Leptospirosis, Q fever, scrub typhus, and murine typhus are endemic zoonotic diseases in southern Taiwan that often present as acute undifferentiated febrile illness. We retrospectively compared epidemiological, clinical, laboratory, and outcome characteristics of leptospirosis (n = 41) and rickettsial infections, including Q fever, scrub typhus, and murine typhus (QSM; n = 103), in Kaohsiung City from 2013 to 2024. Leptospirosis occurred mainly during rainy and typhoon seasons and was associated with myalgia, gastrointestinal symptoms, jaundice, conjunctival suffusion, hepatic and renal dysfunction, leukocytosis, elevated C-reactive protein, and higher rates of acute kidney injury and shock. QSM occurred year-round, with eschar characteristic of scrub typhus, while prolonged activated partial thromboplastin time and relative bradycardia were more common in QSM. QSM generally showed a milder clinical course, particularly Q fever. Distinct clinical and seasonal patterns may facilitate early differentiation and risk stratification in endemic areas.

OBJECTIVES:Current guidelines recommend at least 14 days of antifungal therapy for uncomplicated candidaemia after blood culture clearance, despite limited supporting evidence. We evaluated whether antifungal treatment duration was associated with clinical outcomes. METHODS:This multicentre retrospective study in Taiwan (January 2014 to June 2024) included adults with uncomplicated candidaemia (microbiological clearance within 5 days, adequate source control, and no deep-seated or metastatic infection) completing 7-20 days of antifungal therapy. Patients were classified into short-course (7-13 days) and long-course (14-20 days) groups. Primary outcomes were all-cause mortality within 14 days and recurrence within 90 days after the end of treatment (EOT) and secondary outcomes were EOT 90-day mortality and EOT 1-year recurrence. Inverse probability of treatment weighting (IPTW) was applied to adjust for confounders. RESULTS:Among 203 patients, 72 (35.5%) received short-course and 131 (64.5%) long-course therapy. Overall, EOT 14-day mortality was 7.4% (5.6% versus 8.4% in short-course and long-course groups, respectively). Short-course therapy was not associated with increased EOT 14-day mortality in crude (OR 0.64, 95% CI 0.17-1.95), multivariable (aOR 0.33, 95% CI 0.06-1.35), or IPTW-weighted analyses (aOR 0.42, 95% CI 0.11-1.55). The EOT 90-day recurrence rate was 4.4%, with no significant differences across analyses. IPTW-weighted Kaplan-Meier and subgroup analyses showed consistent findings. No significant differences were observed in secondary outcomes, including EOT 90-day mortality and EOT 1-year recurrence. CONCLUSIONS:Short-course antifungal therapy was not associated with increased mortality or recurrence compared with long-course therapy among patients with uncomplicated candidaemia who achieved adequate source control and microbiological clearance.

BACKGROUND:Melioidosis is an infectious disease caused by the Gram-negative bacterium Burkholderia pseudomallei. The disease is difficult to diagnose and treat. Here, we investigated outcomes of patients with suspected or confirmed melioidosis in Laos and Thailand. METHODOLOGY:We conducted a prospective, multinational, multicenter, observational study at Mahosot Hospital (MH) in Laos, and Srinagarind Hospital (SRH) and Sunpasitthiprasong Hospital (SUH) in Thailand. We enrolled adult patients (age ≥ 18 years) with suspected or confirmed melioidosis. For suspected-melioidosis cases, patients who had septic shock, had sepsis with at least one risk factor associated with melioidosis (including diabetes mellitus, chronic kidney disease, thalassemia major, malignancy and immunosuppressive therapy) or were prescribed ceftazidime or meropenem by attending physicians were enrolled, provided they were within 24 hours of hospitalization at the study hospitals. For confirmed-melioidosis cases, patients who had a clinical specimen tested positive for B. pseudomallei by either culture or antigen-detecting immunofluorescence microscopy were enrolled. The primary endpoints were 28-day and 90-day mortality. PRINCIPAL FINDINGS:From November 2023 to October 2024, 627 patients were screened and 200 patients were enrolled (43 for suspected-melioidosis and 157 for confirmed-melioidosis). Five of 43 patients enrolled with suspected-melioidosis (12%) were subsequently diagnosed with culture-confirmed melioidosis since enrollment. 28-day and 90-day mortality were 14% (6/43) and 23% (10/43) in suspected-melioidosis patients, respectively; and 25% (39/157) and 36% (57/157) in confirmed-melioidosis patients, respectively. In multivariable Cox regression models, higher Sequential Organ Failure Assessment (SOFA) score at enrollment and intensive care unit (ICU) admission on the day of enrollment were strongly associated with mortality outcomes. Admission to SRH and longer duration of symptoms prior to enrollment were independently associated with survival outcomes. CONCLUSIONS:Future clinical trials aiming to reduce mortality in patients with suspected or confirmed melioidosis should consider stratification based on the severity of organ dysfunction at enrollment. Differences in mortality between study sites may reflect residual confounding and should be carefully considered in sample size calculations.

