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• The risk of hypoglycemia within a very short time in patients co-prescribed antimicrobials and sulfonylureas were analyzed.

The bla OXA-51 -like gene with an upstream IS Aba1 (IS Aba1 - bla OXA-51 -like gene) was originally found on the chromosomes of carbapenem-resistant or -susceptible Acinetobacter baumannii isolates. However, a plasmid-borne IS Aba1 - bla OXA-51 -like gene has recently been identified in Acinetobacter genomic species 13TU and several A. baumannii isolates in Taiwan, and all of the isolates are carbapenem resistant. This study aimed to characterize the plasmids bearing the IS Aba1 - bla OXA-51 -like gene and their significance in A. baumannii . Among the 117 IS Aba1 - bla OXA-51 -like-harboring isolates collected from 10 hospitals in Taiwan, 58 isolates (49.6%) from 24 clones had the genes located on plasmids that likely originated from a common progenitor. Among the 58 isolates, four had additional copy of the IS Aba1 - bla OXA-51 -like gene on their chromosomes. Based on the analysis of these four isolates, the plasmid-located IS Aba1 - bla OXA-51 -like gene appeared to be acquired via one-ended transposition (Tn 6080 ). The isolates with a plasmid bearing the IS Aba1 - bla OXA-51 -like gene had higher rates of resistance to imipenem (98% versus 46.6%; P < 0.001) and meropenem (98% versus 69%; P = 0.019) than those with the genes chromosomally encoded, which is most likely due to increased gene dosage provided by the higher copy number of associated plasmids. Transformation with a recombinant plasmid harboring only the IS Aba1 - bla OXA-51 -like gene was enough to confer a high level of carbapenem resistance to A. baumannii , eliminating the possible contribution of other factors on the original plasmids. This study demonstrated that the carbapenem resistance-associated plasmids carrying the IS Aba1 - bla OXA-51 -like gene are widespread in A. baumannii strains in Taiwan.

The contribution of the bla OXA-58 gene and its promoter to β-lactam resistance has not been validated in Acinetobacter spp. other than Acinetobacter baumannii . We identified a multidrug-resistant (including carbapenem resistance) Acinetobacter genomic species 13TU in which bla OXA-58 was the only detected carbapenemase gene. The bla OXA-58 gene was plasmid located, flanked by IS Aba3 (downstream) and an IS Aba3- like element (upstream). An IS 1006 element was inserted into IS Aba3 -like (IS 1006 -ΔIS Aba3 -like) to generate a hybrid promoter for bla OXA-58 , with a −35 promoter located in IS 1006 and a −10 promoter in IS Aba3 -like. The reference strain of Acinetobacter genomic species 13TU, ATCC 17903, revealed higher MICs of amoxicillin, ticarcillin, and piperacillin and heteroresistance to imipenem and meropenem when it was transformed with a shuttle vector containing a fragment encompassing ΔIS Aba3 -like- bla OXA-58 , compared to the same host containing only bla OXA-58 . When the fragment was changed from ΔIS Aba3 -like- bla OXA-58 to IS 1006 -ΔIS Aba3 -like- bla OXA-58 , the ATCC 17903 transformant revealed a markedly higher level of bla OXA-58 transcription (12-fold), increased cefuroxime and piperacillin-tazobactam MICs, and homoresistance to imipenem and meropenem. Different roles of the insertion elements preceding the bla OXA-58 gene in Acinetobacter genomic species 13TU are demonstrated. The IS Aba3 -like- -bla OXA-58 construct can mediate resistance to penicillin derivatives but only heteroresistance to carbapenems. The insertion of IS 1006 into IS Aba3 -like, generating a hybrid promoter, could further enhance the transcription of bla OXA-58 and mediate homoresistance to carbapenems and also enhanced resistance to piperacillin-tazobactam.

Background Optimal nutrition during the 1st year of life is critical to infants' healthy growth and development, and breastfeeding is a key component. However, little is known about the effect of breastfeeding duration on infant growth in Taiwan. Purpose The aim of this study was to examine the effect of breastfeeding duration on infant growth. Methods This study was based on questionnaire interviews as part of the Taiwan Birth Cohort Study, which collected information on breastfeeding duration and infant growth among infants aged from 0 to 18 months. Participants were selected from Taiwan birth registry data for 2005, using multistage stratified random sampling. The sample population was 15,868 infants ranging in gestational age between 37 and 41 weeks, excluding those with birth defects or who were hospitalized after birth. The χ2 test, analysis of variance and generalized estimating equations were used to analyze the effects of infant feeding patterns and other factors on infant growth. Results Breastfeeding duration had no significant effect on infant weight within the first 6 months, but after the 7th month, infants who had been breastfed for ≥6 months were lighter than infants who were not breastfed. Before 18 months of age, infants who had been breastfed for ≥6 months were slightly shorter than infants who had been breastfed for Conclusion These results show that different infant feeding practices correspond to differences in infant growth from 0 to 18 months, and are consistent with the World Health Organization's new growth standards.

Six patients with Acinetobacter genomic species 10 bacteremia were identified. The clinical features of the patients, phenotypic and genotypic identifications, antimicrobial susceptibilities, and genes flanking IS Aba1 of the bacteria were described. The results revealed that this bacterium is a potentially lethal pathogen that can cause health care-associated infections in debilitated patients.

