of resistance genes probably occurred under antibiotic selection pressure. This study highlights the importance of routine checks for and detection of ESBL producers. Effective therapy against ESBL producers should be considered early for children who have malignancies and neutropenia and who are septic, despite treatment with a regimen that includes an extended-spectrum β-lactam, in a clinical setting of an increased incidence of ESBL-producing bacteria.

From September 1990 to October 1990, 15 patients who were admitted to four different departments of the National Taiwan University Hospital, including nine patients in the emergency department, three in the hematology/oncology ward, two in the surgical intensive care unit, and one in a pediatric ward, were found to have positive blood (14 patients) or pleural effusion (1 patient) cultures for Bacillus cereus . After extensive surveillance cultures, 19 additional isolates of B. cereus were recovered from 70% ethyl alcohol that had been used as a skin disinfectant (14 isolates from different locations in the hospital) and from 95% ethyl alcohol (5 isolates from five alcohol tanks in the pharmacy department), and 10 isolates were recovered from 95% ethyl alcohol from the factory which supplied the alcohol to the hospital. In addition to these 44 isolates of B. cereus , 12 epidemiologically unrelated B. cereus isolates, one Bacillus sphaericus isolate from a blood specimen from a patient seen in May 1990, and two B. sphaericus isolates from 95% alcohol in the liquor factory were also studied for their microbiological relatedness. Among these isolates, antibiotypes were determined by using the disk diffusion method and the E test, biotypes were created with the results of the Vitek Bacillus Biochemical Card test, and random amplified polymorphic DNA (RAPD) patterns were generated by arbitrarily primed PCR. Two clones of the 15 B. cereus isolates recovered from patients were identified (clone A from 2 patients and clone B from 13 patients), and all 29 isolates of B. cereus recovered from 70 or 95% ethyl alcohol in the hospital or in the factory belonged to clone B. The antibiotype and RAPD pattern of the B. sphaericus isolate from the patient were different from those of isolates from the factory. Our data show that the pseudoepidemic was caused by a clone (clone B) of B. cereus from contaminated 70% ethyl alcohol used in the hospital, which we successfully traced to preexisting contaminated 95% ethyl alcohol from the supplier, and by another clone (clone A) without an identifiable source.

Sixty-seven clinical isolates of Streptococcus pneumoniae (40 of serotype 23F, 19 of serotype 19F, and 8 of serotype 6B) with decreased susceptibilities to penicillin and erythromycin were characterized by antimicrobial susceptibility patterns; DNA restriction endonuclease cleavage profiles of the penicillin-binding protein genes pbp1a , pbp2b , and pbp2x ; random amplified polymorphic DNA (RAPD) patterns generated by arbitrarily primed PCR; and chromosomal macrorestriction profiles based on pulsed-field gel electrophoresis. A total of 22 clones (identical or closely related pulsotypes and identical RAPD patterns) were identified; 14 clones of 23F, 6 of 19F, and 2 of 6B. Three 23F clones (26 isolates) and one 19F clone (9 isolates) expressed high-level resistance to penicillin, cefotaxime, and erythromycin (MICs ≥ 256 μg/ml). These data strongly suggest that multiple high-level penicillin-, extended-spectrum cephalosporin-, and macrolide-resistant clones of S. pneumoniae have been disseminated in Taiwan.

We report the first case of purulent pericarditis with greenish pericardial effusion caused by Shewanella algae in a patient with gastric and gallbladder cancer. This case expands the reported spectrum of infection caused by S. algae and raises the possibility that S. algae is a causative pathogen for purulent pericarditis.

