Journal of Microbiology, Immunology and Infection

Role of moxifloxacin for the treatment of commmunity-acquired complicated intra-abdominal infections in Taiwan

2012-01-13

Complicated intra-abdominal infections (cIAIs) are common yet serious infections that can potentially lead to substantial morbidity and morbidity. As an essential adjunct to source control, the goals of antimicrobial therapy are to promote patient recovery, reduce recurrence risk, and prevent antimicrobial resistance. The current international guidelines on the empirical treatment of community-acquired complicated IAIs were published by the Infectious Diseases Society of America (IDSA) and Surgical Infections Society (SIS) in 2010. These guidelines all recommend the use of a fluoroquinolone (ciprofloxacin or levofloxacin) plus metronidazole for mild-to-moderate- and high-severity cases. Moxifloxacin monotherapy is recommended by the current IDSA/SIS guidelines for the treatment of mild-to-moderate complicated IAIs. Moxifloxacin has demonstrated a broad spectrum coverage of both aerobic and anaerobic pathogens, good tissue penetration into the gastrointestinal tract, and a good tolerability profile. Clinical data have demonstrated that moxifloxacin is at least as effective as other standard therapeutic regimens recommended by current clinical guidelines. Due to the high rates of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and fluoroquinolone-resistant Enterobacteriaceae among isolates causing community-acquired IAIs in Asia, any fluoroquinolones (including moxifloxacin) are not recommended as drugs of choice for the empirical treatment of community-acquired IAIs, particularly in countries (China, India, Thailand, and Vietnam) with fluoroquinolone resistance rates among Escherichia coli isolates of >20%. Given the low rates of fluoroquinolone-resistant (<20%) and extended-spectrum β-lactamase (ESBL)-producing (<10%) Enterobacteriaceae isolates associated community-acquired IAIs in Taiwan, it appears that moxifloxacin is considered an appropriate first-line therapy for patients with community-acquired complicated IAIs in this country.

Protein enrichment, cellulase production and in vitro digestion improvement of pangolagrass with solid state fermentation

Chan-Chin Hu, Li-Yun Liu, Shang-Shyng Yang — 2011-12-12

Background and Purpose: Pangolagrass, Digitaria decumbens Stent, is a major grass for cow feeding, and may be a good substrate for protein enrichment. To improve the quality of pangolagrass for animal feeding, cellulolytic microbes were isolated from various sources and cultivated with solid state fermentation to enhance the protein content, cellulase production and in vitro digestion. The microbes, culture conditions and culture media were studied.Methods: Cellulolytic microbes were isolated from pangolagrass and its extracts, and composts. Pangolagrass supplemented with nitrogen and minerals was used to cultivate the cellulolytic microbes with solid state fermentation. The optimal conditions for protein enrichment and cellulase activity were pangolagrass substrate at initial moisture 65–70%, initial pH 6.0–8.0, supplementation with 2.5% (NH4)2SO4, 2.5% KH2PO4 and K2HPO4 mixture (2:1, w/w) and 0.3% MgSO4.7H2O and cultivated at 30oC for 6 days.Results: The protein content of fermented pangolagrass increased from 5.97–6.28% to 7.09–16.96% and the in vitro digestion improved from 4.11–4.38% to 6.08–19.89% with the inoculation of cellulolytic microbes by solid state fermentation. Each 1 g of dried substrate yielded Avicelase 0.93–3.76 U, carboxymethylcellulase 1.39–4.98 U and β-glucosidase 1.20–6.01 U. The isolate Myceliophthora lutea CL3 was the strain found to be the best at improving the quality of pangolagrass for animal feeding with solid state fermentation.Conclusion: Solid state fermentation of pangolagrass inoculated with appropriate microbes is a feasible process to enrich protein content, increase in vitro digestibility and improve the quality for animal feeding.