We report a 44-year-old man with primary gastric small cell carcinoma who showed a remarkable response to chemotherapy specific for pulmonary small cell carcinoma. The patient had been admitted to another local hospital because of intermittent epigastralgia. An upper gastrointestinal examination there revealed an ulcerative tumor, 5 cm in diameter, on the lesser curvature side of the cardia, and endoscopic biopsy reported adenocarcinoma. Computed tomography revealed a mass over the lesser curvature of the stomach and some enlarged regional lymph nodes. Radical total gastrectomy, lymph node dissection, Roux-en-Y esophagojejunostomy and splenectomy were performed at our hospital. Pathology revealed gastric mucosa infiltrated by small-sized tumor cells with scanty cytoplasm and hyperchromatic nuclei. Immunohisto- chemically, the tumor cells were positive for synaptophysin, chromogranin A, and CD56. Primary gastric small cell carcinoma was diagnosed. The postoperative course, complicated by shock due to bleeding, wound infection and intra-abdominal abscess, took more than 2 months to resolve. Follow-up computed tomography showed tumor recurrence with multiple enlarged lymph nodes in the aortocaval region and hepatic hilum. The patient received palliative chemotherapy consisting of cisplatin 80 mg/m 2 on day 1 and etoposide 80 mg/m 2 on days 1–3 every 28 days, and had partial response to the chemotherapy, with a progression-free survival of 10 months. Chemotherapy with cisplatin and etoposide used for small cell carcinoma of the lung is a good treatment for gastric small cell carcinoma.

This study compared the health-related quality of life (HRQOL) of mothers using different infant feeding methods. We used the Medical Outcomes Study 36-item Short-Form (SF-36) to measure the HRQOL of 1,747 mothers and used the scores to look for associations with infant feeding methods (not breastfeeding, breastfeeding for

Although oral antidiabetic drugs (OADs) have been associated with immunomodulation in preclinical studies, little is still known about the association between the use of OADs and the risk of sepsis. Using a cohort of patients, extracted from Taiwan’s National Health Insurance Research Database, with type 2 diabetes who were newly diagnosed between 2010 and 2012 and treated with OADs, we conducted a nested case-control study involving 43,015 cases (patients who were first hospitalized for sepsis) and 43,015 matched controls. Compared with non-use, metformin use was associated with a decreased risk of developing sepsis (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.77–0.83, P P

The sulbactam resistance rate in Acinetobacter baumannii has increased worldwide. Previous reports have shown that the β-lactamase bla TEM-1 confers resistance to sulbactam in A. baumannii. The purpose of this study was to examine whether other β-lactamases, including the Acinetobacter-derived cephalosporinase (ADC), OXA-23, OXA-24/72, and OXA-58 families, also contribute to sulbactam resistance in A. baumannii. The correlation between these β-lactamases and the sulbactam minimal inhibitory concentration (MIC) was determined using A. baumannii clinical isolates from diverse clonality, which were collected in a nationwide surveillance program from 2002 to 2010 in Taiwan. A possible association between the genetic structure of ISAba1-bla ADC-30 and sulbactam resistance was observed because this genetic structure was detected in 97% of sulbactam-resistant strains compared with 10% of sulbactam-susceptible strains. Transformation of ISAba1-bla ADC-30 into susceptible strains increased the sulbactam MIC from 2 to 32 μg/ml, which required bla ADC-30 overexpression using an upstream promoter in ISAba1. Flow cytometry showed that ADC-30 production increased in response to sulbactam, ticarcillin, and ceftazidime treatment. This effect was regulated at the RNA level but not by an increase in the bla ADC-30 gene copy number as indicated by quantitative PCR. Purified ADC-30 decreased the inhibitory zone created by sulbactam or ceftazidime, similarly to TEM-1. In conclusion, ADC-30 overexpression conferred resistance to sulbactam in diverse clinical A. baumannii isolates.

BACKGROUND We present the first comprehensive analysis of Mycobacterium tuberculosis (MTB) isolates circulating in southern Taiwan. In this 9-year population-based study, the TB situation in the Kaohsiung region was characterized by genotypic analysis of 421 MTB isolates. METHODS All 421 isolates of MTB were analyzed by spoligotyping and MIRU-VNTR typing. Drug-resistance patterns were also analyzed. RESULTS The percentage of EAI (East African-Indian) strains increased across sampling years (2000-2008) in southern Taiwan, whereas the proportion of Beijing lineages remained unchanged. Clustering was more frequent with EAI genotype infections (odds ratio = 3.6, p

Background/purpose Patients with Acinetobacter pittii and Acinetobacter nosocomialis bacteremia have lower mortality rates than those with Acinetobacter baumannii bacteremia. However, it is unknown whether these organisms differ in outcomes of bacteremic patients. We conducted this study to answer this question. Methods In this retrospective study conducted at a teaching hospital in Taiwan, we enrolled all 86 patients who had developed A. pittii bacteremia and those with A. nosocomialis bacteremia from 2000 to 2008 while matching for age, sex, Acute Physiology and Chronic Health Evaluation II score, and appropriate antimicrobial therapy. After adjustment, we accessed the clinical characteristics and 14- and 28-day mortalities. Results We found that the patients with A. pittii bacteremia had multiple comorbidities less often and received invasive procedures less frequently. The 14-day mortality rate of patients with A. pittii or A. nosocomialis bacteremia was 14% and 7%, respectively, whereas their 28-day mortality rate was 17% and 9%, respectively. Using the mortality rate in patients with A. nosocomialis bacteremia as a reference, the odds ratios for the 14- and 28-day crude morality in those with A. pittii were 2.16 [95% confidence interval (CI), 0.77–6.05] and 2.06 (95% CI, 0.82–5.15), respectively, whereas the adjusted odds ratios for 14- and 28-day mortality were 1.89 (95% CI, 0.56–6.14) and 1.67 (95% CI, 0.59–4.78) respectively. Conclusion Our 8-year study showed that the mortality rate of A. pittii bacteremia was higher but the difference was not statistically significant.