From 7 to 24 March 1997, four patients developed Pseudomonas fluorescens bacteremia at the hospital; one on the oncology ward and the other three in the chemotherapy room. These patients all had underlying malignancies and had the Port-A-Cath (Smiths Industries Medical Systems, Deltec, Inc., St. Paul, Minn.) implants. Three patients had primary bacteremia, and one had Port-A-Cath-related infection. None of these patients had received a blood transfusion before the episodes of bacteremia. All patients recovered: two received antimicrobial agents with in vitro activity against the isolates, and the other two did not have any antibiotic treatment. A total of eight blood isolates were recovered from these patients during the febrile episodes that occurred several minutes after the infusion of chemotherapeutic agents via the Port-A-Cath. These isolates were initially identified as P. fluorescens or Pseudomonas putida (four), Burkholderia ( Ralstonia ) pickettii (three), and a non-glucose-fermenting gram-negative bacillus (one) by routine biochemical methods and the Vitek GNI card. These isolates were later identified as P. fluorescens on the basis of the characteristic cellular fatty acid chromatogram and the results of supplemental biochemical tests. The identification of identical antibiotypes by the E test and the random amplified polymorphic DNA patterns generated by arbitrarily primed PCR of the isolates showed that the outbreak was caused by a single clone of P. fluorescens . Surveillance cultures of the possibly contaminated infusion fluids and disinfectants, which were performed 7 days after recognition of the last infected patient, failed to isolate P. fluorescens . This report of a small outbreak caused by P. fluorescens suggests that timely, accurate identification of unusual nosocomial pathogens is crucial for early initiation of an epidemiological investigation and timely control of an outbreak.

Based on a pair of primers developed initially for differentiating the anginosus group from other viridans streptococci, the PCR reported here can also differentiate between members of the anginosus group and Streptococcus dysgalactiae subsp. equisimilis among beta-hemolytic group C and G streptococci. The resulting 742-bp PCR product was specific for members of the anginosus group, although a smaller, nonspecific product (361 bp) was generated from S. dysgalactiae subsp. equisimilis . Restriction digestion of the amplicon with XbaI and BsmI further differentiated Streptococcus anginosus from Streptococcus constellatu s within the anginosus group.

We present a case of fatal histoplasmosis in a patient with Addison's disease and long-term use of corticosteroid. The patient acquired Histoplasma capsulatum in China and initially presented with a laryngeal mass. He developed fulminant pneumonia and respiratory failure 9 years later. Nucleotide sequences of internal transcribed spacer regions of rRNA genes of the H. capsulatum isolate recovered from biopsied lung tissue and of the extracted fungal DNA from the laryngeal lesion were identical, indicating the recurrent nature of infection.

Among 36 Mycobacterium masilliense and 22 M. abscessus isolates identified by erm (41) PCR and sequencing analysis of rpoB and 23S rRNA genes, the rate of accurate differentiation between these two subspecies was 100% by cluster analysis of spectra generated by Bruker Biotyper matrix-assisted laser desorption ionization–time of flight mass spectrometry.

Clinical infections caused by Flavobacterium indologenes have never been documented. Thirteen isolates derived from seven patients with indwelling device-associated F. indologenes infections were identified from 1 April through 30 November 1995. The antimicrobial susceptibilities to 20 antimicrobial agents of the isolates, the cellular fatty acid chromatograms for the isolates, and the random amplified polymorphic DNA (RAPD) patterns generated by arbitrarily primed PCR of the isolates were studied. The antibiotypes and RAPD patterns differed among the isolates recovered from different patients. However, both antibiotypes and RAPD patterns were identical among the five isolates from one patient with multiple episodes of central venous catheter-associated bacteremia within a 1.5-month period and between the two isolates from another patient suffering from two episodes of catheter-related bacteriuria at an interval of 14 days. It is documented that the recurrent infections in each of these two patients were caused by a single F. indologenes clone, respectively. Identical antibiotypes and RAPD patterns were also demonstrated between two isolates from a patient with ventilator-associated pneumonia, one recovered from an endotracheal aspirate and the other derived from a blood specimen 10 days later, indicating the invasive nature of F. indologenes. Two cellular fatty acid chromatograms were identified among these isolates. All of the isolates showed in vitro resistance to cephalothin, cefotaxime, ceftriaxone, moxalactam, aztreonam, aminoglycosides, erythromycin, clindamycin, vancomycin, and teicoplanin. F. indologenes should be included as an etiologic agent of infections associated with the use of indwelling devices.