Clinical manifestations of a cluster of rotavirus infection in young infants hospitalized in neonatal care units

2011-12-12

Purpose: To define the clinical manifestations of rotavirus (RV) infection in neonates and young infants hospitalized in neonatal care units, which are rarely reported.Materials and Methods: From October 2008 to September 2010, a total of 153 stool specimens positive for RV were detected from 100 neonates and young infants hospitalized in neonatal care units of our hospital. Four infants had two episodes of RV infection. Demographics and clinical presentations of these infants were collected and analyzed. The infants were further classified as having hospital-acquired (HA) or community-acquired (CA) RV infection.Results: Of the 104 episodes from 100 patients, 76 (73%) were classified as HA. Fifty-six infants were male. The mean age of onset was 2 days. The most common presentations were loose stool passages (52.9%), abdominal distension (51.9%), blood or mucus in stool (42.3%), and unstable vital signs (32.7%). Watery character in stool passage was identified in 13.5% of the infants and vomiting in 21.2%. A picture suggestive of necrotizing enterocolitis (NEC) was identified in 22 episodes (21.1%), and 12 of these were stage II or above. The average number of hospitalization days from the onset of HA-RV infection was 23 days. Compared with those in the CA group, the infants in the HA group had a significantly higher rate of blood or mucus in stools (52.6% vs. 14.3%, p < 0.01) and unstable vital signs (39.5% vs. 14.3%, p = 0.02), but a lower rate of watery diarrhea (9.2% vs. 28.6%, p = 0.04) and fever (13.8% vs. 42.9%, p < 0.01). Overall, there were five deaths, but all of these infants had major diseases.Conclusion: Bloody, mucoid stools and unstable vital signs, instead of fever with watery diarrhea, are commonly seen in neonates and young infants with RV infection. A substantial proportion of these infants may present as NEC. Once introduced, RV appears to become a troublesome problem of HA infections in neonatal care settings.

Kawasaki disease and Henoch–Schönlein purpura – 10 years’ experience of childhood vasculitis at a university hospital in Taiwan

2011-12-19

Background/Purpose: To investigate the clinical manifestations, disease activity and prognosis in different types of vasculitis.Methods: The charts of pediatric patients with vasculitis diagnosed from December 1997 to December 2007 were retrospectively reviewed. The first clinical manifestations and laboratory results were recorded at the time of diagnosis, and outcome evaluations with history of flare-ups were analyzed.Results: A total of 508 vasculitis patients were included in this study, of whom 124 had Henoch–Schönlein purpura (HSP), and 351 had Kawasaki disease (KD). Hematuria was observed in 79% of recurrent HSP patients at the time of diagnosis, and was associated with an increased risk of relapse (p = 0.000). In Kawasaki disease, the clinical symptoms with erythematous changes in Bacille Calmette-Guérin scars and coronary artery dilatation were more prominent in patients younger than 1 year old, and lymphadenopathy was more common in patients older than 1 year old (p = 0.001). The risk of coronary dilatation was significant in the patients with an initial presentation of thrombocytosis, and greater in patients younger than 1 year old (p = 0.027). Thrombocytopenia was more prominent in vasculitis-associated autoimmune diseases. Marked lymphocytosis with increased C-reactive protein levels was significantly noted in urticarial vasculitis patients compared with HSP patients in multivariate logistic regression analysis.Conclusion: Vasculitis disease activity and prognosis were associated with initial laboratory results and clinical manifestations. Further large-scale clinical trials are warranted to validate these findings.

Clinical and bacteriological characteristics of Klebsiella pneumoniae causing liver abscess with less frequently observed multi-locus sequences type, ST163, from Singapore and Missouri, US

