Journal of Microbiology, Immunology and Infection - Articles in Press

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

2012-05-21

Background and Purpose: Cryptococcus species are the most common causative agents of fungal meningitis. Different populations may show different clinical manifestations and outcomes. In this retrospective study, we investigated these differences in patients with and without HIV infection.Methods: From 1995 to 2009, we collected data from HIV-infected or HIV-uninfected patients aged 18 years or over who had cryptococcal meningitis (CM) in a medical center in Taiwan. We reviewed and analyzed their demographic data, clinical manifestations, therapeutic strategies and outcomes.Results: Among the 72 patients with CM, 19 HIV-infected patients were predominantly younger males, and all of them had AIDS status when CM was diagnosed. In contrast, the 53 HIV-uninfected patients were mostly older males with underlying diseases. The time from initial symptoms to diagnosis was shorter in HIV-infected patients (median 10 vs. 18 days, p = 0.048). The HIV-infected patients presented with less pleocytosis (p = 0.003) and lower protein levels in the cerebrospinal fluid (CSF), but a higher proportion had positive results for cryptococci in the CSF (90% vs. 60%, p = 0.02) and blood (53% vs. 21%, p = 0.009) cultures. Surgical drains and repeated lumbar punctures for the management of increased intracranial pressure were performed in 47% of the HIV-infected patients and 38% of the HIV-uninfected patients. A lower mortality rate was observed in the HIV-infected patients (p = 0.038). On multivariate analysis, initial CD4 count ≤20/mm3 was an indicator of death or relapse in HIV-infected patients. In the HIV-uninfected group, the initial high cryptococcal antigen titer in the CSF (≥1:512) and hydrocephalus were related to unsatisfactory outcomes.Conclusion: In addition to well-known differences, we found a lower mortality in HIV-infected patients than in HIV-uninfected patients. Cryptococci and inflammation in the central nervous system may play important roles in the pathogenesis of CM. Low intensity of inflammation and effective surgical CSF drains for increased intracranial pressure and cryptococci removal may contribute to lower mortality in HIV-infected patients.

Changing trends in antimicrobial susceptibility of Streptococcus pneumoniae isolates in Taiwan, 2006–2007 - Corrected Proof

2012-05-21

Background: Multiple antibiotic-resistant clones of Streptococcus pneumoniae have spread throughout the world and continue to evolve under the selective pressure of antibiotics and vaccines. The aim of this study is to assess the susceptibility of S. pneumoniae isolates and to analyze the resistance trends in Taiwan.Methods: Antimicrobial susceptibility tests were performed on 152 nonmeningeal isolates of S. pneumoniae that were collected from 13 different hospitals around Taiwan from 2006–2007. Tests were performed using the broth microdilution method according to recommendations of the Clinical and Laboratory Standards Institute.Results: The minimal inhibitory concentrations (MIC50/MIC90) of penicillin, cefotaxime, vancomycin, and moxifloxacin were 0.5/1.0, 0.25/1.0, 0.25/0.5, and 0.06/0.12 μg/mL, respectively. The susceptibility rates of penicillin, cefotaxime, vancomycin, and moxifloxacin were 99.3%, 99.3%, 100%, and 98.7%, respectively. However, if the meningitis breakpoints were applied to these nonmeningeal isolates, the susceptibility rates of penicillin and cefotaxime were reduced to 18.4% and 76.3%, respectively. Compared with the findings from previous studies in Taiwan, our results show that the percentage of S. pneumoniae isolates with a penicillin MIC of 0.12–1.0 μg/mL increased from 43.3% in 1996–1997 to 73.7% in 2006–2007 (p < 0.001). The percentage of S. pneumoniae isolates with a cefotaxime MIC of 1.0 μg/mL increased from 11.3% in 1996–1997 to 23.0% in 2006–2007 (p < 0.001). Regarding the serial MIC intervals of the four antimicrobial agents, there was no significant difference between bacteremic and nonbacteremic isolates.Conclusion: Although nonmeningeal S. pneumoniae isolates remained susceptible to penicillin, the proportion of isolates with a penicillin MIC of 0.12–1.0 μg/mL or cefotaxime MIC of 1.0 μg/mL increased during the past decade in Taiwan. The ever-increasing resistance of S. pneumoniae has a great impact on the treatment of meningitis.

Invasive Brevundimonas vesicularis bacteremia: Two case reports and reviews of literatures - Corrected Proof

2012-05-21

There are few reports of invasive infections caused by Brevundimonas vesicularis. We report two cases of B vesicularis bacteremia confirmed by culture and 16S rRNA sequence analysis with highly variable sensitivity to broad-spectrum antibiotics. Initial empiric therapy with anti-pseudomonal antibiotics plus trimethoprim-sulfamethoxazole for hospital-acquired B vesicularis infections should be considered.

Systemic lupus erythematosus with initial presentation of empyematous pleural effusion in an elderly male patient: A diagnostic challenge - Corrected Proof

Wei-Ting Chang, Tung-Han Hsieh, Ming-Fei Liu — 2012-05-21

Systemic lupus erythematosus (SLE) poses great difficulty in making an early diagnosis in elderly males, often presenting with atypical manifestations. Acute onset of empyematous pleural effusion has rarely been seen. Herein, we report a 66-year-old man with SLE presenting with rapid progression of bilateral pleural effusion. Diagnostic thoracocentesis disclosed neutrophil-predominant exudates and chest computed tomography revealed multiple loculated pleural effusions. Nevertheless, optimal antibiotic therapy plus surgical decortication of the pleura did not improve his condition. The diagnosis of SLE was readily established after LE cells were accidentally found in the pleural effusion. Large amounts of pleural effusion subsided soon after high dose corticosteroid therapy.

Laboratory identification, risk factors, and clinical outcomes of patients with bacteremia due to Escherichia coli and Klebsiella pneumoniae Producing Extended-Spectrum and AmpC type β-Lactamases - Corrected Proof

2012-05-14

Background: Extended-spectrum β-lactamase (ESBL)-producing bacteria coexpressing AmpC type β-lactamase (ACBL) are associated with the laboratory issue of false susceptibility to third-generation cephalosporins. This study was to evaluate laboratory tests and clinical significance of bacteremic isolates of Escherichia coli and Klebsiella pneumoniae with both ESBL and ACBL [dual-type lactamases (DTL)].Methods: From 2006 to 2009, 78 E coli and 12 pneumoniae bacteremic isolates with reduced susceptibility to cefotaxime (CTX) or ceftazidime (CAZ) were identified and relevant patients’ data were collected for analysis. Phenotypic and genotypic characterizations of these selected isolates were determined by inhibitor-based assays and polymerase chain reaction–based genetic analyses, respectively.Results: Among the 90 isolates, 47 had DTL production. There was an increasing annual prevalence from 29% in 2006 to 56% in 2009 (p=0.02). Phenotypic assays had a sensitivity and specificity of 57% (43/76) and 93% (13/14) for ESBL detection and 95% (58/61) and 34% (10/29) for ACBL, respectively. Among the DTL-producing isolates, phenotypic assays yielded a higher false negative rate of ESBL detection than that of ACBL detection (70% versus 6%), while all false negative ESBL results were associated with ESBL genes other than blaCTx-M. The majority of the DTL-producing isolates were in the category of resistance to CTX (47/47, 100%) and CAZ (44/47, 94%) by the Clinical and Laboratory Standards Institute (CLSI) 2010 interpretive criteria, of which many were considered intermediate or fully susceptible to CTX (25/47, 53%) and CAZ (15/47, 32%) by the previous ones (CLSI-2009). The DTL-producing isolates exhibited a lower susceptibility rate to fluoroquinolones, aztreonam, and β-lactam/lactamase inhibitors than those with either ESBL or ACBL alone. The use of indwelling catheters or nasogastric tubes was associated with bacteremia due to the DTL isolates, but the mortality rates were not different among those due to isolates with ESBL, ACBL, or both. By multivariate analysis, Pittsburg bacteremia score and Charlson comorbidity index were the significant predictors for all-cause mortalities.Conclusion: Bacteremic episodes due to DTL-producing E coli and K pneumoniae became increasingly prevalent and were often associated with coresistance to antibiotics other than β-lactams, but they were not associated with a worse prognosis than those due to ESBL- or ACBL-producing bacteria.