Intensive care unit (ICU)-acquired weakness is a common issue for sepsis survivors that is characterized by impaired muscle strength and causes functional disability. Although inpatient rehabilitation has not been found to reduce in-hospital mortality, the impact of postdischarge rehabilitation on sepsis survivors is uncertain.To investigate the benefit of postdischarge rehabilitation to long-term mortality in sepsis survivors.We conducted a nationwide, population-based, high-dimensional propensity score-matched cohort study using Taiwan's National Health Insurance Research Database. The rehabilitation cohort comprised 15,535 ICU patients who survived sepsis and received rehabilitation within 3 months after discharge between 2000 and 2010. The control cohort consisted of 15,535 high-dimensional propensity score-matched subjects who did not receive rehabilitation within 3 months after discharge. The endpoint was mortality during the 10-year follow-up period.Compared with the control cohort, the rehabilitation cohort had a significantly lower risk of 10-year mortality (adjusted hazard ratio, 0.94; 95% confidence interval, 0.92-0.97; P0.001), with an absolute risk reduction of 1.4 per 100 person-years. The frequency of rehabilitation was inversely associated with 10-year mortality (≥3 vs. 1 course: adjusted hazard ratio, 0.82; P0.001). Compared with the control cohort, improved survival was observed in the rehabilitation cohort among ill patients who had more comorbidities, required more prolonged mechanical ventilation, and had longer ICU or hospital stays, but not among those with the opposite conditions (i.e., less ill patients).Postdischarge rehabilitation may be associated with a reduced risk of 10-year mortality in the subset of patients with particularly long ICU courses.

Nontyphoid salmonellosis (NTS) is one of the most common foodborne diseases worldwide, affecting millions of persons each year [1, 2]. Usually acquired by consumption of contaminated food, especially eggs and poultry products, NTS may cause gastroenteritis, bacteremia, and focal infections [3]. Predisposing host factors include gastric hypoacidity [1], diabetes [3, 4], autoimmune diseases [1, 4], cancer [5], hepatic cirrhosis [3], gallstones [1], previous gastrointestinal surgery [6], AIDS [7, 8], and prior use of antimicrobial agents [3, 7, 8]. Proton pump inhibitors (PPIs) have also been associated with NTS [9–11]. This association is thought to be due to disruption of the natural gut microbial ecology [12] caused by inhibition of gastric acid secretion, mucosal permeability [13], and neutrophil bactericidal activity [14]. Most studies have shown an association between PPI use and susceptibility to NTS but failed to consider the confounding effects of host factors that enhance susceptibility to NTS [9–11]. A recent study, which controlled for individual confounding factors by using the patients as their own control over a 12-month period, found no association between PPIs use and NTS, suggesting that predisposing factors other than PPIs may contribute to the increased rate of NTS [15]. Because of the conflicting results in the literature, problems of selection bias [16], and differences in the intervals of time between the use of a PPI and onset of NTS we believed that a large, community-based study was needed to adjust for the effect of predisposing host factors and to determine the critical interval between use of a PPI and the onset of NTS. To accomplish this we conducted a nested case-control study, matching for demographic and predisposing host factors for NTS. The Taiwan National Health Insurance Research Database (NHIRD) 2000–2010 was used to identify a large number of case patients and controls during an 11-year period.

Background Older patients with advanced chronic kidney disease (CKD) face the decision of whether to undergo dialysis. Currently available data on this issue are limited because they were generated by small, short-term studies with statistical drawbacks. Further research is urgently needed to provide objective information for dialysis decision making in older patients with advanced CKD. Methods This nationwide population-based cohort study was conducted using Taiwan’s National Health Insurance Research Database. Data from 2000 to 2010 were extracted. A total of 8,341 patients ≥70 years old with advanced CKD and serum creatinine levels >6 mg/dl, who had been treated with erythropoiesis-stimulating agents were included. Cox proportional hazard models in which initiation of chronic dialysis was defined as the time-dependent covariate were used to calculate adjusted hazard ratios for mortality. The endpoint was all-cause mortality. Results During a median follow-up period of 2.7 years, 6,292 (75.4%) older patients chose dialysis therapy and 2,049 (24.6%) received conservative care. Dialysis was initiated to treat kidney failure a median of 6.4 months after enrollment. Dialysis was associated with a 1.4-fold increased risk of mortality compared with conservative care (adjusted hazard ratio 1.39, 95% confidence interval 1.30 to 1.49). In subgroup analyses, the risk of mortality remained consistently increased, independent of age, sex and comorbidities. Conclusions In older patients, dialysis may be associated with increased mortality risk and healthcare cost compared with conservative care. For patients who are ≥70 years old with advanced CKD, decision making about whether to undergo dialysis should be weighted by consideration of risks and benefits. Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0169-3) contains supplementary material, which is available to authorized users.