We evaluated the performance of the DR. TBDR/NTM IVD kit, which was designed to detect Mycobacterium tuberculosis , rifampin-resistant M. tuberculosis , and nontuberculous mycobacteria, for detecting 110 positive and 50 negative cultures in Mycobacterium Growth Indicator Tubes. The accuracy rate of this kit for identification of Mycobacterium species was 95.5% (105/110).

This study investigated the clinical and microbiological characteristics of patients with recurrent bacteremia caused by the Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB) complex at a medical center. All ACB complex isolates associated with recurrent bacteremia were identified to the genomic species level using a 16S-23S rRNA gene intergenic spacer sequence-based method. Genotypes were determined by the random amplified polymorphic DNA patterns generated by arbitrarily primed PCR and by pulsotypes generated by pulsed-field gel electrophoresis. Relapse of infection was defined as when the genotype of the recurrent isolate was identical to that of the original infecting strain. Reinfection was defined as when the genospecies or genotype of the recurrent isolate differed from that of the original isolate. From 2006 to 2008, 446 patients had ACB complex bacteremia and 25 (5.6%) had recurrent bacteremia caused by the ACB complex. Among the 25 patients, 12 (48%) had relapse of bacteremia caused by A. nosocomialis ( n = 7) or A. baumannii ( n = 5). Among the 13 patients with reinfection, 5 (38.5%) had reinfection caused by different genospecies of the ACB complex. Most of the patients were immunocompromised, and most of the infection foci were catheter-related bloodstream infections. The overall in-hospital mortality rate was 33.3%. A. baumannii isolates had lower antimicrobial susceptibility rates than A. nosocomialis and A. pittii isolates. In conclusion, relapse of ACB complex bacteremia can develop in immunocompromised patients, especially those with central venous catheters. Molecular methods to identify the ACB complex to the genospecies level are essential for differentiating between reinfection and relapse of bacteremia caused by the ACB complex.

Gordonia amicalis infection has never been reported in humans. We report here the first case of G. amicalis -related cutaneous infection after a traumatic injury. The isolate was confirmed by 16S rRNA sequencing analysis, and the patient responded well to repeated debridement and antibiotic treatment.

Although Escherichia fergusonii has been identified for decades, it has rarely been recovered from clinical specimens and its clinical significance remains unclear. We describe a case of E. fergusonii bacteremia in a diabetic patient with pancreatic cancer. The isolate was confirmed by three commercial identification systems and 16S rRNA gene sequence analysis. The patient's clinical condition gradually improved, and repeated blood cultures were negative after antibiotic treatment with an in vitro active agent (ceftriaxone).

A total of 274 Streptococcus dysgalactiae subsp. equisimilis isolates was analyzed by emm typing and by determining the organization of their mgrC loci. Three of the most frequent emm types were stG485.0 (45/274, 16.4%), stG6.1 (43/274, 15.7%), and stC839.0 (32/274, 11.7%), in decreasing order. The cpdB-positive mgrC locus appears to be predominant in some emm types.

Enterococcus cecorum (formerly Streptococcus cecorum ), originally isolated from poultry intestines, has rarely been encountered in human diseases. A 60-year-old man with liver cirrhosis and hepatocellular carcinoma developed peritonitis on the seventh day of his hospitalization. Cultures of one blood sample and one ascites fluid sample obtained on that day both grew E. cecorum . The patient received intravenous cefoxitin therapy and initially responded well. Unfortunately, another episode of peritonitis associated with septic shock developed 24 days after the start of treatment, and culture of one blood specimen yielded the same organism. The isolates were identified by the conventional biochemical tests, the API Rapid ID 32 Strep system, and the API ZYM system (both systems from bioMerieux, Marcy L'Etoile, France) and were further confirmed by cellular fatty acid chromatography and 16S rRNA gene partial sequencing. The identical biotype, antibiotype, and random amplified polymorphic DNA pattern of the three isolates documented the long-term persistence of this organism in the patient. To the best of our knowledge, this is the first clinical description of recurrent bacteremic peritonitis caused by E. cecorum.