Prevalence of attention-deficit/hyperactivity disorder in patients with pediatric allergic disorders: A nationwide, population-based study - Corrected Proof

Ching-Shan Shyu, Heng-Kuei Lin, Ching-Heng Lin, Lin-Shien Fu — 2012-05-14

Background: Allergic disorders are common, chronic conditions in pediatric populations. The characteristic symptoms of allergic disorders mainly include bronchial asthma (BA), allergic rhinitis (AR), and atopic dermatitis (AD), all of which may disturb sleep, leading to daytime inattention, irritability, and hyperactivity, which are also components of attention-deficit/hyperactivity disorder (ADHD). Conflicting data exist in the literature regarding the relationship between ADHD and allergic disorders. The aim of this nationwide, population-based study is to examine the prevalence and risk of developing ADHD among allergic patients in a pediatric group.Methods: Data from a total of 226,550 pediatric patients under 18 years of age were collected from Taiwan’s National Health Insurance Research Database recorded from January 1 to December 31, 2005 and analyzed. We calculated the prevalence of allergic diseases based on various demographic variables, including ADHD. We also used multivariable logistic regression to analyze the risk factors of ADHD.Results: In 2005, the period prevalence rates of allergic disorders and ADHD in persons under the age of 18 were 21.5% and 0.6%, respectively. Pediatric patients with allergic disorder(s) had a substantially increased rate of developing ADHD (p < 0.001) in terms of period prevalence and odds ratio (OR). This significance existed across various demographic groups regardless of age, gender, location, or degree of urbanization of their residence. BA and AR, but not AD, were determined to be risk factors for ADHD. Co-morbidities of allergic disorders, including AR+AD, AR+BA and AR+BA+AD, but not BA+AD, were also determined to increase the risk of ADHD.Conclusion: Allergic disorders appear to increase the risk of ADHD in pediatric patients. Our detailed analysis shows that the main contributing factor is AR. Co-morbidity with AD, BA, and BA+AD in AR patients further increases the risk of ADHD.

Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan - Corrected Proof

2012-05-14

Background: A high catheter-related bloodstream infection (CRBSI) rate, in comparison with that in the National Healthcare Safety Network report, is an important concern in our hospital. Therefore, evidence-based interventions have been introduced to reduce the rate of CRBSI.Methods: A surveillance study conducted from March 2008 to May 2010 to observe the reduction of infection rate after interventions in two intensive care units (ICUs). The major intervention, introduced in November 2009, was the standardization of the process of central venous catheter (CVC) implantation, including hand hygiene and maximal sterile barrier precautions.Results: The utilization ratios of CVC changed little during the study. The median CRBSI infection rates decreased from 1.95 (mean 1.58) infections per 1000 catheter-days at baseline to 0 (mean 1.06) after interventions (p = 0.310 by the Wilcoxon signed ranks test). The rate of CRBSI in one ICU showed 0 infections per 1000 catheter-days, which was sustained for 6 months after interventions.Conclusion: The reduction of infection rates could be possible by standardizing the CVC implantation procedure. However, more interventions, such as cleaning the skin with chlorhexidine, avoiding the femoral site when possible, and removing unnecessary catheters, should also be considered to reduce the rate of CRBSI.

Mycobacterium tuberculosis and M bovis infection in Feedlot Deer (Cervus unicolor swinhoei and C nippon taiouanus) in Taiwan - Corrected Proof

Chi-Shih Chu, Chang-You Yu, Chien-Tung Chen, Yao-Chi Su — 2012-05-14

Background/purpose: Mycobacterium bovis frequently infects wild and farm deer species with tuberculosis. This study investigated mycobacterial infection in two native deer species Cervus unicolor swinhoei (Formosan Sambar, Sambar) and C nippon taiouanu (Formasan Sika, Sika).Methods: Based on different sampling sources of 19 intradermal tuberculin test (ITT) Sambar, mycobacterial infection and/or species were detected by acid-fast stain, duplex polymerase chain reaction (PCR) and multiplex nested PCR (mnPCR) methods, traditional mycobacterial culture and gross lesion. Blood samples of 167 Sambar deer and 147 Sika deer were then tested by duplex PCR and mnPCR methods to investigate the prevalence of mycobacterial infection. Sequence variations of these mycobacterial species were analyzed as well.Results: Duplex PCR and mnPCR assays could differentiate between MTBC (M bovis and M tuberculosis) and M avium, as well as between M bovis and M tuberculosis, respectively. These PCR methods showed a higher detection rate than traditional culture and matched the gross lesions examined in 19 ITT-examined Sambar. Therefore, the mycobacterial infection in blood samples of 314 deer samples was detected using these PCR methods. Duplex PCR and mnPCR showed an identical prevalence of 16.1% in Sambar and 8.2% in Sika and a significant difference in prevalence between these two deer species. M bovis and M tuberculosis were the species detected in feedlot Sambar and Sika. M tuberculosis was found only and first in Sambar fed in central Taiwan. Sequence analysis revealed diverse genetic variations in M bovis and M tuberculosis associated with deer subspecies.Conclusion: Multiplex PCR methods were established, and the M bovis and M tuberculosis were identified in feedlot deer in Taiwan. Sequence variations indicated diverse sources of both mycobacterial species.

Is there any difference in pyogenic liver abscess caused by Streptococcus milleri and Klebsiella spp?: Retrospective analysis over a 10-year period in a regional hospital - Corrected Proof

Siu-Tong Law, Michael Kin Kong Li — 2012-05-14

Background/Purpose: To compare the clinical characteristics of patients with Streptococcus milleri (SM) and Klebsiella spp. associated pyogenic liver abscess (PLA).Methods: A retrospective study of patients with PLA due to SM and Klebsiella spp. was conducted. Clinical characteristics, laboratory and radiological features, management and outcomes were analyzed.Results: From 2000 to 2009 inclusive, 21 and 140 patients had SM and Klebsiella spp. associated monomicrobial infected PLA, respectively. A higher incidence of active malignancy occurred in the SM group (14.3% vs. 3.6%, p < 0.03). The common clinical features of the patients were fever, chill and right upper quadrant pain. A longer duration (6.3 vs. 4.4 day, p = 0.04) of symptoms and a higher incidence of hepatomegaly (14.3% vs. 2.9%, p < 0.01) occurred in the SM group. Common laboratory and imaging abnormalities included: anemia, leukocytosis, high erythrocyte sedimentation rate and C-reactive protein, hypoalbuminemia, elevated total bilirubin and alanine aminotransferase, right hepatic lobe involvement, hypoechoic in ultrasonograpghy, rim enhancement and septal lobulation in computed tomography. The biliary tract disorder was the most common cause of the disease in the two groups. Patients with Klebsiella spp. associated PLA tended to have more complications: bacteremia (61.6% vs. 31.6%, p < 0.01) septic shock (33.6% vs. 19%, p = 0.11), disseminated intravascular coagulation (20.7% vs. 4.8%, p = 0.04), metastatic infections (10.7% vs. 0%, p = 0.06), acute renal and respiratory failure (5% vs. 0%, p = 0.14). However, both were effectively managed by the combination of antibiotics and image-guided aspiration with/without drainage, and their mortality rates were comparable to each other. Those patients with metastatic infection might need a longer duration (6.07 vs. 5.32 week, p = 0.144) of antibiotic therapy, which was due to the longer mean duration (3.85 vs. 2.86, p < 0.04) of an intravenous counterpart.Conclusion: SM associated PLA tends to have a distinct clinical syndrome as compared with that of Klebsiella spp. with regard to risk factors, clinical manifestations and complications. However, both can be effectively treated with a combination of antibiotics and image-guided aspiration with/without drainage.

Characterization of the modified Hodge test-positive isolates of Enterobacteriaceae in Taiwan - Corrected Proof

Kuei-Hsiang Hung, Jing-Jou Yan, Jang-Jih Lu, Hung-Mo Chen, Jiunn-Jong Wu — 2012-05-14

Background: The modified Hodge test is a phenotypic test to detect KPC-type carbapenemase producers among Enterobacteriaceae, as recommended by the Clinical Laboratory Standards Institute. However, false positive results were reported. In this study, we aimed to large-scale investigate the characterization of the modified Hodge test-positive isolates of Enterobacteriaceae collected between 2006 and 2010 in Taiwan.Methods: Fifty-six isolates, including 24 Enterobacter cloacae, 17 Escherichia coli, 10 Klebsiella pneumoniae, and 5 Citrobacter freundii, tested positive with the modified Hodge test. The in vitro activities of 10 antimicrobial agents were determined by the agar dilution method. Boronic acid combined-disk test was used to further confirm the KPC producers. Phenotype of ESBL, AmpC, class B carbapenemases, and profile of outer membrane proteins were investigated by the confirmatory test, boronic acid disk method, 2-mercaptopropionic acid double-disk method, and urea/sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), respectively. β-lactamase genes were examined by PCR and sequencing.Results: These isolates were resistant to ceftazidime (100%), aztreonam (82.1%), ertapenem (64.3%), gentamicin (53.6%), ciprofloxacin (50%), levofloxacin (48.2%), cefepime (19.6%), imipenem (16.1%), meropenem (12.5%), and amikacin (8.9%). Phenotypic testing among isolates revealed the production of ESBLs, metallo-β-lactamases (MBLs), and AmpC in 10 (17.9%), 16 (28.6%), and 12 (44.4%) isolates, respectively. Carbapenemase and non-carbapenemase β-lactamase genes blaTEM-1, blaSHV, blaCTX-M, blaIMP-8, blaCMY-2, and blaDHA-1 were found in 32 (57.1%), 19 (33.9%), 4 (7.1%), 16 (28.6%), 14 (25%), and 5 (8.9%) of the strains, respectively. No class A and D carbapenemase genes were detected. Outer membrane protein profile showed obviously decreased expression in 49 (87.5%) isolates with positive result of modified Hodge test.Conclusions: Our data show that ESBLs, AmpC, and imipenemase-8 (IMP-8) carbapenemase coupled with decreased expression of outer membrane protein were prevalent in Enterobacteriaceae isolates testing positive for the modified Hodge test in Taiwan.