The role of carbapenem-resistant Acinetobacter baumannii (CRAb) in polymicrobial infection remains elusive. Having observed the ability of CRAb to shelter other susceptible bacteria from carbapenem killing, we sought to determine the factors contributing to this sheltering effect by transforming different recombinant plasmids into recipient A. baumannii cells. The sheltering effects of CRAb were reproduced in recipient A. baumannii cells that highly expressed carbapenem-hydrolyzing class D β-lactamases (CHDLs) through their associated strong promoter. With the use of Western blot analysis and a bioassay, the highly expressed CHDLs were found to be extracellularly released and led to hydrolysis of carbapenem. The level of extracellular CHDLs increased after challenge with a higher concentration of CHDL substrates, such as carbapenem and ticarcillin. This increased CHDL may, in part, be attributed to cell lysis, as indicated by the presence of extracellular gyrase. In the planktonic condition, the sheltering effect for the cocultured susceptible bacteria might represent an indirect and passive effect of the CRAb self-defense mechanism, because coculture with the susceptible pathogen did not augment the amount of the extracellular CHDLs. Polymicrobial infection caused by CRAb and a susceptible counterpart exerted higher pathogenicity than monomicrobial infection caused by either pathogen alone in mice receiving carbapenem therapy. This study demonstrated that CHDL-producing CRAb appears to provide a sheltering effect for carbapenem-susceptible pathogens via the extracellular release of CHDLs and, by this mechanism, can enhance the pathogenesis of polymicrobial infection in the presence of carbapenem therapy.

Although statins have been shown to have cholesterol-lowering effects, their pleiotropic benefits on sepsis remain a matter of debate. In addition, the influence of statin potency on sepsis-related mortality has never been explored. The aim of our study was to determine the sepsis outcomes of low- and high-potency statin users and non-users.This nationwide, population-based, propensity score-matched analysis used data from the linked administrative databases of Taiwan's National Health Insurance program. Patients were hospitalized for sepsis between 2000 and 2010. All-cause mortality and major adverse consequences of sepsis, such as in-hospital death, intensive care unit admission, shock events, and the use of mechanical ventilation, were assessed. Patients were divided into high-potency statin users (at least 10 mg rosuvastatin, at least 20 mg atorvastatin, or at least 40 mg simvastatin), low-potency statin users (all other statin treatments), and non-users.A propensity score-matched cohort of 27,792 statin users and 27,792 non-users was included. Of 27,792 statin users, 9,785 (35.2 %) were treated with high-potency statins and 18,007 (64.8 %) were treated with low-potency statins. The 1-year mortality risk was significantly lower among both low-potency [adjusted hazard ratio (aHR) 0.89, 95 % confidence interval (CI) 0.85-0.93] and high-potency (aHR 0.80, 95 % CI 0.75-0.86) statin users compared with non-users. The risks of mortality and adverse consequences of sepsis were lower among high-potency than among low-potency statin users.High-potency statin use is associated with a lower risk of sepsis-related mortality compared with low-potency statin use.

Two children suffered from corneal superinfection following acute viral keratoconjunctivitis. Group A β-hemolytic streptococci were isolated in one child and cultures were negative in the other child. The corneal ulcers resolved with prompt antibiotic therapy, but both patients developed amblyopia. Visual outcome following corneal superinfection in acute viral conjunctivitis may be poor when it occurs in young children.

Background To control tuberculosis (TB), it is critical to identify at risk populations. Schizophrenia is recognized as an important risk factor for TB. However, previous studies have been confounded by comorbidities, and reports of TB infection outcomes are rare. Therefore, the current nation-wide study aimed to compare the adjusted incidence and outcome of TB diseases in schizophrenics and the general population. Method Using the National Health Insurance Research Database from 1998 to 2009, this retrospective longitudinal study included 60,409 schizophrenics and general population matched for age, Charlson’s score, and comorbidities. Diagnosis of TB was based on the international classification of disease, ninth revision and use of anti-TB drugs. Unfavorable outcome for TB was defined as death, loss to follow-up, or use of anti-TB treatment for more than 9 months. Results The adjusted incidence of TB in schizophrenics was significantly higher than in the general population [hazard ratio, 1.52; 95% confidence interval (CI), 1.29-1.79; p < 0.001; Kaplan-Meier log-rank test, p < 0.001]. Cox regression revealed age and male gender as risk factors for newly-diagnosed TB. The outcome of TB was comparable in schizophrenics and the general population [odds ratio (OR), 0.78; 95% CI, 0.55-1.09; p =0.144]. Logistic regression revealed a statistical trend for diabetes mellitus to predict poor outcome in schizophrenics with TB (OR, 2.30; 95% CI, 0.96-5.74; p = 0.062). Conclusions Schizophrenics are at increased risk for TB, and screening may be warranted for those living in areas with high prevalence of TB.

Background Acinetobacter baumannii hospital-acquired pneumonia (HAP) is associated with a high mortality worldwide. Non-ventilated patients with HAP (NVHAP) caused by nosocomial pathogens are reported to have a more favorable outcome than those with ventilator-associated pneumonia (VAP). The current study was designed to determine whether bacteremic patients with A. baumannii NVHAP also have a lower mortality than those receiving assisted ventilation. Methods This retrospective 10-year study was conducted at a 2900-bed teaching hospital located in Northern Taiwan. The population consisted of 144 patients with A. baumannii bacteremia and HAP. Of these 96 had VAP and 48 had NVHAP. Charts were reviewed for demographic characteristics, comorbidities, clinical manifestations, antimicrobial susceptibility, and 14-day mortality. Clonal relationships were determined by molecular typing. Results There were no significant differences between the two groups in comorbidities (Charlson scores). Patients with NVHAP were more likely to have developed bacteremia earlier, outside the ICU and undergone fewer invasive procedures. They had significantly lower APACHE II scores, fewer bilateral pneumonias and lower rates of antimicrobial resistance. No specific clones were identified in either group. The unadjusted (crude) 14-day mortality rates were not significantly different between the groups (NVHAP 43.8% vs. VAP 31.3%, p = 0.196). The adjusted 14-day mortality risk was significantly lower in ventilator-assisted patients (odds ratio = 0.201; 95% confidence interval = 0.075-0.538; p = 0.001). Conclusions Patients with bacteremic NVHAP and VAP caused by A. baumannii had similar crude mortality rates, but on logistic regression analysis those receiving ventilator assistance had a significantly lower mortality. This may have been due to better airway protection, more intensive monitoring with earlier diagnosis and treatment in patients with VAP, greater innate susceptibility to infection in those with NVHAP and differences in the virulence of A. baumannii.

