To study the association between number and positions of mutations with MICs of fluoroquinolone non‐susceptible Haemophilus influenzae.

We investigated the clinical characteristics of patients with pneumonia caused by Aeromonas species. Patients with pneumonia caused by Aeromonas species during the period 2004 to 2011 were identified from a computerized database of a regional hospital in southern Taiwan. The medical records of these patients were retrospectively reviewed. Of the 84 patients with pneumonia due to Aeromonas species, possible Aeromonas pneumonia was diagnosed in 58 patients, probable Aeromonas pneumonia was diagnosed in 18 patients, and pneumonia due to Aeromonas was conclusively diagnosed in 8 patients. Most of the cases of Aeromonas pneumonia developed in men and in patients of advanced age. A. hydrophila (n = 50, 59.5 %) was the most common pathogen, followed by A. caviae (n = 24, 28.6 %), A. veronii biovar sobria (n = 7, 8.3 %), and A. veronii biovar veronii (n = 3, 3.6 %). Cancer (n = 37, 44.0 %) was the most common underlying disease, followed by diabetes mellitus (n = 27, 32.1 %). Drowning-associated pneumonia developed in 6 (7.1 %) patients. Of 47 patients who were admitted to the intensive care ward, 42 patients developed acute respiratory failure and 24 of those patients died. The overall in-hospital mortality rate was significantly associated with liver cirrhosis, cancer, initial presentation of shock, and usage of mechanical ventilation. In conclusion, Aeromonas species should be considered as one of the causative pathogens of severe pneumonia, especially in immunocompromised patients, and should be recognized as a cause of drowning-associated pneumonia. Cirrhosis, cancer, and shock as the initial presenting symptom are associated with poor outcome.

Aeromonas dhakensis, often phenotypically identified as Aeromonas hydrophila, is an important human pathogen. The present study aimed to compare the clinical and biological features of A. dhakensis and A. hydrophila isolates from human wounds. A total of 80 Aeromonas wound isolates collected between January 2004 and April 2011 were analysed. The species was identified by the DNA sequence matching of rpoD and gyrB (or rpoB if necessary). Most of the Aeromonas isolates were identified as A. dhakensis (37, 46.3%), and 13 (16.3%) as A. hydrophila. Both species alone can cause severe skin and soft-tissue infections. More A. dhakensis isolates were found in wounds exposed to environmental water (32.4% vs 0%, p 0.042). More biofilm formation was noted among A. dhakensis isolates (mean optical density at 570 nm, 1.23 ± 0.09 vs 0.78 ± 0.21, p 0.03). The MICs of ceftriaxone, imipenem and gentamicin for A. dhakensis isolates were higher (p <0.0001, <0.04, and <0.01, respectively). The survival rates of Caenorhabditis elegans co-incubated with A. dhakensis from day 1 to day 3 were lower than those of worms infected with A. hydrophila in liquid toxicity assays (all p values <0.01). Isolates of A. dhakensis exhibited more cytotoxicity, as measured by the released leucocyte lactate dehydrogenase levels in human normal skin fibroblast cell lines (29.6 ± 1.2% vs 20.6 ± 0.6%, p <0.0001). The cytotoxin gene ast was primarily present in A. hydrophila isolates (100% vs 2.7%, p <0.0001). In summary, A. dhakensis is the predominant species among Aeromonas wound isolates, and more virulent than A. hydrophila.

SUMMARY Non-typhoidal Salmonella (NTS) is a common pathogen causing foodborne infections, bacteraemia, and extra-intestinal focal infections (EFIs) in humans. The study compares the clinical characteristics of elderly patients with NTS bacteraemia with those of young adults. Of 272 adults with NTS bacteraemia identified in this study, 162 (59·6%) were aged ⩾55 years. EFIs were observed in 36% of the 162 patients. The most common EFIs in the elderly patients (⩾55 years) was mycotic aneurysm, followed by pulmonary infections and bone/joint infections. Elderly patients more often had chronic heart, lung, renal and malignant diseases, had more EFIs, and a higher 30-day mortality rate. Independent factors of 30-day mortality in elderly patients were solid-organ tumour [adjusted odds ratio (aOR) 4·4, P=0·003], mycotic aneurysm (aOR 3·7, P=0·023) and shock (aOR 12·1, P<0·0001). HIV infection, autoimmune diseases, and receipt of immunosuppressive therapy were more often observed in young patients.

The purpose of this study was to understand the seasonal, geographical and clinical characteristics of Taiwanese patients hospitalized for non-typhoidal Salmonella (NTS) infections and their economic burden. Hospital data obtained from the Taiwan National Health Insurance (NHI) database between 2006 and 2008 were analysed. Infants had the highest annual incidence of 525 cases/100 000 person-years. Elderly patients aged >70 years had the highest in-hospital mortality rate (2·6%). Most (82·6%) gastroenteritis occurred in children aged <10 years. Septicaemia, pneumonia, arthritis and osteomyelitis occurred mainly in patients aged >50 years. A median medical cost for NTS-associated hospitalizations was higher for patients with septicaemia than for those with gastroenteritis. Seasonal variation of NTS-associated hospitalizations was correlated with temperature in different areas of Taiwan. In summary, infants had a high incidence of NTS-associated hospitalizations. However, the elderly had a higher in-hospital mortality rate and more invasive NTS infections than children.