Seroepidemiology of novel influenza A (H1N1) infection among HIV-infected patients in the era of highly active antiretroviral therapy - Corrected Proof

2012-05-14

Background: The seroprevalence and seroincidence of novel influenza A infection among HIV-infected patients, who were believed to have more severe outcomes than healthy individuals, are rarely investigated in the era of highly active antiretroviral therapy (HAART). Our aim was to determine the seroprevalence and seroincidence of novel influenza A infection among HIV-infected patients in Taiwan.Methods: Between September and November 2009, before the implementation of a nationwide vaccination for novel influenza A in Taiwan, 931 HIV-infected patients and 566 persons seeking voluntary counseling and testing (VCT) for HIV infection at our university hospital were enrolled in this study. Antibody responses to novel influenza A were determined using a hemagglutination-inhibition (HI) assay.Results: HIV-infected patients had a significantly lower seroprevalence of novel influenza A infection than VCT clients (14.7% vs. 33.9%, p < 0.001). The seroincidence of novel influenza A infection among HIV-infected patients was 9.4% (95% confidence interval [CI]: 7.6–11.4). On the multivariate analysis, heterosexual (odds ratio [OR]: 1.89; 95% CI: 1.105–3.227) and baseline HI titer (OR: 1.02; 95% CI: 1.001–1.038) were significantly associated with seroconversion to novel influenza A virus.Conclusion: HIV-infected patients demonstrated a lower seroprevalence of novel influenza A infection than HIV-uninfected patients in Taiwan in the HAART era. Among HIV-infected patients, seroconversion to novel influenza A virus, which was infrequent during the 2009 influenza epidemic, was associated with heterosexual behavior and baseline HI titer.

Emergence of vancomycin-resistant Enterococcus bloodstream infections in southern Taiwan - Corrected Proof

2012-05-11

Background: An increased incidence of vancomycin-resistant enterococcal bloodstream infections (VRE BSI) in the United States has been noted in recent years. There were a few reports of VRE BSI in Taiwan. This study is intended to show the epidemiology, clinical features and outcomes of VRE BSI at a medical center in southern Taiwan.Methods: A retrospective study was conducted from January 1, 2005 to December 31, 2010. All patients with VRE BSI episodes were identified and their medical records were reviewed.Results: A total of 69 episodes of VRE BSI were identified in the study period. The incidence rate increased from 0.01 episodes of VRE BSI/1000 patient-days in 2005 to 0.07 episodes of VRE BSI/1000 patient-days in 2010. The 30-day mortality rate was 52.17% for all patients with VRE BSI. The mortality rate of patients who received in vitro active and inactive antimicrobial therapy for VRE BSI was 40% and 100%, respectively (p < 0.001). Factors associated with mortality were shock [odds ratio (OR) 24.4, 95% confidence interval (CI) 3.6–163.2, p = 0.001], renal failure (OR 90.9, 95% CI 1.9–4404.3, p = 0.02), and underlying liver cirrhosis (OR 12.4, 95% CI 1.2–125.8, p = 0.03). Use of linezolid for VRE BSI showed a trend for lower 30-day mortality than daptomycin therapy (35.5% vs. 56.3%, p = 0.17).Conclusion: VRE BSI is increasingly important in the study hospital and is associated with a significant mortality rate. Appropriateness of antimicrobial therapy has a prognostic impact on patients with VRE BSI.

Mastoiditis diagnosed by clinical symptoms and imaging studies in children: Disease spectrum and evolving diagnostic challenges - Corrected Proof

2012-05-11

Background/purpose: Acute mastoiditis has been increasingly reported. We reviewed our experience of mastoiditis in children in the era of expanding application of imaging tools and endless emerging antimicrobial resistance.Methods: We reviewed all medical records of children (< 18 years of age) hospitalized with mastoiditis between January 2001and December 2010. Diagnosis of mastoiditis was based on clinical features and confirmed by imaging studies. Patients were classified as having acute or nonacute mastoiditis according to the duration of the disease. Acute mastoiditis was defined as illness of less than 3 weeks prior to hospitalization. Cases of longer than 3 weeks’ duration were defined as nonacute mastoiditis. We compared the clinical, laboratory and microbiological features of acute and nonacute mastoiditis.Results: A total of 104 children were enrolled in this study, comprising 56 acute cases and 48 nonacute cases. Fever and coryza were significantly more common in acute cases. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both initially higher in acute mastoiditis. CRP, rather than ESR, declined faster in acute than in nonacute mastoiditis. Computerized tomography (CT) scans, but not plain films, were highly sensitive. Streptococcus pneumoniae and Haemophilus influenzae accounted for 52% of all isolates. Staphylococci, Pseudomonas spp. and polymicrobials were predominantly seen in non-acute mastoiditis.Conclusion: With the application of imaging studies, many cases of mastoiditis were identified. The classical postauricular signs were present in only 10% of patients. The presenting symptoms, inflammatory markers, pathogens, management and outcome were greatly influenced by the duration of the illness prior to admission.

Clinical and laboratory characteristics of human immunodeficiency virus-infected adolescents: Experience from a single medical center - Corrected Proof

2012-05-11

Background: Recently, the proportion of adolescents diagnosed with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) has increased. The aim of this study is to evaluate the clinical and laboratory characteristics of HIV-infected adolescents in southern Taiwan.Methods: From June 1997 to December 2010, a total of 40 HIV-infected adolescents who sought medical care in a university hospital in southern Taiwan were enrolled in the study. They were classified into three HIV at-risk groups, men who have sex with men (MSM), heterosexuals, and intravenous drug users (IDUs). Clinical and laboratory data were obtained from medical records.Results: The median age of the 40 HIV-infected adolescents was 19 years. The HIV at-risk groups were MSM (22/40, 55%), heterosexuals (7/40, 17.5%), IDUs (5/40, 12.5%), and unknown (6/40, 15%). The initial median CD4 count and log plasma HIV viral load were 318 cells/mm3 and 4.61, respectively. The seroprevalence of anti-HAV, anti-HBc, anti-HCV antibodies and HBsAg was 5.3%, 26.1%, 13% and 13%, respectively. Among 17 adolescents who had regular follow-ups more than twice, 7 (41.2%) had a concurrent sexually transmitted disease (STD). The most common STD was genital warts (41.2%) followed by syphilis (11.8%). Among 7 patients who received highly active antiretroviral agents (HAART) for more than 12 months, 5 (71.4%) had sustained virologic suppression.Conclusion: MSM are the largest risk group in HIV-infected adolescents in southern Taiwan and are characterized by a high prevalence of anogenital warts and low seroprevalence of anti-HAV.

Eight years experience in treatment of prosthetic joint infections at a teaching hospital in Central Taiwan - Corrected Proof

2012-05-11

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

The phylogenetic analysis and putative function of lysine 2,3-aminomutase from methanoarchaea infers the potential biocatalysts for the synthesis of β-lysine - Corrected Proof

Chuan-Chuan Hung, Mei-Chin Lai — 2012-05-11

Background: β-amino acids play important biological roles as precursors in the biosynthesis of antibiotics, anticancer agents, neurotransmitters, and other high molecular weight polymers. Microbial cells and enzymes from extreme environments offer new opportunities for biocatalysis and biotransformations as a result of their extreme stability. Lysine 2,3-aminomutase catalyzes the interconversion of L-α-lysine and L-β-lysine. L-β-lysine is a precursor in the bacterial biosynthesis of several antibiotics, and also is a precursor in the biosynthesis of osmolyte Nε-acetyl-β-lysine for salt stress and adaptation in methanoarchaea.Methods: Lysine 2,3-aminomutase (AblA) genes from the marine Methanosarcina mazei N2M9705, halotolerant Methanocalculus chunghsingensis K1F9705bT, and halophilic Methanohalophilus portucalensis FDF1T were cloned by PCR and southern hybridization. Both nucleotide and amino acid sequences of AblAs were analyzed and phylogenetic comparisons performed. Additionally, the functional motifs and 3D structure of aminomutases were aligned and compared.Results: The deduced amino acid sequences of AblAs from methanoarchaea share high identity with the known clostridial and Bacillus lysine 2,3-aminomutase. The conserved amino acid residues for cofactors, such as the iron-sulfur cluster, S-adenosylmethionine (SAM), pyridoxal 5'-phosphate (PLP) and zinc-binding sites in methanoarchaeal AblAs suggested that they were lysine 2,3-aminomutases.Conclusion: AblAs from methanoarchaea are lysine 2,3-aminomutases that may function as potential biocatalysts for the synthesis of β-lysine in vivo and in vitro.