Background Melioidosis is a significant yet neglected cause of sepsis in tropical regions, particularly in southeast Asia, with poor clinical outcomes. It is a growing threat with an expanding global footprint. The causative organism, Burkholderia pseudomallei, is intrinsically resistant to most first-line empiric antibiotic regimens, but acquired resistance to recommended antibiotics for this infection is uncommon. Nonetheless, the genetic determinants of resistance in this species remain poorly elucidated. Case presentation A 60-year-old farmer presented in septic shock to a hospital in Laos, and B. pseudomallei was grown from blood cultures. Following initial antibiotic treatment with meropenem and co-trimoxazole, his infection relapsed. Several subsequent B. pseudomallei isolates from the patient were resistant to multiple antibiotics, and whole genome sequencing demonstrated that this phenotype was associated with a novel 54-kb genomic deletion. This deletion, on chromosome 1, includes the 5’ end of amrR – which encodes a regulator of an efflux pump known to be important in conferring meropenem resistance – as well as 46 other genes, some of which have not been characterised. Treatment was targeted to the new antibiogram, requiring a further prolonged intravenous course and second-line oral eradication therapy. The patient made a full recovery. Conclusions Mutations in Burkholderia pseudomallei lead to increased virulence and drug resistance. Repeat microbiological sampling of patients who do not make clinical improvement as anticipated is essential, with repeat full antimicrobial susceptibility testing on subsequent isolates. Characterisation of drug-resistant mutants is required to understand mechanisms of resistance and to predict phenotypes from whole genome sequencing.

Mixed bloodstream infections (BSIs) involving Candida and other bacterial pathogens present significant diagnostic and therapeutic challenges. The incidence of these co-infections has been increasing. However, the limited literature on this topic necessitates a deeper understanding of its epidemiological and clinical characteristics. This retrospective study evaluated adult patients with candidemia across three hospitals in Taiwan between January 2014 and December 2020. Mixed Candida/bacterial BSIs were defined as the concurrent isolation of bacterial species from any set of blood cultures within 1 week of the initial Candida culture. The clinical features and 30-day mortality of mixed Candida/bacterial BSIs were investigated. Among 766 patients with candidemia, 193 (25.2%) had mixed Candida/bacterial BSIs. The 30-day mortality for mixed infections was significantly higher than for monomicrobial candidemia (62.7% vs. 51.7%, P = 0.009). The mortality rates and intervals between Candida and bacterial blood culture isolation had a negative correlation (P = 0.004). In the mixed Candida/bacterial BSI cases, the most common bacteria included coagulase-negative staphylococci, Enterococcus spp., and Klebsiella spp. Co-infection with vancomycin-resistant Enterococcus had a significantly higher mortality rate than mono-candidemia (P = 0.015). Significant predictors of 30-day mortality included high Pitt score, high sequential organ failure assessment (SOFA) score, inappropriate empiric antibiotics, and lack of adherence to the European Confederation of Medical Mycology Quality of Clinical Candidaemia Management (EQUAL) score. In conclusion, mixed Candida/bacterial BSIs are associated with high mortality and severe clinical conditions. Empirical antibiotic strategies and tailored antifungal treatments, aligned with clinical guidelines, have significantly improved patient outcomes.IMPORTANCEMixed bloodstream infections with Candida and bacteria are serious and deadly. This study demonstrated that Candida/bacterial bloodstream infections (BSIs) accounted for 25.2% of all candidemia cases and were associated with significantly higher 30-day mortality compared with monomicrobial candidemia (62.7% vs 51.7%). Patients with mixed BSIs exhibited more severe clinical conditions, a higher rate of inappropriate antibiotic use, and a greater prevalence of multidrug-resistant organisms. The study further demonstrated that adherence to antifungal treatment recommendations (EQUAL Candida score) and timely initiation of appropriate empirical antibiotics were associated with improved survival. These findings fill a critical gap in the literature and provide important insights into the management of mixed Candida/bacterial BSIs, with implications for optimizing diagnostic and therapeutic strategies in clinical practice.