Getahun Abate, Tse-Hsien Koh, Morey Gardner, L. Kristopher Siu — 2011-12-05

Background: Klebsiella pneumoniae is the major cause of liver abscesses in several Asian countries. Differences in the type of circulating Klebsiella strains and/or the genetic make up of the host seem to be plausible explanations for this.Methods: Two recent K. pneumoniae strains isolated from patients with liver abscess, one from Missouri in the US, and a second one from Singapore, were fully characterized by molecular typing, association of virulent genes, neutrophil phagocytosis, susceptibility to serum killing, and lethality in mice.Results: Both strains had mucoid colony morphology and were similar in multilocus sequence type (ST-163), drug-susceptibility profile, resistance to phagocytosis and susceptibility to serum killing. Although ST-163 is a single nucleotide variant (SNV) to the major ST-23, which is specific to serotype K1 K. pneumoniae that causes liver abscess in Taiwan, these two isolates differ in capsular serotype. One was serotype K1 and the other K29. Since a serotype K35 with ST163 was reported previously to cause peritonitis, serotype K29 with SNV to ST-23 was not impossible. Pulsed field gel electrophoresis by XbaI digestion showed different restriction patterns. The virulence-associated genes rmpA and aerobactin were only present in the serotype K1 isolate from Singapore and not in the serotype K29 isolate from Missouri. The serotype K1 isolate was also more virulent to mice.Conclusion: The reasons underlying the high prevalence of ST-23 or its SNV in K. pueumonaie liver abscesses is worth further investigation.

Clonal spread of multidrug-resistant Acinetobacter baumannii in eastern Taiwan

2011-12-12

Background and Purpose: This study was conducted to investigate the molecular epidemiology and antimicrobial susceptibility of multidrug-resistant (MDR) Acinetobacter baumannii to three types of antibiotics.Methods: One hundred and thirty-four specimens of MDR A baumannii were collected from three branches (Taipei, Dalin, and Hualien branches) of Buddhist Tzu Chi Hospital, which are located in northern, southern, and eastern Taiwan, during 2007. Genotyping was performed by pulsed-field gel electrophoresis. Antibiotic susceptibilities to colistin, rifampicin, and tigecycline were determined. The synergistic effects of rifampin and colistin were also evaluated.Results: Antibiotic susceptibility testing showed that 10.4%, 47.8% and 45.5% of the MDR A baumannii isolates are resistant to colistin, rifampicin, and tigecycline, respectively. A majority of the rifampicin-resistant isolates (62.7%) were found in the Haulien branch, whereas 62.2% of tigecycline-resistant isolates were found in the Taipei branch. The combination of colistin and rifampicin had a synergistic effect on all of the isolates. Genotyping by pulsed-field gel electrophoresis identified 17, 23, and 11 pulsotypes in the Taipei, Dalin, and Haulien branches, respectively. Furthermore, 74.5% of isolates in the Haulien branch were identified as one of three pulsotypes. Among 37 rifampicin-resistant and 22 tigecycline-resistant MDR A baumannii isolates found in the Haulien branch, 51.3% (19/37) and 50% (11/22) of the isolates belonged to the same clone, respectively.Conclusion: This study confirms the high prevalence of resistance to rifampicin and tigecycline in MDR A baumannii in the three hospitals that were studied, and the high proportion of identical strains that exist in eastern Taiwan.

Outbreak of imipenem-resistant Acinetobacter calcoaceticus–Acinetobacter baumannii complex harboring different carbapenemase gene-associated genetic structures in an intensive care unit