Molecular detection and incidence of human papillomavirus in neonates: Methodology and a pilot study in a medical center - Corrected Proof

2012-05-10

Background/Purpose: Human papillomavirus (HPV) infection can cause laryngeal papillomas in children. Vertical transmission has been confirmed. This study aimed to establish a sensitive molecular diagnostic method and understand the incidence of the HPV-6 and HPV-11 in neonates with intubation.Methods: We enrolled 108 newborns between October 2007 and January 2010. All neonates were intubated due to underlying disease. The specimens were collected via endotracheal aspiration. DNA of HPV types 6 and 11 was detected by real-time PCR and nested PCR.Results: HPV-DNA was detected in eight of the 108 newborns studied. Seven respiratory specimens tested positive for HPV-11 and one was positive for HPV-6. The HPV 6/11 detection rate in neonates was 7.4% (8/108).Conclusion: A rapid, sensitive, specific, and reproducible RT-PCR method and nest PCR were developed for the detection and differentiation of HPV-6 and HPV-11 genomic variants in a single PCR reaction. The assays are of great value for clinical and epidemiologic studies of HPV-6 and HPV-11 infections. Neonatal HPV colonization may be related to juvenile-onset recurrent respiratory papillomatosis. The transmission route may be from mother to child. The clinical significance of neonatal carriage of HPV-6 or HPV-11 warrants further study.

Risk factors and molecular analysis of Panton-Valentine leukocidin-positive methicillin-susceptible Staphylococcus aureus colonization and infection in children - Corrected Proof

Yaw-Kwan Chiu, Wen-Tsung Lo, Chih-Chien Wang — 2012-05-10

Background and Purpose: Limited information is available regarding the role Panton-Valentine leukocidin (PVL) plays in methicillin-susceptible Staphylococcus aureus (MSSA). In this study, we compared the frequency of the PVL gene between MSSA strains isolated from patients with MSSA infections and MSSA strains isolated from patients with evidence of MSSA nasal colonization. We also explored the role that the PVL toxin plays in the ability of MSSA to cause disease as well as the phylogenetic relationship between these S aureus strains.Methods: The presence of MSSA strains was screened among children aged <18 years during routine health maintenance visits and among children aged <7 years at daycare centers or kindergartens during the 2003 to 2008 period. At the same time, clinical MSSA isolates were recovered from patients with various types of bacterial infections. Polymerase chain reaction was applied to detect the presence of the PVL and SEB genes in these strains. The strains were also subjected to pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) studies. Clinical features were compared between patients with PVL-positive and those with PVL-negative isolates.Results: A total of 495 colonizing MSSA and 71 clinical MSSA isolates were used. The prevalence of PVL-positive S aureus was significantly higher among clinical isolates than among colonizing isolates (14/71, 19.7%; 5/495, 1.0%; p < 0.05). In addition, we found that patients with PVL-positive MSSA infections had a significantly longer duration of fever and tended to have higher C-reactive protein levels than patients with PVL-negative MSSA infections. MLST typing of the 19 PVL-positive MSSA isolates revealed ST59, a strain that is similar to the MLST type of community-associated methicillin-resistant Staphylococcus aureus found in Taiwan. The PFGE typing of PVL-positive/ST59 MSSA isolates revealed multiple pulsotypes.Conclusion: The prevalence of the PVL gene was significantly higher among clinical strains of MSSA (19.7%) than among colonizing strains (1.0%). In addition, patients infected with PVL-positive MSSA strains had fever for a significantly longer duration and tended to have higher C-reactive protein levels than patients with PVL-negative MSSA infections. Our findings imply that PVL may play an important role in the pathogenesis of S aureus infection.

Risk factors and clinical outcomes of patients with carbapenem-resistant Acinetobacter baumannii bacteremia - Corrected Proof

2012-05-10

Background: It 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.Methods: This 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.Results: A 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 < 0.001), shock (OR: 2.68; 95% CI: 1.11–6.23; p = 0.025) and inappropriate antimicrobial therapy (OR: 2.14; 95% CI: 1.01–4.53; p = 0.046).Conclusion: Risk factors for CRAB bacteremia were hematological malignancies, previous use of cefepime and use of total parenteral nutrition. Acquisition of CRAB itself is not a poor prognostic factor for the patients with A. baumannii bacteremia.

Nontyphoidal Salmonella bacteremia in patients with connective tissue diseases - Corrected Proof

2012-05-10

Background/Purpose: Nontyphoidal Salmonella (NTS) is a crucial pathogen in immunocompromised patients, especially those with connective tissue disease (CTD) and corticosteroid or immunosuppressant therapy. The aim of this study is to identify the clinical characteristics and outcomes of patients with CTD and NTS bacteremia, and the clinical variations between systemic lupus erythematosus (SLE) and other CTDs.Methods: During a 15-year study period, from 1994 to 2009, NTS bacteremia patients were reviewed from the database of clinical microbiology laboratory. Medical records were reviewed for clinical information and only patients with underlying CTD were included.Results: From 1994 to 2009, there were 299 patients with NTS bacteremia. Forty-six (15.4%) patients had certain connective tissue diseases, and SLE was the major CTD, accounting for 73.9% (34) of 46 patients. In comparison with patients without CTD, the patients with CTD were younger (p<0.0001), had a predominance of female gender (p<0.0001), fewer extra-intestinal focal infections (p=0.011), and a lower mortality rate (p=0.008). Overall, there were four fatal cases, accounting for a mortality rate of 8.7% of those afflicted with CTD. The factors of old age (p<0.006), shock at presentation (p=0.033), acute renal failure (p=0.001), and presence of any extra-intestinal focal infection (p<0.0001) were associated with mortality in the univariate analysis.Conclusion: Nontyphoidal Salmonella bacteremia causes substantial morbidity and mortality in patients with connective tissue disease, especially in the elderly population. The aggressive detection of extra-intestinal infections may be beneficial.

Molecular typing of Mycobacterium tuberculosis isolated from adult patients with tubercular spondylitis - Corrected Proof

2012-05-10

Background/Purposes: Tuberculosis (TB) is endemic in Taiwan and usually affects the lung, spinal TB accounting for 1–3% of all TB infections. The manifestations of spinal TB are different from those of pulmonary TB. The purpose of this study was to define the epidemiological molecular types of mycobacterial strains causing spinal TB.Methods: We retrospectively reviewed the medical charts of adult patients diagnosed with spinal TB from January 1998 to December 2007. Patients with positive culture results and/or pathological findings characteristic of TB were enrolled in this study. Spoligotyping was performed to type the Mycobacterium tuberculosis isolates.Results: A total of 38 patients with spinal TB were identified. Their mean age was 68 years, and their median duration of symptoms was 60 days (range 3–720 days). The lumbar and thoracic spine accounted for 76% of the sites involved. Thirteen specimens (from seven male and six female patients) were available for typing. Spoligotyping of these 13 specimens revealed three Beijing (23%) and 10 non-Beijing types (77%). The non-Beijing types included two EAI2 Manilla (15%), two H3 (15%), two unclassified (15%), and one each of BOVIS1, U, T2, and orphan type. No significant predominant strain was found in this study, and no drug-resistant Beijing strains were identified.Conclusion: TB spondylitis was found to occur in older patients. Spoligotyping results showed that most of the TB spondylitis cases were caused by non-Beijing type Mycobacterium tuberculosis.

Infective endocarditis caused by community-associated methicillin-resistant Staphylococcus aureus in a previously healthy preschool child - Corrected Proof

Chun-Yi Lee, Tung-Ming Chang, Chao-Jen Lin, Yhu-Chering Huang — 2012-05-10

Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported recently and has become an emerging pathogen of infective endocarditis (IE) in adults, but still rarely reported in children. A previously healthy preschool child without any heart anomaly developed IE and pneumonia with pleural effusion. Blood cultures repeatedly yielded MRSA and did not become negative until 13 days after a teicoplanin-containing regimen was administered. In total, a 4-week intravenous antibiotic therapy and an additional 8-week oral antibiotic therapy were given. The patient recovered uneventfully. All five MRSA blood isolates were molecularly characterized and shared common characteristics, which were consistent with those of the endemic CA-MRSA clone in Taiwan. This case highlights that physicians should be aware of the growing role of CA-MRSA in childhood IE and should meticulously choose an appropriate empiric antibiotic regimen for such a severe disease.

Is 2 weeks of antibiotic therapy enough to treat elderly patients with nontyphoid Salmonella bacteremia? A case report of fatal endovascular infection - Corrected Proof

Po-Lin Chen, Liang-Miin Tsai, Chung-Dann Kan, Wen-Chien Ko — 2012-05-10

Nontyphoid Salmonella (NTS) can cause invasive diseases in the elderly. Notably, the most feared complication of NTS bacteremia is endovascular infection. The risk factors for infected aortic aneurysm include old age and atherosclerosis. Extended use of antimicrobial therapy (> 2 weeks) for NTS bacteremia should be considered for those who demonstrate the risk factors for endovascular infection, even when a metastatic focus is clinically elusive. Herein, we report the case of a 75-year-old patient with diabetes mellitus, hypertension, chronic kidney disease, and myocardial infarction who died of an infected aortic aneurysm despite 3 weeks of antibiotic therapy that was administered to treat the initial NTS bacteremia.