Background: Leptospirosis (LS) and hantavirus (HV) are rodent-borne diseases and share similar clinical manifestations, posing diagnostic challenges. Methods: This retrospective study compared clinical characteristics, laboratory data, complications and outcomes of 33 LS and nine HV cases in Kaohsiung, Taiwan, from 2006 to 2021. Results: Both LS and HV diseases had high rates of acute kidney injury (84.8% vs 66.7%) and hepatitis (65.6% vs 88.9%); LS showed more hyperbilirubinemia (70% vs 12.5% in HV, p=0.005), higher initial creatinine levels (2.9 vs 1.37, p=0.018) and elevated initial C-reactive protein (218.3 vs 28.6 mg/dl, p<0.001), but lower initial lymphocyte percentage (6.63% vs 14.2%, p=0.005) and platelets (138.7/mm3 vs 68.9, p=0.016) compared with HV. Microscopic hematuria was significantly more prevalent in LS (80% vs 28.65% in HV, p=0.016). Notably, the LS and HV groups exhibited statistically significant differences in thrombocytopenia (57.5% vs 100%, p=0.019), hyperbilirubinemia (70% vs 12.5%, p=0.005), shock (45.5% vs 0%, p=0.016) and hematuria (80% vs 28.6%, p=0.016). Neither group experienced fatalities. Conclusions: Fever, thrombocytopenia and acute kidney injury alert physicians to consider LS and HV for differential diagnosis. Elevated bilirubin, along with hematuria or shock, suggests a preferred diagnosis for LS.

Download This Paper Open PDF in Browser Add Paper to My Library Share: Permalink Using these links will ensure access to this page indefinitely Copy URL Preprints with The Lancet is part of SSRN´s First Look, a place where journals identify content of interest prior to publication. Authors have opted in at submission to The Lancet family of journals to post their preprints on Preprints with The Lancet. The usual SSRN checks and a Lancet-specific check for appropriateness and transparency have been applied. Preprints available here are not Lancet publications or necessarily under review with a Lancet journal. These preprints are early stage research papers that have not been peer-reviewed. The findings should not be used for clinical or public health decision making and should not be presented to a lay audience without highlighting that they are preliminary and have not been peer-reviewed. 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Using Machine Learning to Identify Severe Dengue Cases in the Elderly and Non-Elderly in Southern Taiwan: A Step Toward International Collaboration on Dengue Syndromic Surveillance 47 Pages Posted: 27 Feb 2024 See all articles by Tzong-Shiann HoTzong-Shiann HoNational Cheng Kung University - National Cheng Kung University HospitalWei ChenNational Cheng Kung UniversityChin-Rur YangNational Taiwan UniversityChi-Hua YuNational Cheng Kung UniversityYu-Pei ChenMinistry of Health and Welfare (Taiwan)Chih-Huan ChungKuo General HospitalYa-Yun ChengNational Sun Yat-sen UniversityKo ChangKaohsiung Medical UniversityWei-Ting HsuNational Taiwan UniversitySingLek LiewNational Taiwan UniversityYin-Chuan ChaoNational Cheng Kung UniversityWen-Xuan HuangNational Cheng Kung UniversityChun-Ying WuNational Taiwan UniversityThomas Claudio Guillermo TsaiNational Taiwan UniversityMarie Yung-Chen WuNational Taiwan UniversityYa-Fan TsaoNational Taiwan UniversityChia-Chun ChangNational Taiwan UniversityIng LeeKaohsiung Chang Gung Memorial HospitalChwan-Chuen KingNational Taiwan University More... Abstract Background: High severity and case fatality rates among elderly dengue patients have become growing threats globally. Early recognition of severe dengue is crucial to saving lives.Methods: To evaluate the predictive factors leading to severe dengue in elderly patients, we enrolled 1,728 laboratory-confirmed dengue cases [including 267 severe (15.5%) and 1461 mild cases] from southern Taiwan: (1) two community hospitals and one tertiary medical center in 2015 outbreak in Tainan and (2) another medical center during outbreaks from 2002-2013 in Kaohsiung. Among these, 606 (35.1%) patients were elderly (≥ 65 years). The individual’s clinical symptoms/signs and laboratory findings of dengue were retrospectively