Creating supportive environments that encourage mothers to breastfeed their children has emerged in recent years as a key health issue for women and children. Taiwan has a large and still growing number of new mothers in the workplace. Early postpartum return to work and inconvenient workplace conditions often discourage women from breastfeeding or cause early discontinuation. This study describes the current status of worksite breastfeeding-friendly policies in Taiwan and selected other countries and assesses the effects of work-related factors on working mother breastfeeding behavior. Although maternity leave has been positively correlated with breastfeeding duration, maternity leave in Taiwan remains significantly shorter than in other countries. Flexible working conditions, the provision of lactation rooms, and support from colleagues are critical components of promoting breastfeeding in the workplace.

To investigate the association between the use of nonselective or cyclooxygenase (COX)-2-selective nonsteroidal antiinflammatory drugs (NSAIDs) and risk of acute kidney injury (AKI) in a general Asian population. We conducted an observational, nationwide, nested case-control cohort study using Taiwan's National Health Insurance Research Database between 2010 and 2012. AKI cases were defined as hospitalization with a principle diagnosis of AKI. Each case was matched to 4 randomly selected controls based on age, sex, and the month and year of cohort entry. Odds ratios (ORs) were used to demonstrate the association between hospitalization for AKI and current, recent, or past use of an oral NSAID. During the study period, we identified 6199 patients with AKI and 24,796 matched controls. Overall, current users (adjusted OR 2.73, 95% confidence interval [CI] 2.28-3.28) and recent users (adjusted OR 1.17, 95% CI 1.01-1.35) were associated with increased risk of hospitalization for AKI. The risk was also similar for nonselective NSAIDs. However, neither current nor recent use of COX-2 inhibitors was significantly associated with AKI events. Our study supported that the initiation of nonselective NSAIDs rather than COX-2 inhibitors is associated with an increased risk of AKI requiring hospitalization. Future randomized trials are needed to elucidate these findings.

The phenotypically indistinguishable Acinetobacter baumannii and Acinetobacter nosocomialis have become leading pathogens causing nosocomial pneumonia in critically ill patients. A. baumannii and A. nosocomialis nosocomial pneumonias were grouped as a single clinical entity previously. This study aimed to determine whether they are the same or a different clinical entity. A total of 121 patients with A. baumannii and 131 with A. nosocomialis bacteremic nosocomial pneumonia were included during an 8-year period. Despite the similar Charlson co-morbidity scores at admission, patients with A. baumannii pneumonia were more likely to have abnormal haematological findings, lobar pneumonia, significantly higher Acute Physiology and Chronic Health Evaluation II scores and higher frequency of shock at the onset of bacteraemia than those with A. nosocomialis pneumoni. A. baumannii isolates were resistant to more classes of antimicrobials, except colistin, and therefore the patients with A. baumannii pneumonia were more likely to receive inappropriate antimicrobial therapy. The 14-day mortality was significantly higher in patients with A. baumannii pneumonia (34.7% vs. 15.3%, p 0.001). A. baumannii was an independent risk factor for mortality (OR, 2.03; 95% CI, 1.05–3.90; p 0.035) in the overall cohort after adjustment for other risk factors for death, including inappropriate antimicrobial therapy. The results demonstrated the difference in clinical presentation, microbial characteristics and outcomes between A. baumannii and A. nosocomialis nosocomial pneumonia, and supported that they are two distinct clinical entities.

The clinical characteristics and risk factors for 28-day mortality in 120 patients with solid tumours with Acinetobacter nosocomialis bacteraemia were retrospectively analysed. Eighty-one patients (67.5%) had advanced-stage cancer. Most of the bacteraemia (37.5%) did not have an identified source. The bacteraemia episodes developed at a median of 15 days after hospitalization, and most during a non-neutropenic period (97.5%). Although only half of the patients received appropriate antimicrobial therapy, the mortality was relatively low (11.7%). High Pitt bacteraemia score and receipt of chemotherapy within the month before bacteraemia onset were independently associated with 28-day mortality.