Impact of vancomycin MIC creep on patients with methicillin-resistant Staphylococcus aureus bacteremia - Corrected Proof

2012-05-09

Background/Purpose: To date, vancomycin is still the standard treatment for methicillin-resistant Staphylococcus aureus (MRSA) infections, but minimum inhibitory concentration (MIC) creep is becoming a major concern. The aims of this study were to investigate trends in vancomycin use and MIC values over the last decade at our institute and to evaluate the outcomes of bacteremic patients infected with MRSA isolates with reduced vancomycin susceptibility.Methods: Vancomycin use and density were evaluated using the defined daily doses (DDD) method. Patients with MRSA bacteremia were enrolled retrospectively. Patient demographic data and clinical outcomes were analyzed. The first isolate from each patient was collected for E-testing in order to determine vancomycin MIC. MIC trends were assessed as MIC50, MIC90, and the geometric mean.Results: Vancomycin use has increased over the last decade. One hundred and forty patients were enrolled and their respective isolates were retrieved, including isolates from 45 patients in 2001, 46 patients in 2005, and 49 patients in 2009. The geometric mean (± standard deviation) of the vancomycin MIC for MRSA isolates obtained in 2009 was 1.39 ± 0.30 μg/mL, which is significantly higher than the mean vancomycin MIC obtained in 2001 (1.19 ± 0.34 μg/mL, p < 0.01) and 2005 (1.99 ± 0.25 μg/mL, p < 0.001). There were no significant differences in terms of the in-hospital mortality rate between patients with MRSA isolates with MICs ≥ 1.5 μg/mL or < 1.5 μg/mL.Conclusion: We identified a significant upward trend in the use of vancomycin and its MIC over the last decade. This study shows that patients infected with MRSA isolates with high MICs (≥1.5 μg/mL) do not have a significantly higher mortality rate compared with isolates with low MICs (<1.5 μg/mL).

Proteus mirabilis urinary tract infection and bacteremia: Risk factors, clinical presentation, and outcomes - Corrected Proof

Chi-Yu Chen, Yen-Hsu Chen, Po-Liang Lu, Wei-Ru Lin, Tun-Chieh Chen, Chun-Yu Lin — 2012-05-09

Background/Purpose: Proteus mirabilis is a common pathogen responsible for complicated urinary tract infections (UTIs) that sometimes causes bacteremia. Most cases of P. mirabilis bacteremia originate from a UTI; however, the risk factors for bacteremia and mortality rates from P. mirabilis UTI have not been determined.Methods: A retrospective, case-control study was performed between May 2008 and November 2010 to identify the risk factors and markers for P. mirabilis bacteremic UTI. Each subject in the case group (all patients were diagnosed with P. mirabilis bacteremia from a urinary tract source) was matched by age and gender to two subjects in the control group (patients diagnosed with P. mirabilis UTI but with negative blood culture results). Clinical presentation and laboratory data were analyzed to determine the risk factors and markers of P. mirabilis bacteremic UTI.Results: Sixty-seven bacteremic UTIs and 124 nonbacteremic UTIs were included in this study. Community-acquired infection (p=0.017), hydronephrosis (p=0.017), band neutrophils accounting for >10% of the white blood cell count (p=0.001), hyperthermia or hypothermia (p=0.047), and a serum C-reactive protein concentration >100mg/L (p=0.002) were identified as independent risk factors for P. mirabilis bacteremic UTI. Seventeen patients died in hospital, including 11 in the bacteremic group and 6 in the nonbacteremic group. The bacteremic group had a higher mortality rate (p=0.016). Bacteremic UTI (p=0.049), shock (p=0.014), and a low body mass index (BMI) <18kg/m2 (p=0.033) were identified as independent risk factors for mortality.Conclusion: Because bacteremic P. mirabilis UTIs are associated with higher mortality, clinicians should carefully manage cases that present with the risk factors for bacteremia, including community-acquired infection, hydronephrosis, band neutrophils accounting for >10% of the white blood cell count, hyperthermia or hypothermia, and a high level of C-reactive protein.

Herpetic gingivostomatitis with severe hepatitis in a previously healthy child - Corrected Proof

Chun-Kuei Chen, Shih-Hao Wu, Yhu-Chering Huang — 2012-05-09

A previously healthy boy aged 9 years and 11 months was admitted due to herpetic gingivostomatitis with poor intake. He also had fever, neutropenia, and elevated serum aminotransferase level (> 1000IU/mL). Prolonged prothrombin time, mild gastrointestinal hemorrhage and transient decreased conscious level were noted during hospital days 2 and 3. Intravenous acyclovir therapy commenced on hospital day 2 and his serum aminotransferase level peaked (> 4000IU/mL) on hospital day 3 and then improved gradually. A throat swab was positive for human herpes simplex virus (HSV)-1, serological test was positive for acute primary HSV-1 infection, and a blood specimen was also strongly positive for HSV-1 by polymerase chain reaction. He received a 14-day course of intravenous acyclovir and recovered uneventfully. Herpetic gingivostomatitis, although mostly benign and self-limited, may be complicated with severe hepatitis, even in immunocompetent hosts.

Bacterial characteristics and glycemic control in diabetic patients with Escherichia coli urinary tract infection - Corrected Proof

2012-05-09

Background: Patients with diabetes mellitus have an increased risk of infection. The roles of bacterial characteristics and glycemic control in diabetic patients with Escherichia coli infection have not been well investigated. The aims of this study were to examine the bacterial characteristics and glycemic control in diabetic patients with E. coli infections arising in the urinary tract.Methods: A total of 271 E. coli isolates were collected from urine and bloodstream. Phylogenetic groups, the presence of virulence genes, and antimicrobial susceptibility of E. coli isolates were determined.Results: There were few differences in E. coli bacterial characteristics between 190 diabetic and 81 nondiabetic patients. In diabetic patients with urosepsis, there was a higher hemoglobin A1C level, and the related E. coli strains had more neuA, papG II, afa and hlyA genes, and a lower prevalence of antimicrobial resistance to cephalosporins and fluoroquinolones than those with asymptomatic bacteriuria and urinary tract infection. Multivariate logistic regression analysis revealed that increased hemoglobin A1C and presence of papG II and afa genes were independent factors associated with development of urosepsis in diabetic patients.Conclusion: This study demonstrated that more virulent E. coli isolates, especially with papG II and afa genes, and poorer glycemic control were important determinants for development of urosepsis in diabetic patients.

Factors for poor prognosis of neonatal bacterial meningitis in a medical center in Northern Taiwan - Corrected Proof

Mu-Chun Lin, Hsin Chi, Nan-Chang Chiu, Fu-Yuan Huang, Che-Sheng Ho — 2012-05-09

Background: Bacterial meningitis has long been a severe infectious disease in neonates, as well as a leading cause of adverse outcomes. We designed this study to know the factors for poor prognosis in neonatal bacterial meningitis.Methods: We enrolled children aged less than 1 month who were admitted to Mackay Memorial Hospital from 1984 to 2008 and had culture-proven bacterial meningitis. The laboratory data and children’s clinical features were recorded. The patients’ outcomes were divided into four groups: death, having sequelae, complete recovery, and loss to follow-up. Patients with the outcomes of death and having sequelae were regarded as having a poor prognosis. Those who were lost to follow-up were excluded from the analysis of outcome. Multivariate analyses were performed to find the risk factors for poor prognosis.Results: One hundred fifty-six neonates fulfilled the inclusion criteria. Among these, 96 were boys (61.5%) and 102 (65.4%) had concomitant bacteremia. Group B streptococci (39.1%) and Escherichia coli (20.1%) were the two leading pathogens. Excluding those who were lost to follow-up (4.5%), 22 of 149 patients (14.8%) died, 36 (24.2%) had sequelae, and 91 (61.1%) recovered completely. Cerebrospinal fluid (CSF) protein more than 500 mg/dL at admission {odds ratio (OR): 171.18 [95% confidence interval (CI): 25.6–1000]}, predisposition to congenital heart disease [OR: 48.96 (95% CI: 6.06–395.64)], hearing impairment found during hospitalization [OR: 23.40 (95% CI: 3.62–151.25)], and seizure at admission or during hospitalization [OR: 10.10 (95% CI: 2.11–48.32)] were the factors predicting poor prognosis.Conclusion: In this 25-year study of newborns with bacterial meningitis, approximately one-seventh of the patients died, while two-fifths had sequelae. Nearly two-thirds of these had concomitant bacteremia. Group B streptococci and E coli remained the two leading pathogens throughout the study period. Several factors for poor prognosis in newborns with culture-proven bacterial meningitis were found: high CSF protein concentration, congenital heart disease, hearing impairment, and seizure.