2011-12-15

Background and Purpose: To investigate the clinical and molecular epidemiology of the imipenem-resistant Acinetobacter calcoaceticus–Acinetobacter baumannii (IRAcb) complex during an outbreak in an intensive care unit (ICU).Methods: Forty-six clinical and 11 environmental isolates of the IRAcb complex were collected from the ICU of Taipei Veterans General Hospital, Taiwan between December 2003 and March 2004. These isolates were genotyped using pulsed-field gel electrophoresis (PFGE). Carbapenemase genes and their associated genetic structures were analyzed using PCR. Clinical data obtained from the patients were also reviewed and analyzed.Results: The isolates were identified at the genomic species level as A. baumannii (42 clinical and five environmental isolates) and Acinetobacter genomic species 13TU (four clinical and six environmental isolates). Both species were comprised of two pulsotypes, but those of A. baumannii were closely related (83% similar). IS1008-ΔISAba3-blaOXA-58-like and ISAba1-blaOXA-51-like were identified in 22 and 21 clinical isolates of A. baumannii, respectively (one isolate contained both). The ISAba3-bracketed blaOXA-58-like gene was detected in all isolates of Acinetobacter genomic species 13TU. Patient transfers between different sections of the ICU were important factors that contributed to the spread of the two pulsotypes of A. baumannii. However, among the A. baumannii isolates identified, only those carrying IS1008-ΔISAba3-blaOXA-58-like could be found in the environment, indicating an additional route of transmission. The prior use of carbapenem or cefepime was associated with the subsequent infection with A. baumannii carrying the ISAba1-blaOXA-51-like gene, while prior piperacillin/tazobactam use was associated with the subsequent infection with A. baumannii carrying the IS1008-ΔISAba3-blaOXA-58-like gene.Conclusion: A. baumannii isolates carrying different carbapenemase genes and their associated genetic structures might be transmitted or selected in different ways.

Safety and efficacy of daptomycin for the treatment of hospitalized adult patients in Taiwan with severe staphylococcal infections

2011-12-08

Background and Purpose: The safety and efficacy of treating serious infections caused by Staphylococcus aureus with daptomycin in a Taiwanese population were studied.Methods: A retrospective, multicenter study was performed in Taiwan between December 2007 and June 2009. This study included adult hospitalized patients who had received intravenous daptomycin therapy for infections caused by S aureus. All patients were followed until discharge from the hospital or death.Results: A total of 52 patients (males, n=44; median age: 62 years) were evaluated. Infections included complicated skin and soft-tissue infections (n=14), catheter-related bacteremia (n=14), osteomyelitis and septic arthritis (n=12), endovascular infections and endocarditis (n=11), and urinary tract infections (n=1). Overall, 47 (90.4%) patients were successfully treated and their clinical symptoms were resolved. Adverse effects related to daptomycin were detected in nine patients, but none were required to discontinue daptomycin.Conclusion: The results support daptomycin as an effective and safe treatment for staphylococcal infections in Taiwanese populations.

Clinical characteristics and treatment outcomes of patients with tubo-ovarian abscess at a tertiary care hospital in Northern Taiwan

2011-12-12

Background/Purpose: Controversy exists regarding the need for surgical intervention in patients with tubo-ovarian abscess (TOA). This study was aimed at investigating the clinical characteristics and treatment outcomes in patients with TOA at a tertiary care hospital in Taiwan.Methods: The medical records of 83 patients who presented at the hospital with TOA between January 1, 2006, and December 31, 2007, were retrospectively reviewed. Outcomes of patients who received medical treatment alone or underwent surgical intervention were analyzed using univariate and logistic regression analyses.Results: Among the 83 patients with TOA, 13 patients (15.7%) underwent surgical intervention, and 70 patients (84.3%) received medical treatment alone. Significant variables related to surgical treatment in the univariate analysis were length of stay (short vs. long; t = −2.267, p = 0.026), department of admission (emergency room vs. outpatient department; χ2 = 7.459, p = 0.006), number of live births (nulliparous vs. multiparous; χ2 = 18.202, p = 0.001), and C-reactive protein (CRP) level (high vs. low; t = −2.250, p = 0.028). Logistic regression analysis performed to determine influential factors for surgical treatment showed that the operation odds ratio of three to four live births versus no live births was 33.995 (p = 0.043) and that of two live births versus no live births was 13.598 (p = 0.026).Conclusion: Patients with TOA who underwent surgery had a longer duration of hospitalization. Among the patients who underwent surgical intervention, those admitted to the emergency room had higher CRP levels and were more likely to be multiparous.