We present the first comprehensive analysis of Mycobacterium tuberculosis isolates circulating in the Kaohsiung region of southern Taiwan. The major spoligotypes found in the 224 isolates studied were Beijing lineages (n = 97; 43.3%), EAI lineages (n = 72; 32.1%) and Haarlem lineages (n = 18; 8.0%). By 24 MIRU-VNTR typing, 174 patterns were identified, including 24 clusters of 74 isolates and 150 unique patterns. The combination of spoligotyping and 12-MIRU-VNTR revealed that 129 (57.6%) of the 224 isolates were clustered in 18 genotypes. Moreover, 63.6% (7/11) of infected persons younger than 30 years had a Beijing strain, which could suggest recent spread among younger persons by this family of TB strains in Kaohsiung. Among the 94 Beijing family (SIT1, SIT250 and SIT1674) isolates further analyzed for SNPs by mass spectrometry, the most frequent strain found was ST10 (n = 49; 52%), followed by ST22 (n = 17; 18%) and ST19 (n = 11; 12%). Among the EAI-Manila family isolates analyzed by region deletion-based subtyping, the most frequent strain found was RD type 1 (n = 63; 87.5%), followed by RD type 2 (n = 9; 12.5%). In our previous study, the proportion of modern Beijing strains (52.5%) in northern Taiwan was significantly higher than the proportion of EAI strains (11%). In contrast, in the present study, EAI strains comprised up to 32% of Beijing strains in southern Taiwan. In conclusion, both 'modern' (Beijing) and 'ancient' (EAI) M. tuberculosis strains are prevalent in the Kaohsiung region, perhaps suggesting that both strains are somehow more adapted to southern Taiwan. It will be interesting to investigate the dynamics of the lineage composition by different selection pressures.

Renin and aldosterone activity levels are low in elderly patients, raising concerns about the benefits and risks of angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARB) use. However, data from direct comparisons of the effects of ACEIs on ARBs in the elderly population remain inconclusive. In this nationwide study, all patients aged ≥ 70 years were retrieved from the Taiwan National Health Insurance database for the period 2000 to 2009 and were followed up until the end of 2010. The ARB cohort (12,347 patients who continuously used ARBs for ≥ 90 days) was matched to ACEI cohort using high-dimensional propensity score (hdPS). Intention-to-treat (ITT) and as-treated (AT) analyses were conducted. In the ITT analysis, after considering death as a competing risk, the ACEI cohort had similar risks of myocardial infarction (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.79–1.06), ischemic stroke (HR 0.98, 95% CI 0.90–1.07), and heart failure (HR 0.93, 95% CI 0.83–1.04) compared with the ARB cohort. No difference in adverse effects, such as acute kidney injury (HR 0.99, 95% CI 0.89–1.09) and hyperkalemia (HR 1.02, 95% CI 0.87–1.20), was observed between cohorts. AT analysis produced similar results to those of ITT analysis. We were unable to demonstrate a survival difference between cohorts (HR 1.03, 95% CI 0.88–1.21) after considering drug discontinuation as a competing risk in AT analysis. Our study supports the notion that ACEI and ARB users have similar risks of major adverse cardiovascular events (MACE), even in elderly populations.

The bla OXA-51 -like gene, originally intrinsic to Acinetobacter baumannii , had been detected in two clones of Acinetobacter nosocomialis and one clone of Acinetobacter genomic species “Close to 13TU.” These bla OXA-51 -like genes, all preceded by IS Aba1 , were located on plasmids that might have originated with A. baumannii . The plasmid-borne IS Aba1 -- bla OXA-51 -like confers a high level of carbapenem resistance and affects the accuracy of using bla OXA-51 -like detection as a tool for differentiating A. baumannii from other Acinetobacter species.

To report a hepatitis B virus (HBV) reactivation during the treatment of etanercept for rheumatoid arthritis (RA). The chronological course of a patient with RA who developed HBV reactivation associated with etanercept treatment was recorded. A Taiwanese woman with RA was treated by etanercept. A severe deterioration of liver biochemistry occurred soon after the start of the biologicals because of the previously unrecognised HBV carrier status. The condition was successfully alleviated by oral lamivudine administration. In the prevalent area of HBV, viral titre monitoring and pre-emptive antiviral treatment may be fundamentally important to avoid serious complications of HBV reactivation whenever a new treatment modality such as biologicals is started for patients with RA.

Molecular identification methods based on the staphylococcal cassette chromosome mec (SCCmec) genotype are more reliable than clinical risk factors and demographic data for differentiating community-acquired and healthcare-associated (HCA) meticillin-resistant Staphylococcus aureus (MRSA). However, patients with community-onset (CO) MRSA infections, defined as a culture-positive sample obtained

Background Emergence of daptomycin-nonsusceptible (DNS) Staphylococcus aureus is a dreadful problem in the treatment of endocarditis. Few current therapeutic agents are effective for treating infections caused by DNS S. aureus. Case presentation We describe the emergence of DNS S. aureus. in a patient with implantable cardioverter-defibrillator (ICD) device -related endocarditis who was priorily treated with daptomycin. Metastatic dissemination as osteomyelitis further complicated the management of endocarditis. The dilemma was successfully managed by surgical removal of the ICD device and combination antimicrobial therapy with high-dose daptomycin and fosfomycin. Conclusions Surgical removal of intracardiac devices remains an important adjunctive measure in the treatment of endocarditis. Our case suggests that combination therapy is more favorable than single-agent therapy for infections caused by DNS S. aureus.