Comparison of efficacies of bovine immune colostral antibody and each immunoglobulin class against verotoxin 2, flagellum and somatic cells of Escherichia coli O157:H7 in mice - Corrected Proof

Tetsurou Seita, Takashi Kuribayashi, Toshio Honjo, Shizuo Yamamoto — 2012-05-09

Purpose: The efficacy of bovine immune colostral (colostral) antibodies against verotoxin (VT) 2, flagellum and somatic cells of Escherichia coli (E coli) O157:H7 in mice was determined.Methods: Three major immunoglobulin (Ig) classes were isolated from the colostral antibody against VT2 by affinity chromatography and were used for estimation. Mice inoculated with VT2 were administered each Ig class from the colostral antibody, colostral antibody (colostral whey containing antibody) or serum antibody against VT2 at 1 hour after VT2 inoculation.Results: All control mice (20/20) died after administration of sterilized saline instead of the colostral antibody. The survival rate was 93.3% (14/15) after administration of S-IgA or IgM antibody, or colostral antibody. Survival rates for IgG antibody and serum antibody administration were 80% (12/15) and 60% (9/15), respectively. Serum concentrations of VT2, which was absorbed from the small intestine in mice after administration of VT2 and colostral antibody, were measured by fluorescence enzyme immunoassay (FEIA). Serum concentrations of VT2 after administration of colostral antibody were lower than those after administration of sterilized saline. Mice inoculated with VT2-producing E coli 157:H7 were administered anti-flagellum or anti-somatic colostral antibodies. Survival rates for E coli O157:H7-infected mice administered the anti-flagellum and anti-somatic colostral antibodies were 52.4% (11/21) and 22.2% (4/18), respectively. Furthermore, survival rates increased to 89.5% (17/19) with combined administration of anti-flagellum and anti-VT2 colostral antibodies.Conclusion: These results suggest that colostral antibodies against VT2, flagellum and somatic cells are effective against E coli O157:H7 infection.

Lactobacillus casei cell wall extract directly stimulates the expression of COX2 independent of Toll-like receptor 2 in rat glial cells - Corrected Proof

2012-05-09

Kawasaki disease is an acute illness of early childhood that is characterized by prolonged fever and vasculitis of unknown pathogenesis. Lactobacillus casei cell wall extract (LCWE)-induced vasculitis in mice is a well-validated model of Kawasaki disease. In the nervous system, glial cells play an important role in fever development. This study investigated whether LCWE directly stimulates glial cells, resulting in the induction of cyclooxygenase-2 (COX2), which is required for prostaglandin synthesis and fever development. We found that LCWE induced COX2 expression and activated the nuclear factor-κB signaling pathway in rat B92 glial cells, but Toll-like receptor-2, which is one of the receptors for LCWE, could not be detected in the cells. These results suggest that LCWE activates the nuclear factor-κB signaling pathway and induces COX2 in rat B92 glial cells through another LCWE receptor other than Toll-like receptor-2.

Efficacy of combination oral antimicrobial agents against biofilm-embedded methicillin-resistant Staphylococcus aureus - Corrected Proof

2012-05-09

Background: The combination of fusidic acid and rifampicin has a demonstrated synergistic effect against methicillin-resistant Staphylococcus aureus (MRSA), including planktonic and biofilm-related organisms. However, the in vitro efficacy of other combinations of oral anti-MRSA antibiotics in biofilm models has not been established.Methods: The antibacterial activity of fusidic acid, linezolid, rifampicin, and minocycline against 33 biofilm-embedded MRSA isolates in low susceptibility and high resistance breakpoint concentrations was investigated using the 3-[4, 5-dimethyl-2-thiazolyl]-2, 5-diphenyl-2H-tetrazolium-bromide staining method. The compounds were further examined to determine their antibacterial efficacies in combination. The optical density ratio (ODr) was used to evaluate the antibacterial effects of these antibiotics, and the results indicate higher survival rates of MRSA on biofilm. A biofilm-positive phenotype (determined using the crystal violet stain) was defined as an optical density ≥ 0.17 at 492nm, and strong biofilm formation was defined as an optical density ≥ 1.0.Results: One-third of the MRSA isolates demonstrated weak biofilm formation, and two-thirds demonstrated strong biofilm formation. At low concentrations, linezolid alone lowered the ODr to 0.55 and was effective against biofilm-embedded MRSA (p<0.001). The activity of minocycline was concentration-dependent and more effective against MRSA isolates that demonstrated weak biofilm formation. The effect of minocycline seems to be further enhanced when used in combination with either fusidic acid or linezolid at low concentrations, with the obtained results equal to those obtained with rifampicin-based regimens (p<0.001). Rifampicin plus minocycline was also effective against MRSA in biofilm.Conclusion: In comparison with monotherapy, minocycline-based combinations exhibit highly effective bactericidal effects against biofilm-embedded MRSA.

Emphysematous cholecystitis complicating liver abscess due to Clostridium baratii infection - Corrected Proof

Wen-Cheng Huang, Wen-Sen Lee, Tzesian Chang, Tsong-Yih Ou, Carlos Lam — 2012-05-07

Clostridium baratii bacteremia is a rare but severe anaerobic infection. Its major clinical features are neurological presentation, and significant risk factors include hemodialysis, intestinal disease or malignancy. We describe a case of emphysematous cholecystitis complicated by a liver abscess due to C baratii infection in a healthy adult without neurological manifestation.

Correlation between levofloxacin consumption and the incidence of nosocomial infections due to fluoroquinolone-resistant Escherichia coli - Corrected Proof

Hui-Hsiu Wu, Hsin-Yi Liu, Yi-Chun Lin, Po-Ren Hsueh, Yuarn-Jang Lee — 2012-05-07

Background/purpose: The relationship between fluoroquinolone resistance in Escherichia coli isolates causing nosocomial infection and hospital antibiotic consumption were investigated. Restriction of levofloxacin use was implemented to control the incidence of fluoroquinolone-resistant E coli in the hospital.Methods: The study was conducted from January 2004 to December 2010. Antimicrobial agent consumption was obtained from the pharmacy computer system and presented as the defined daily doses per 1000 patient-days every 6 months. The incidence of fluoroquinolone-resistant E coli isolates causing nosocomial infections was obtained from the Department of Infection Control every 6 months. An antimicrobial stewardship program, restricting levofloxacain use, was implemented in July 2007.Results: The incidence of fluoroquinolone-resistant E coli causing nosocomial infections was significantly correlated with fluoroquinolone usage (p = 0.005), but not with the use of third- or fourth-generation cephalosporins, piperacillin-tazobactam, or carbapenems. Parenteral (p = 0.002), oral (p = 0.018), and total levofloxacin (p = 0.001) use were significantly correlated with the extent of fluoroquinolone resistance. With a reduction of levofloxacin use, a decrease of the incidence of fluoroquinolone resistance in E coli isolates was observed.Conclusion: There is a significant correlation between levofloxacin use and the incidence of nosocomial fluoroquinolone-resistant E coli isolates. The incidence of fluoroquinolone-resistant E coli could be reduced by limiting levofloxacin consumption.

Analysis of serum total IgE, specific IgE and eosinophils in children with acute and chronic urticaria - Corrected Proof

2012-05-07

Background: Increased IgE and eosinophil levels are frequently observed in cutaneous inflammation and are thought to provoke the occurrence of urticaria. However, the relationship of these factors with the disease duration of urticaria remains unclear. The aim of this study was to compare serum total IgE levels, specific IgE sensitization rates and eosinophil percentages between acute and chronic urticaria in children.Methods: A total of 165 patients (104 with acute and 61 with chronic urticaria) from a tertiary referral hospital were enrolled in this study. Serum levels of total IgE, prevalence of sensitization to food and aeroallergens and blood eosinophil percentages were compared by the disease duration of urticaria.Results: There were no statistical differences in total IgE production, positive sensitization to specific allergens and eosinophil percentages between the patients with acute and chronic urticaria. There is a higher prevalence of sensitization to aeroallergens than food allergens in children with urticaria. In terms of gender, males had significantly higher serum IgE levels than females.Conclusion: Boys potentially have a higher serum IgE expression than girls children with urticaria. IgE levels and eosinophil percentages are not good indicators for a prolonged course of urticaria. The prevalence of sensitization to aeroallergens was significantly higher than that of food allergens in children with urticaria. Routine laboratory analysis for common allergens is not appropriate, and it could be a feasible approach to detect a predilection for atopy when respiratory infections are causative factors of urticaria occurrence.

Occurrence and phenotypic detection of class A carbapenemases among Escherichia coli and Klebsiella pneumoniae blood isolates at a tertiary care center - Corrected Proof

Varsha Gupta, Neha Bansal, Nidhi Singla, Jagdish Chander — 2012-04-27

Background: Resistance to carbapenems is a significant therapeutic threat. The increasing frequency of car bapenemase enzymes among Gram-negative bacilli makes their early detection and differentiation urgent. Carbapenemases belonging to Class A are most commonly produced by members of family Enterobacteriaceae and are inhibited to various degrees by clavulanic acid. The present study is aimed to determine the occurrence and phenotypic detection of Class A carbapenemases in Escherichia coli and Klebsiella pneumoniae blood isolates from septicemic patients.Methods: A total of 75 isolates of K pneumoniae and 25 E coli were screened for resistance to carbapenems by using meropenem and imipenem discs and meropenem E-test. Positive strains were then subjected to a modified Hodge test combined with carbapenemase inhibition tests to phenotypically detect and differentiate Class A serine carbapenemases from other classes of carbapenem hydrolyzing enzymes.Results: The screening test showing the number of isolates resistant to meropenem and imipenem were 41 and 35 for K pneumoniae and nine and four for E coli, respectively. A total of 25 (33.3%) K pneumoniae isolates and two (8.0%) E coli isolates were classified as Class A carbapenemase producers. Multidrug resistance with coexistence of extended spectrum-beta-lactamases occurred in 44.4% isolates. However, all of the isolates were susceptible to colistin, polymyxin B, and tigecycline by disc diffusion test.Conclusion: We conclude from the present study that Class A carbapenemases appear to be the predominant cause of resistance to carbapenems in Enterobacteriaceae at our center and, thus, phenotypic detection based on simple methods should be employed routinely in clinical microbiology laboratories.