Serum levels of dehydroepiandrosterone sulfate (DHEAS) in ocular toxoplasmosis

2011-12-08

There are no previous study about ocular toxoplasmosis and serum levels of dehydroepiandrosterone sulphated hormone (DHEAS). We use the chemoluminiscence automatized Immulite assay to determine the levels of DHEAS. Four groups were studied: (1) Individuals with chronic asymptomatic infection with a positive test for IgG anti-Toxoplasma and without ocular lesions (n = 16); (2) Chronic asymptomatic patients with retinal scars of retinochoroiditis by Toxoplasma (n = 19); (3) Acute symptomatic patients with active retinochoroiditis by Toxoplasma (n = 26); (4) Individuals with negative assays for IgG anti-Toxoplasma (n = 21). Comparison of DHEAS levels between groups were adjusted by age and sex and non-parametric Kruskall Wallis statistical tests were applied. No significant differences in serum levels of DHEAS were found between groups when age and sex were controlled. DHEAS levels were not significantly different in active ocular toxoplasmosis related to non active or non infected persons.

Higher levels of soluble Fas ligand and transforming growth factor-β after omalizumab treatment: A case report

2012-01-16

A skewed T-helper (Th)1/Th2 immune response is considered to be the major cause of allergic disorders. Overproduction of Th2 cytokines, which promote recruitment and activation of mast cells and eosinophils, plays a key part in the pathogenesis of allergic asthma. The mechanisms by which omalizumab is effective in asthma treatment are not yet fully understood. A 16-year-old girl who was experiencing frequent asthma attacks in spite of daily administration of budesonide (640μg) and montelukast (10mg) was given omalizumab (375mg) at intervals of 2 weeks, to prevent a visit to the emergency room. Plasma levels of Th1 cytokines [interferon (IFN)-γ and interleukin (IL)-12p70], Th2 cytokines (IL-4 and IL-13), other proinflammatory and regulatory cytokines [IL-6, IL-10, IL-17, tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β], chemokines [monocyte chemotactic protein (MCP)-1, chemokine ligand (CCL)7, and CCL17], and soluble Fas ligand (sFasL) were measured before treatment and after treatment for 8 weeks. She showed a good clinical response to omalizumab: her lung function parameters improved and the use of β2-agonist decreased. No emergency room visits were required after omalizumab treatment for 8 weeks. Plasma levels of sFasL and TGF-β showed obvious increases after omalizumab therapy. IL-12p70 levels were decreased as compared to the corresponding baseline levels. These findings suggest that the effects of omalizumab in asthma treatment are not restricted to the regulation of the skewed Th1/Th2 cytokine immune response, and sFasL-mediated apoptosis and regulatory T-cell (Treg)-mediated TGF-β seem to have important roles in the therapeutic effects of omalizumab.

Lemierre syndrome complicating multiple brain abscesses caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae cured by fosfomycin and meropenem combination therapy

Wen-Sen Lee, Fu-Der Wang, Ying-Hua Shieh, Sing-On Teng, Tsong-Yih Ou — 2011-12-12

A woman aged 56 years of age had a community-acquired left neck abscess and internal jugular vein thrombosis with septicemia due to extended-spectrum β-lactamase (ESBL)–producing Klebsiella pneumoniae. Even though she was treated with intravenous meropenem, the bacteremia persisted. She was complicated with multiple brain abscesses, seizure, and leucopenia. After a combination of intravenous fosfomycin and meropenem, her clinical condition became stable. Combination treatment was continued for 2 months and she recovered. In individual cases of Lemierre syndrome with brain abscess caused by ESBL-producing Enterobacteriaceae, fosfomycin combination therapy may be the alternative choice.

Leptospirosis with transient paraparesis and thrombocytopenia: A case report

2011-12-08

Leptospirosis is the most widespread zoonosis in the world. We present an unusual case of leptospirosis in a 44-year-old man with severe thrombocytopenia and transient paraparesis. The diagnosis of leptospirosis was confirmed by blood nested polymerase chain reaction, seroconversion of Leptospira IgM and the microscopic agglutination test. Nerve conduction studies were suggestive of early polyneuropathy involving the right peroneal nerve and bilateral sural nerves. Peripheral nerve palsy is a potential clinical feature of leptospirosis.