Background and purpose Amino acid substitutions in GyrA and ParC are associated with resistance to quinolones in Acinetobacter baumannii ( A baumannii ), but this association is rarely elucidated in Acinetobacter genomic species (AGS) 13TU. This study aims to compare the association of amino acid substitutions in GyrA and ParC with quinolone resistance in A baumannii and AGS 13TU in Taiwan. Methods Eleven representative strains of A baumannii and 13 strains of AGS 13TU were selected from 402 bacteremic isolates. The sequences of quinolone resistance determining regions of gyrA and parC were determined. Minimal inhibitory concentrations (MICs) of nalidixic acid, ciprofloxacin, levofloxacin and moxifloxacin were determined by agar dilution method. Results Ser83Leu substitution in GyrA in A baumannii (one strain) was associated with resistance to all tested quinolones. This substitution plus a Ser80Leu or Ser80Tyr in ParC in A baumannii (four strains) and AGS 13TU (two strains) were associated with higher MICs of all quinolones. All but one quinolone MICs of A baumannii (one strain) and AGS 13TU (two strains) carrying a single substitution Ser56Asn in ParC remained in the susceptibility breakpoint. The Ser83Leu substitution in GyrA, even with additional Ser56Asn substitution in ParC, was associated with resistance to only nalidixic acid, but not other newer quinolones in AGS 13TU (two strains). Conclusion A baumannii and AGS 13TU possessed similar quinolone resistance associated with amino acid substitutions in GyrA and ParC. Further study with more strains is needed to determine whether a single Ser83Leu substitution in GyrA was associated with a high level of quinolone MIC only in A baumannii , but not in AGS 13TU.

BackgroundIt is still controversial whether carbapenem-resistant Acinetobacter baumannii (CRAB) is an independent risk factor for mortality. This study aimed to determine the risk factors and outcomes of patients with CRAB bacteremia, compared to those with carbapenem-susceptible A. baumannii (CSAB) bacteremia.MethodsThis retrospective cohort study was conducted in Taipei Veterans General Hospital, Taiwan. Patients with bacteremia due to A. baumannii during June 2002 and December 2007 were included.ResultsA total of 62 patients with CRAB and 164 with CSAB bacteremia were included. Among these patients, the independent risk factors for acquiring CRAB bacteremia were hematological malignancy [odds ratio (OR): 4.04; 95% confidence interval (CI): 1.29–12.70; p = 0.017], previous use of cefepime (OR: 2.60; 95% CI 1.11–6.08; p = 0.028) and use of total parenteral nutrition (OR: 3.06; 95% CI 1.12–8.39; p = 0.029). The patients with CRAB bacteremia had higher mortality rate than those with CSAB bacteremia. However, multivariate analysis showed that among patients with A. baumannii bacteremia, acquisition of CRAB by itself was not an independent risk factor for 14-day mortality. Instead, the independent factors predicting14-day mortality were Acute Physiology and Chronic Health Evaluation (APACHE) score > 20 (OR: 6.33; 95% CI: 2.32–17.26; p

The bla(OXA-51)-like gene with an upstream ISAba1 (ISAba1-bla(OXA-51)-like gene) was originally found on the chromosomes of carbapenem-resistant or -susceptible Acinetobacter baumannii isolates. However, a plasmid-borne ISAba1-bla(OXA-51)-like gene has recently been identified in Acinetobacter genomic species 13TU and several A. baumannii isolates in Taiwan, and all of the isolates are carbapenem resistant. This study aimed to characterize the plasmids bearing the ISAba1-bla(OXA-51)-like gene and their significance in A. baumannii. Among the 117 ISAba1-bla(OXA-51)-like-harboring isolates collected from 10 hospitals in Taiwan, 58 isolates (49.6%) from 24 clones had the genes located on plasmids that likely originated from a common progenitor. Among the 58 isolates, four had additional copy of the ISAba1-bla(OXA-51)-like gene on their chromosomes. Based on the analysis of these four isolates, the plasmid-located ISAba1-bla(OXA-51)-like gene appeared to be acquired via one-ended transposition (Tn6080). The isolates with a plasmid bearing the ISAba1-bla(OXA-51)-like gene had higher rates of resistance to imipenem (98% versus 46.6%; P0.001) and meropenem (98% versus 69%; P = 0.019) than those with the genes chromosomally encoded, which is most likely due to increased gene dosage provided by the higher copy number of associated plasmids. Transformation with a recombinant plasmid harboring only the ISAba1-bla(OXA-51)-like gene was enough to confer a high level of carbapenem resistance to A. baumannii, eliminating the possible contribution of other factors on the original plasmids. This study demonstrated that the carbapenem resistance-associated plasmids carrying the ISAba1-bla(OXA-51)-like gene are widespread in A. baumannii strains in Taiwan.

Candidaemia is associated with high mortality and high healthcare costs. The incidence of candidaemia in Taiwan rose markedly during the period 1980-2000. We conducted this hospital-based surveillance study in order to explore the secular trend in incidence of candidaemia during the period 2000 to 2008. In our study, Candida spp. were the fourth most common cause of bloodstream infections, with a 30-day crude mortality rate of 36.7%. Candida albicans was the most common species identified, although mortality rate did not differ significantly among species. The incidence of candidaemia began to decrease in 2004. Risk factors related to higher mortality included longer hospital stay before onset of candidaemia, liver cirrhosis, malignancy, end-stage renal disease requiring renal dialysis, dependence on mechanical ventilation and urinary catheterisation.

Background To determine whether the susceptibilities and the trends of nonsusceptibility of imipenem, meropenem, sulbactam, and colistin differed among Acinetobacter baumannii , Acinetobacter genomic species 3 (AGS 3), and Acinetobacter genomic species 13TU (AGS 13TU) over 11 years. Methods A total of 1,039 nonduplicate blood isolates of A baumannii complex from bacteremic patients between 1997 and 2007 were collected at Taipei Veterans General Hospital and were identified to the species level using a multiplex polymerase chain reaction method and sequence analysis of 16S–23S intergenic spacer. The minimal inhibitory concentrations of antibiotics were determined by the agar dilution method. Results The nonsusceptibility rates of carbepenems and sulbactam were highest in A baumannii , which also showed a trend toward increasing rate of carbapenems nonsusceptibility over the 11-year period of the study. AGS 13TU had the highest nonsusceptible rate to colistin, comparably increasing trend of carbapenem nonsusceptiblity as that of A baumannii , and is the only species with increasing sulbactam nonsusceptibility. AGS 3 had the lowest rate of nonsusceptibility to all four antimicrobial agents. Conclusion Although A baumannii had the highest nonsusceptibility rate to imipenem, meropenem, and sulbactam over the years, the higher rate of colistin nonsusceptibility and the emergence of nonsusceptibility of carbapenems and sulbactam in AGS 13TU suggested that this species might cause a great problem in the near future.