Background: Antiretroviral drug resistance can reduce the effectiveness of HIV-1 therapy. Resistance should be examined among the treatment-naïve HIV-1 infected so that optimal drugs therapy can be prescribed. We studied its prevalence and pattern among 101 newly identified HIV-1 patients in southern Taiwan. Methods: HIV-1 RNA from plasma was sequenced for the protease (PR) and reverse transcriptase region, from which the HIV-1 subtype can also be determined. Drug-resistant mutations were examined using the algorithm of the French National Agency for AIDS Research (ANRS). Results: Subtypes were 43 B', 8 CRF01_AE and 50 CRF07_BC. Averages of two clinical parameters were calculated for each subtype: CD4 counts and HIV copies (in log10) were both the worse among patients with the CRF01_AE and the best in patients with the CRF07_BC (all p < 0.05, t-test). Resistance to 3 categories of drugs was examined: Nucleoside Reverse Transcriptase Inhibitor (NRTI), non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) and Protease Inhibitor (PI); five and nine patients harbored mutations that conferred resistance and possible resistance to at least one drug, respectively. Among the 3 subtypes, B' had the highest resistance to any drug, 6.4%, followed by CRF07_BC, 4%. When analyzed by 3 drug categories: 1 patient was resistant and 2 were possible resistant to any NRTI; 4 were resistant and 1 was possible resistant to any NNRTI; 1 was resistant and 7 was possible resistant to any PI. When further stratified by subtypes: 2% CRF07_BC was resistant and 4.7% B' were possible resistant to any NRTI; 4.7% B' and 4% CRF07_BC were resistant, as well as 2.3% B' was possible resistant to any NNRTI; 2.3% B' was resistant, as well as 4.7% B', 50% CRF01_AE and 2% CRF07_BC were possible resistant to any PI. The 50% "possible resistance" to PI drugs for CRF01_AE was unusually high. Because resistance-mutation definitions in ANRS, including secondary mutations, were mostly based on B subtype, the PR gene of the CRF01_AE could contain polymorphic substitutions that were mis-interpreted as mutations. Conclusion: Among HIV-1 treatment-naïve patients in southern Taiwan, B' subtype and NNRTIs were associated with higher percentages of drug resistance as compared to other groups. Further in-vitro studies on the PR gene of the CRF01_AE are warranted to clarify roles of the known secondary mutations in this subtype.

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

Vancomycin-resistant enterococci (VRE) were isolated from 41 patients at a medical centre in southern Taiwan from 1999 to 2005. This accounted for 0.55% of 7449 patients with clinical colonisation or infection due to Enterococcus species. Nine (22%) patients had clinical infections caused by VRE. Twenty-five (61%) VRE isolates were Enterococcus faecalis with VanA phenotype and vanA gene cluster, the remaining 16 (39%) isolates were Enterococcus faecium with VanB phenotype and vanB (15 isolates) or vanA (1 isolate) gene cluster. The esp gene cluster was found in 6 (24%) E. faecalis isolates and 14 (87.5%) E. faecium isolates, and hyl in 2 (8%) E. faecalis and 6 (37.5%) E. faecium isolates. Analysis of SmaI-digested DNA by pulsed-field gel electrophoresis revealed that most isolates of E. faecalis were distinct, indicating a limited person-to-person spread or sporadic nature of spread. By contrast, 10 (67%) of 15 VanB phenotype E. faecium isolates were identical, suggesting the presence of an occult and limited clonal spread at the hospital. The presence of the esp or hyl gene was not associated with the virulence or outbreak of VRE. In summary, epidemiological data and molecular typing suggest that there was occult clonal spread of VanB phenotype-vanB genotype E. faecium in the surgical ICU, and the limited person-to-person spread or sporadic nature of E. faecalis. Infection control measures are warranted due to the potential for spread of VRE.

Fluoroquinolones have been widely used to treat respiratory tract infections, but fluoroquinolone resistance in Haemophilus influenzae has remained rare. In 2007, prospective surveillance cultures of throat swabs and sputum were conducted every two months on 150 residents of four nursing homes in southern Taiwan. Forty-eight H. influenzae isolates were obtained from 30 (20%) residents. All isolates were non-b serotype and 27 (56.3%) possessed beta-lactamases. Resistance to levofloxacin [minimum inhibitory concentration (MIC) >2 microg/mL] and moxifloxacin (MIC >1 microg/mL) was found in 20 (41.7%) and 21 (43.8%) isolates, respectively. High level levofloxacin and moxifloxacin resistance (MIC >32 microg/mL) was detected in 19 (39.6%) and 15 (31.3%) isolates, respectively. Among 150 residents, those with urinary catheterisation (P=0.018) and tracheostomy tubes (P=0.029) were independently associated with airway colonisation by moxifloxacin-resistant H. influenzae. Among 30 residents with carriage of H. influenzae, no factor was significantly associated with moxifloxacin resistance. Pulsed-field gel electrophoresis of the isolates revealed 14 distinct types. Two major clones accounted for 29 isolates, 27 of which were obtained from 13 residents in one nursing home. All but two of the fluoroquinolone-resistant isolates belonged to these two major clones. This study highlights the emergence of fluoroquinolone-resistant H. influenzae and its clonal spread among nursing home residents in southern Taiwan. Further studies on clinical implications and the extent of fluoroquinolone non-susceptibility and resistance are needed.

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

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

Klebsiella pneumoniae was rarely reported to cause complicated skin and soft tissue infections (cSSTIs). Our study was to delineate clinical characteristics and outcome of cSSTIs involving extremities caused by K. pneumoniae.

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