Study of the endoparasitic fauna of commensal rats and shrews caught in traditional wet markets in Taichung City, Taiwan - Corrected Proof

2012-04-20

Background: Rats live in close proximity to human populations. Feral rodents are known to transmit diseases and act as reservoir hosts to many zoonotic parasites that pose health risks to humans. The aim of this study is to investigate endoparasitic infections in commensal rats and shrews caught in traditional wet markets in Taichung City, Taiwan.Methods: A total of 51 commensal wild rodents and shrews were caught in traditional wet markets in Taichung City, including 32 Rattus norvegicus, 11 R rattus, and eight Suncus murinus. All tissues, organs, and intestinal contents were carefully examined after euthanasia for the detection of parasites.Results: The overall prevalence of infection was 94.1%, and the infection rates in R norvegicus, R rattus, and S murinus were 93.8%, 90.9%, and 100.0%, respectively. Four cestodes (Taenia taeniaeformis, Hymenolepis diminuta, H nana, and Raillietina celebensis), seven nematodes (Angiostrongylus cantonensis, Capillaria hepatica, Heterakis spumosa, Nippostrongylus brasiliensis, Strongyloides ratti, Syphacia muris, and Trichosomoides crassicauda), and one protozoan (Sarcocystis spp.) were detected.Conclusion: Our findings indicate that commensal rodents and shrews found in the traditional wet markets of Taichung City are hosts to various zoonotic parasites and, therefore, pose a serious health risk to humans and domestic animals in Taiwan.

Uncommitted role of enterococcal surface protein, Esp, and origin of isolates on biofilm production by Enterococcus faecalis isolated from bovine mastitis - Corrected Proof

Mohamed Elhadidy, Asmaa Elsayyad — 2012-04-20

Purpose: This study was conducted in order to determine the occurrence of esp and biofilm formation among Enterococcus faecalis causing mastitis isolated from different bovine and environmental origins.Materials and methods: A total of 41 E faecalis isolates were obtained from clinical mastitis before antibiotic therapy, subclinical mastitis, dried manure bedding samples, and postpartum milk samples. Isolates were screened for biofilm formation using microtiter plate method using tryptic soy broth with 0.25% glucose as media. Isolates were tested for the presence of the esp gene, which has been reported to be essential for biofilm formation in enterococci, by means of the polymerase chain reaction.Results: Analysis of the relationship between the presence of esp and the biofilm formation capacity in E faecalis showed that the esp gene was not identified in any of the 18 biofilm-producing E faecalis isolates. Moreover, two of the three non-biofilm-producing E faecalis strains were esp positive. In addition, the biofilm assay mean values were not changed with different origins of isolation.Conclusions: These results suggest the following: (1) lack of strict association between the presence of esp and biofilm formation and (2) widespread biofilm formation capacity among different sources of E faecalis isolates derived from bovine mastitis.

Comparison between patients under hemodialysis with community-onset bacteremia caused by community-associated and healthcare-associated methicillin-resistant Staphylococcus aureus strains - Corrected Proof

2012-04-20

Background/Purpose(s): Patients receiving hemodialysis infected with methicillin-resistant Staphylococcus aureus (MRSA) have been considered to have healthcare-associated (HA) infections, but strains with community-associated (CA) characteristics have also been identified in this population. The authors compared infections of the two strains among patients with end-stage renal disease.Methods: From January 2004 to December 2008 the authors analyzed the demographic and microbiologic data of 57 patients with community-onset (defined as a positive culture obtained ≤ 48 hours after admission) MRSA bacteremia and end-stage renal disease at a 2900-bed tertiary medical center. MRSA isolate with staphylococcal cassette chromosome mec (SCCmec) type II/III was classified as HA strains, and SCCmec type IV/V as CA strains.Results: Forty-seven patients (82%) had HA-MRSA strains and 10 patients (18%) had CA-MRSA strains. The major clones of HA-MRSA were sequence type (ST) 5 with SCCmec type II and staphylococcal protein A (spa) t002 as well as ST239 carrying SCCmec type III and spa t037. The CA-MRSA strains were predominantly ST59, more susceptible to non-β-lactam antimicrobial agents, and had a higher percentage of carrying the Panton-Valentine leukocidin gene in comparision with the HA-MRSA strains. Patients infected with HA-MRSA isolates had a higher overall mortality (57.4%, p = 0.012). In multivariate analysis, male patients were more likely to be infected with HA-MRSA isolates than CA-MRSA strains (p = 0.037), and a history of receiving urinary catheterization within 1 year prior to bacteremia onset (p = 0.047) is an independent risk factor to acquiring HA-MRSA strains.Conclusion: Patients undergoing dialysis and infected with HA-MRSA strains had higher mortality rates and were more commonly associated with urinary catheterization within 1 year before bacteremia.

Brevundimonas vesicularis bacteremia resistant to trimethoprim-sulfamethoxazole and ceftazidime in a tertiary hospital of southern Taiwan - Corrected Proof

Chun-Cheng Zhang, Hui-Jine Hsu, Chien-Ming Li — 2012-04-19

Background: Over the past 20 years, Brevundimonas vesicularis has rarely been reported as a pathogen causing human infection. The clinical manifestations of B vesicularis bacteremia and its susceptibility to antibiotics has not been characterized.Methods: A retrospective study was conducted between 2006 and 2009 in a tertiary-care hospital in southern Taiwan.Results: A total of 22 cases of B vesicularis bacteremia were identified during the study with 86% being community-acquired primary bloodstream infections. Of the 22 patients, 15 (68%) presented with fever, fewer comorbidities, shorter hospital stays, lower mean creatinine levels (1.10 mg/dL vs. 1.74 mg/dL), lower aspartate aminotransferase levels (29.1 IU/L vs. 79.0 IU/L), and lower alanine aminotransferase levels (16.4 IU/L vs. 67.0 IU/L) when compared to afebrile patients. Among the bacterial isolates, 90.9% were susceptible to cefpirome, imipenem and piperacillin/tazobactam while 86.4% were susceptible to gentamicin, amikacin and ciprofloxacin. However, 63.6% of the bacterial isolates were susceptible to ceftazidime, and only 59.1% were susceptible to trimethoprim-sulfamethoxazole (TMP-SMX). The 30-day mortality rate from all causes was 4.5%.Conclusion: B vesicularis is able to cause community-acquired and low-mortality primary bloodstream infections. The resistance of B vesicularis to trimethoprim-sulfamethoxazole and ceftazidime limits the choice of available antibiotics for treatment.

Autoimmune manifestations in patients with visceral leishmaniasis - Corrected Proof

Evangelos Liberopoulos, Anastazia Kei, Fotini Apostolou, Moses Elisaf — 2012-04-19

Visceral leishmaniasis (VL) is a vector-borne protozoal infection caused by replication of Leishmania species in macrophages. VL is characterized by fever, hepatosplenomegaly and cytopenia. Apart from those classic clinical characteristics, VL has been associated with autoimmune clinical and laboratory features. Reported herein are 16 consecutive patients with VL who were checked for laboratory autoimmune manifestations. A variety of autoimmune antibodies including elevated titers of antinuclear antibodies and rheumatoid factor were detected in all patients. Of note, no laboratory autoimmune manifestations were detected in the seven patients who were re-evaluated 3 months after therapy. It is concluded that autoimmune laboratory manifestations during VL infection are common. These may mistakenly lead to diagnosis of an autoimmune disorder.

Involvement of Toll-like receptor 2 in apoptosis of Aggregatibacter actinomycetemcomitans-infected THP-1 cells - Corrected Proof

2012-04-18

Background/Purpose: Aggregatibacter (Actinobacillus) actinomycetemcomitans is a gram-negative bacterium that has been associated with aggressive periodontitis. A actinomycetemcomitans infection induces apoptosis in the human monocytic cell line THP-1, and p38 mitogen-activated protein kinase (p38) activity and tumor necrosis factor-α (TNF-α) production are enhanced by A actinomycetemcomitans infection. However, mechanisms governing the recognition of A actinomycetemcomitans by monocytes during apoptosis have not been elucidated. A actinomycetemcomitans cell wall components stimulate Toll-like receptor (TLR)2 and/or TLR4. The authors examined whether TLR2 and/or TLR4 were involved in the apoptosis of A actinomycetemcomitans-infected THP-1 cells.Methods: A actinomycetemcomitans-infected THP-1 cells were transferred to six-well culture plates and incubated for 0 to 6 hours. In some experiments, THP-1 cells were incubated with anti-TLR2, anti-TLR4, or isotype control antibody (10 μg/mL) for 30 minutes prior to A actinomycetemcomitans infection. Expression of messenger RNA (mRNA) was examined by reverse transcription-polymerase chain reaction. Intracellular bacteria recovered from A actinomycetemcomitans-infected cells and apoptotic cells were detected by APOPercentage dye (Biocolor Ltd, Northern Ireland, UK) staining. Cellular p38 activity and TNF-α production were assessed with enzyme-linked immunosorbent assay.Results: The expression of TLR2 mRNA was increased by A actinomycetemcomitans infection. Phagocytosis and apoptosis in A actinomycetemcomitans-infected THP-1 cells were inhibited by the addition of anti-TLR2 antibody. Also, anti-TLR2 antibody suppressed the activation of p38 and production of TNF-α in A actinomycetemcomitans-infected THP-1 cells.Conclusion: These results suggest that A actinomycetemcomitans induces increased expression of TLR2, leading to phagocytosis and apoptosis of THP-1 cells via p38 activation and TNF-α production.