Background Tigecycline was approved for the treatment of complicated intra-abdominal and complicated skin/skin structure infections. Because of its in vitro effectiveness for multidrug-resistant (MDR) isolates, tigecycline has been prescribed more broadly. This study evaluated tigecycline use after its first introduction in Taiwan and experience with tigecycline for the treatment of MDR Acinetobacter baumannii (MDRAB) infection, especially for ventilator-associated pneumonia. Methods Patients treated with tigecycline were collected retrospectively from February 2008 to July 2008 in Taipei Veterans General Hospital, a 2,900-bed tertiary care medical center in Taiwan. Patients were divided into three groups according to the indications: Group 1, Food and Drug Administration–approved indications; Group 2, health care–associated pneumonia (HAP); and Group 3, urinary tract infection, osteomyelitis, bacteremia, etc. Cases of MDRAB were also identified. Results Among 66 cases, indications for the administration of tigecycline included Food and Drug Administration–approved indications (12, 18.2%), HAP (38, 57.6%), bacteremia (3, 4.5%), catheter-related infections (3, 4.5%), urinary tract infection (4, 6.1%), osteomyelitis (4, 6.1%), and others (2, 3%). Clinical outcome was positive in 20 cases, with higher clinical success rate for Group 1 than Group 2, which may correlate with higher Sequential Organ Failure Assessment score, older age, and more frequent intensive care admission in Group 2. Of the microbiologically evaluable cases, MDRAB predominated (33/51, 64.7%). Among infections with MDRAB (excluding pneumonia without ventilator), the clinical success rate was 12% (3/25). Conclusions The most common indication for the prescription of tigecycline was HAP. Success rate for MDRAB infection was lower than that previously reported, possibly because of serious underlying conditions and comorbidities in our patients. Because of limited choices, physicians should weigh the risk and benefit for prescribing tigecycline.

Metastasis of mammary cancer involving the orbit is common, and it typically presents with enophthalmos and restrictions of ocular motility. We report a case of mammary cancer with the unusual presentation of unilateral periorbital edema only. The possible mechanisms of unilateral periorbital swelling are discussed.Metastasis of breast cancer involving unilateral eyelid edema was diagnosed in a 66-year-old woman. A biopsy was performed to confirm the etiology after vague neuroimaging findings. The diagnosis was based on the histopathologic features of carcinomatous cells in the excised specimen.Insidious, progressive unilateral upper and lower eyelid swelling of the right eye disappeared after one cycle of palliative chemotherapy. Neither restriction nor proptosis developed in the whole course.Possible metastasis should be considered as a possible etiology of unilateral eyelid edema, even without a palpable mass or limitation of ocular motility. A biopsy should be performed in cases of unexplained eyelid edema.

Tuberculosis incidence among aborigines is significantly higher than for Han Chinese in Taiwan, but the extent to which Mycobacterium tuberculosis (MTB) strain characteristics contribute to this difference is not well understood. MTB isolates from aborigines and Han Chinese living in eastern and southern Taiwan, the major regions of aborigines, were analyzed by spoligotyping and 24-loci MIRU-VNTR. In eastern Taiwan, 60% of aboriginal patients were ≤20 years old, significantly younger than the non-aboriginal patients there; aborigines were more likely to have clustered MTB isolates than Han Chinese (odds ratio (OR) = 5.98, p

Background: Enterobacteriaceae, common pathogens responsible for urinary tract infections are known to be susceptible to aminoglycosides. The emergence of resistant pathogens complicates antimicrobial regimen and becomes a challenge for clinicians. The aim of this study was to evaluate the susceptibility of clinically isolated Enterobacteriaceae to isepamicin and amikacin using disc diffusion method. Materials and Methods: A total of 234 Enterobacteriaceae isolates was collected and examined. Antimicrobial susceptibilities to gentamicin, amikacin, and isepamicin were assessed using disc diffusion method. The production of extended-spectrum β-lactamase (ESBL) or AmpC β-lactamase was also tested. The susceptibilities of the pathogens to isepamicin and amikacin were evaluated. Results: Two hundred and thirty-four Enterobacteriaceae isolates were found to be more susceptible to amikacin and isepamicin than to gentamicin. Of the isolates, 39 (16.7%) produced ESBL and 41 (17.5%) harbored AmpC β-lactamase. The results revealed that amikacin and isepamicin exerted excellent antibacterial activity (94% vs. 93.6%) against all tested isolates. Isepamicin was effective against 89.7% ESBL-producing isolates and 92.7% of AmpC-producing isolates. The susceptibility to amikacin and isepamicin established by the disc diffusion method was mostly consistent with the overall agreement estimated 99.6%. Conclusions: Isepamicin showed excellent activities against infections caused by Enterobacteriaceae, including strains harboring ESBL or AmpC beta-lactamase. The susceptibility of tested isolated to isepamicin measured by disc diffusion method is comparable to that of amikacin.