Bacteremic pneumonia caused by Mycobacterium simiae in non-human immunodeficiency virus (HIV)-infected patients has rarely been reported. We describe a non-HIV-infected adult with refractory bacteremia, osteomyelitis, and colonization of M. simiae in the respiratory tract who subsequently developed fatal bacteremic pneumonia. The isolate was confirmed as M. simiae by 16S rRNA gene analysis.

Helicobacter fennelliae (formerly Campylobacter fennelliae ) has been reported to cause bacteremia in homosexual men with or without human immunodeficiency virus (HIV) infection. We report here a 48-year-old, non-HIV-infected, heterosexual man with diabetes mellitus and cirrhosis of the liver who developed bacteremia and septic shock due to H. fennelliae . The patient was treated successfully initially with intravenous ampicillin-sulbactam and ceftazidime, followed by ampicillin-sulbactam only. These agents were active in vitro against the isolate by E-test results. To our knowledge, this is the first documented case of septic shock due to H. fennelliae in a non-HIV-infected, heterosexual, immunocompromised patient.

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.

The Etest was evaluated as a possible alternative to the standard agar dilution method for susceptibility testing of nine antimicrobial agents against Flavobacterium species. In studies of 100 clinical isolates, the agreement between the MICs (+/-1 log2 dilution) obtained by the two methods was acceptable for cefotaxime, ceftazidime, amikacin, minocycline, ofloxacin, and ciprofloxacin (> 90%). Conversely, the agreement between the results obtained for piperacillin was limited (84%). The overall agreement was 92.5%.

We describe a central venous catheter-related (Port-A-Cath; Smiths Industries Medical Systems [SIMS] Deltec, Inc., St. Paul, Minn.) infection caused by Rhodotorula glutinis in a 51-year-old man with nasopharyngeal carcinoma. He was treated with fluconazole for 8 weeks and had the catheter removed. Two isolates of R. glutinis recovered from blood specimens (one obtained via peripheral veins and one via the catheter) before administration of fluconazole and one recovered from the removed catheter 17 days after initiation of fluconazole therapy exhibited high-level resistance to fluconazole (MICs, >256 μg/ml). These three isolates were found to belong to a single clone on the basis of identical antibiotypes determined by the E test (PDM Epsilometer; AB Biodisk, Solna, Sweden) and biotypes determined by API ID32 C (bioMerieux, Marcy I'Etoile, France) and their identical random amplified polymorphic DNA patterns.

We describe the case of an adult male with nasopharyngeal carcinoma who had meningitis caused by Citrobacter farmeri . The isolate was confirmed as C. farmeri by two commercial identification systems and 16S rRNA gene analysis. The patient developed multiorgan failure and died despite antibiotic treatment with in vitro active agents (ceftriaxone and meropenem).

We describe a case of catheter-related bacteremia due to Staphylococcus pseudintermedius in a child with dog exposure. The organism was confirmed as S . pseudintermedius based on 16S rRNA gene sequence analysis and positive PCR-restriction fragment length polymorphism of the pta gene.