Immune reconstitution inflammatory syndrome of Kaposi’s sarcoma in an HIV-infected patient - Corrected Proof

2012-04-16

We present a case of Kaposi’s sarcoma-related immune reconstitution inflammatory syndrome in an HIV-infected patient who developed fever, worsening pulmonary infiltrates with respiratory distress, and progression of skin tumors at the popliteal region and thigh that resulted in limitation on movement of the right knee joint at 3.5 months following a significant increase of CD4 count after combination antiretroviral therapy.

Tigecycline therapy for bacteremia and aortitis caused by Salmonella enterica serotype Choleraesuis: A case report - Corrected Proof

Hung-Jen Tang, Chi-Chung Chen, Wen-Chien Ko — 2012-04-16

Non-typhoid Salmonella species represent a significant cause of aortitis. Few antimicrobial agents can be used when the patient is allergic or intolerable to cephalosporins or fluoroquinolones. Here, we report a case of bacteremia and aortitis caused by Salmonella enterica serotype Choleraesuis. This patient was cured by initial parenteral tigecycline and subsequent oral ciprofloxacin without surgical intervention.

Plasma-cell type Castleman’s disease of the neck and lymphocyte-depletion Hodgkin lymphoma associated with intestinal intussusception in an AIDS patient - Corrected Proof

Chung-Hsu Lai, Jen-Wei Tsai, Jiun-Nong Lin, Pei-Min Hsieh, Hsi-Hsun Lin — 2012-04-16

A 36-year-old man was diagnosed with plasma-cell type Castleman’s disease with the presentation of recurrent lymphadenpathy of the neck. HIV infection was not suspected or confirmed until esophageal candidiasis developed one year later. Meanwhile, surgery was performed for intestinal intussusception and obstruction caused by lymphocyte-depletion Hodgkin lymphoma. However, he died of rapidly progressive pneumonia and disseminated intravascular coagulation associated with intracerebral hemorrhage, which occurred 6 months later during the course of chemotherapy. This case suggests that HIV infection should be considered in patients who present with plasma-cell type Castleman’s disease or lymphocyte-depletion Hodgkin lymphoma with extra-nodal involvement in order to conduct appropriate diagnosis and initiate treatment for HIV infection.

Orbital cellulitis caused by community-associated methicillin-resistant Staphylococcus aureus in a previously healthy neonate - Corrected Proof

Tzu-Hui Lei, Yhu-Chering Huang, Yen-Chang Chu, Chien-Yu Lee, Reyin Lien — 2012-04-16

A 30-day-old, previously healthy, near-term neonate presented with fever and swelling of the left eye. Orbital cellulitis of the left eye was diagnosed by computed tomography. Both blood culture and pus that was drained from the orbital abscess were positive for methicillin-resistant Staphylococcus aureus (MRSA), which was found to be a strain indigenous to the local community by a molecular method. Using vancomycin therapy and surgical drainage, the infant recovered uneventfully. Orbital cellulitis in neonates may rapidly progress to abscess formation, even to sepsis, and S aureus is the most common pathogen. With the increasing prevalence of community-associated MRSA, empiric antibiotics effective against MRSA should be first considered in endemic areas.

Unusual manifestations of Kawasaki disease with retropharyngeal edema and shock syndrome in a Taiwanese child - Corrected Proof

2012-04-16

We report a 3-year-old girl with Kawasaki disease who presented with retropharyngeal edema and shock syndrome. This is the first reported case in Taiwan.The patient initially presented with fever, cough, and pyuria followed by rapidly progressive enlarged bilateral cervical lymphadenopathy. On the third day of the fever, computed tomography for airway compression sign found widening of the retropharyngeal space mimicking a retropharyngeal abscess. Later, an endotracheal tube was inserted for respiratory distress. A skin rash over her trunk was also noted. On the fifth day of the fever, the clinical course progressed to hypotension and shock syndrome. Because of more swelling of bilateral neck lymph nodes, computed tomography was arranged again and revealed partial resolution of the edematous changes in the retropharyngeal space. Edema of the hands and feet, bilateral bulbar conjunctivitis, and fissured lips were subsequently found. The diagnosis of Kawasaki disease was confirmed on the eighth day of fever. There was no evidence of bacterial infection. She was administered intravenous immunoglobulin (2 mg/kg) and high dose aspirin (100 mg/kg/day). One day later, the fever subsided, and her blood pressure gradually became stable. Heart echocardiography on the Day 13 revealed dilated left coronary artery and mitral regurgitation. Follow-up echocardiography six months later showed normal coronary arteries. To date, the patient has not experienced any complications.This case illustrates that retropharyngeal edema and shock syndrome can be present in the same clinical course of Kawasaki disease. Clinicians and those who work in intensive care units should be aware of unusual presentations of Kawasaki disease to decrease rates of cardiovascular complications.

Response to the letter of Lai and Hsueh - Corrected Proof

Hung-Jen Tang, Wen-Chien Ko — 2012-04-12

We thank Lai and Hsueh for their valuable comments on our article in which we described a case with Nocardia thyroid abscess in a 70-year-old patient and favorable clinical response to trimethoprim-sulfamethoxazole therapy. We agree with their opinion that molecular methods are essential for identifying Nocardia isolates to the species level. The species identification of the Nocardia isolate was based on the results of conventional laboratory methods, including positive modified acid-fast staining, colonial morphotypes, and the hydrolysis pattern of casein, xanthine, hypoxanthine, and tyrosine. With the advent of molecular genotyping methods, such as 16S rRNA gene sequencing and hsp65 gene sequencing, more Nocardia species, which could not be distinguished by traditional biochemical reactions, have been discovered. Unfortunately, the isolate from this patient was not available for further studies, and therefore in a strict sense could be just regarded as a Nocardia isolate.

Infections due to Nocardia species - Corrected Proof

Chih-Cheng Lai, Po-Ren Hsueh — 2012-04-12

Su et al reported an unusual case of disseminated nocardiosis in the June 2011 issue of the Journal of Microbiology, Immunology and Infection. In that report, the authors described a case in which Nocardia asteroides was isolated from a thyroid abscess in a 70-year-old retired farmer and reported that the patient responded well to trimethoprim-sulfamethoxazole treatment. Although their findings are interesting, the methods the authors used to identify the isolate to the species level of the Nocardia genus were not shown in detail.

Lemierre's syndrome in a patient with habitual toothpick usage - Corrected Proof

Alice Ying-Jung Wu, Hsiang-Kuang Tseng, Jian Su, Chang-Pan Liu — 2012-04-09

Lemierre's syndrome is characterized by septic thrombophlebitis of the internal jugular vein that is complicated by metastatic infections. The disease usually presents after oropharyngeal infection. In rare cases, odontogenic infection has been implicated as culprit. Here, we report a case of Lemierre's syndrome that most likely developed secondary to toothpick usage. The patient had an uneventful recovery after the timely administration of the appropriate antibiotics.

The clinical implications of ABO blood groups in Pseudomonas aeruginosa sepsis in children - Corrected Proof

Kuang-Che Kuo, Ho-Chang Kuo, Li-Tung Huang, Chien-Seng Lin, San-Nan Yang — 2012-04-05

Background: Pseudomonas aeruginosa (P. aeruginosa) sepsis is a fetal disease with rapid progressive shock for infants and children in hospital and in the community, without initial treatment with appropriate antibiotics. Because underlying risk factors remain unclear for affected patients, it is still difficult for early diagnosis and therapy. Recently, ABO blood group antigens were associated with several infectious diseases. However, it was not reported whether the ABO blood group could be the clinical implications for pediatric Pseudomonas sepsis.Methods: This study retrospectively reviewed the medical records of 23 infants and children with P. aeruginosa sepsis, who were hospitalized at Kaohsiung Chang Gung Memorial Hospital from 2003 to 2009.Results: Eight cases had nosocomial infections, with a higher mortality rate (50%) than 15 cases (26.7%) in the community. Thirteen patients (86.7%) with community-acquired sepsis were infants, significantly younger than the nosocomial cases. ABO blood group antigens were known in 21 cases and B phenotype was the most significant. In the community-acquired group, fever and diarrhea were the most prevalent symptoms on initial presentation. Moreover, pneumonitis was the most concomitant disease in fatal cases.Conclusion: Blood group B was highly associated with pediatric P. aeruginosa sepsis. This could be a risk factor, and play an important role for the pathogenesis of P. aeruginosa sepsis. Furthermore, if a previously healthy infant with fever and diarrhea suddenly had septic presentation, P. aeruginosa infection should be considered. In addition, more intensive care could be needed for such blood group B pediatric patients, if pneumonitis was concomitant on admission for the high mortality rate.