From January 1996 to December 1997, 200 isolates of Streptococcus pneumoniae recovered from 200 patients treated at National Taiwan University Hospital were serotyped and their susceptibilities to 16 antimicrobial agents were determined by the agar dilution method. Sixty-one percent of the isolates were nonsusceptible to penicillin, exhibiting either intermediate resistance (28%) or high-level resistance (33%). About two-fifths of the isolates displayed intermediate or high-level resistance to cefotaxime, ceftriaxone, cefepime, imipenem, and meropenem. Extremely high proportions of the isolates were resistant to erythromycin (82%), clarithromycin (90%), and trimethoprim-sulfamethoxazole (TMP-SMZ) (87%). Among the isolates nonsusceptible to penicillin, 23.8% were resistant to imipenem; more than 60% displayed resistance to cefotaxime, ceftriaxone, cefepime, and carbapenems; 96.7% were resistant to erythromycin; and 100% were resistant to TMP-SMZ. All isolates were susceptible to rifampin and vancomycin. The MICs at which 50% and 90% of the isolates were inhibited were 0.12 and 1 μg/ml, respectively, for cefpirome, and 0.12 and 0.25 μg/ml, respectively, for moxifloxacin. Six serogroups or serotypes (23F, 19F, 6B, 14, 3, and 9) accounted for 77.5% of all isolates. Overall, 92.5% of the isolates were included in the serogroups or serotypes represented in the 23-valent pneumococcal vaccine. The incidence of macrolide and TMP-SMZ resistance for S. pneumoniae isolates in Taiwan in this study is among the highest in the world published to date.

Long-term colonization of various body sites with a multidrug-resistant Pseudomonas aeruginosa clone (resistant to piperacillin, cefoperazone, ceftazidime, aztreonam, imipenem, cefepime, cefpirome, ofloxacin, ciprofloxacin, minocycline, and aminoglycosides) with subsequent severe infections in burn patients has not been reported previously. Thirty-nine isolates of multidrug-resistant P. aeruginosa (resistant to ceftazidime and at least three of the agents listed above) recovered from various clinical samples from three patients in an intensive care burn unit from April 1997 to May 1997 and seven preserved isolates recovered from six patients in other medical wards at National Taiwan University Hospital from April 1996 to May 1997 were studied for their epidemiological relatedness. The epidemic could be attributed to a multidrug-resistant P. aeruginosa clone belonging to serogroup O:F (serogroup O:4) by means of antimicrobial susceptibility testing, O serogrouping, and analysis of the randomly amplified polymorphic DNA patterns generated by arbitrarily primed PCR of the isolates. The epidemic strain persisted in the three patients for weeks to months; in the meantime, these patients had received multiple antimicrobial agents for the management of intervening episodes of invasive infections (bacteremia, ventilator-associated pneumonia, and/or catheter-related sepsis) caused by this strain, as well as concomitant infections due to other organisms. The strain had been isolated only once previously, from a burn patient who was on the unit in December 1996. The present report, describing a small outbreak due to P. aeruginosa , documents the fact that a single clone of multidrug-resistant P. aeruginosa can cause long-term persistence in different body sites of burn patients and that the colonization can subsequently result in various severe infections.

Two isolates of serum-susceptible Campylobacter coli were recovered in a 7-day interval from blood from a patient with hepatocellular carcinoma and liver cirrhosis whose peritoneal-caval (Denver's) shunt malfunctioned. Identical random amplified polymorphic DNA fingerprints, cellular fatty acid chromatograms, and antibiograms of the two isolates indicate that C. coli has the ability to cause catheter-related bacteremia following its colonization of the catheter.

Two isolates of Streptococcus pneumoniae having different optochin susceptibilities were recovered from a blood sample of a 2-year-old boy with community-acquired pneumonia. The two isolates were documented to belong to a single clone on the basis of the isolates' identical serotype (23F), antibiograms by the E-test, random amplified polymorphic DNA patterns generated by arbitrarily primed PCR, pulsed-field gel electrophoresis, and restriction fragment length polymorphism of the penicillin-binding protein genes pbp2b and pbp2x .

In vitro activities of cefepime and cefpirome against 96 isolates of Chryseobacterium indologenes and 21 of C. meningosepticum were determined by the agar dilution method. Overall, cefepime was more active than cefpirome against C. indologenes (MIC at which 50% of the isolates were inhibited [MIC50] and MIC90, 4 and 16 microg/ml, respectively, for cefepime and 8 and 128 microg/ml, respectively, for cefpirome). Both agents had poor potency against C. meningosepticum (MIC50 and MIC90, 64 and >256 microg/ml, respectively, for cefepime and 128 and >256 microg/ml, respectively, for cefpirome).