collected from chart reviews. Data analyses were run using both epidemiological and machine learning approaches. We further applied the Synthetic Minority Oversampling Technique (SMOTE) to solve the imbalance between severe and non-severe cases. Then, we used a random forest model to select essential features to differentiate between the clinical manifestations of severe and mild cases.Findings: Our model using triage symptoms in the elderly and non-elderly achieved 97% accuracy in training and 95% accuracy in testing on predicting severe dengue. Hemorrhage ranked the highest symptom in predicting severe dengue. Fever was important for diagnosing severe dengue in the elderly, whereas GI-related symptoms were significant for predicting severe dengue in the non-elderly. Lastly, we developed a cloud service to help clinicians detect severe dengue cases earlier.Interpretation: The machine learning model involving 15 triage symptoms, 43 accessory features, and four comorbidities predicted severe dengue cases in the elderly with > 95% accuracy.Funding: The study was sponsored by the National Health Research Institute (NHRI), National Science and Technology Council [NSTC, formerly the Ministry of Science and Technology (MOST) in Taiwan], and National Cheng Kung University Hospital (NCKUH) (NHRI Grant numbers: NHRI 110A1-MRCO-01212103, NHRI-11A1-MRCO-01222202, NHRI-12A1-MRCO-0123-2301, NSTC/MOST Grant Numbers: MOST 105-2815-C-002-059-B, NSTC-111-2327-B-006, NSTC 111-2327-B-005; NCKUH Grant number: NCKUH-11002018) in Taiwan.Declaration of Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.Ethical Approval: Study protocols were reviewed, approved, and executed following the Institutional Review Boards of the National Health Research Institute (NHRI), Miaoli County, Taiwan (NHRI: EC1051108-R2), National Taiwan University (NTU:202212HM042, 202103HM008, 202112HM050), National Cheng Kung University Hospital (NCKUH: A-BR-101-140), Tainan Hospital, Ministry of Health and Welfare (MHW-TNH: 17-017), and Kaohsiung Chang Gung Memorial Hospital (KHCGMH: 202200783B0) Keywords: severe dengue, syndromic surveillance, elderly, comorbidity, machine learning, Taiwan Suggested Citation: Suggested Citation Ho, Tzong-Shiann and Chen, Wei and Yang, Chin-Rur and Yu, Chi-Hua and Chen, Yu-Pei and Chung, Chih-Huan and Cheng, Ya-Yun and Chang, Ko and Hsu, Wei-Ting and Liew, SingLek and Chao, Yin-Chuan and Huang, Wen-Xuan and Wu, Chun-Ying and Tsai, Thomas Claudio Guillermo and Wu, Marie Yung-Chen and Tsao, Ya-Fan and Chang, Chia-Chun and Lee, Ing and King, Chwan-Chuen, Using Machine Learning to Identify Severe Dengue Cases in the Elderly and Non-Elderly in Southern Taiwan: A Step Toward International Collaboration on Dengue Syndromic Surveillance. Available at SSRN: https://ssrn.com/abstract=4736609 Tzong-Shiann Ho National Cheng Kung University - National Cheng Kung University Hospital ( email ) TainanTaiwan Wei Chen National Cheng Kung University ( email ) No.1, University RoadTainanTaiwan Chin-Rur Yang National Taiwan University ( email ) Chi-Hua Yu (Contact Author) National Cheng Kung University ( email ) Yu-Pei Chen Ministry of Health and Welfare (Taiwan) ( email ) Chih-Huan Chung Kuo General Hospital ( email ) Ya-Yun Cheng National Sun Yat-sen University ( email ) 70 Lien-hai Rd.Kaohsiung, 80743Taiwan Ko Chang Kaohsiung Medical University ( email ) Wei-Ting Hsu National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan SingLek Liew National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan Yin-Chuan Chao National Cheng Kung University ( email ) No.1, University RoadTainanTaiwan Wen-Xuan Huang National Cheng Kung University ( email ) No.1, University RoadTainanTaiwan Chun-Ying Wu National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan Thomas Claudio Guillermo Tsai National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan Marie Yung-Chen Wu National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan Ya-Fan Tsao National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan Chia-Chun Chang National Taiwan University ( email ) 1 Sec. 4, Roosevelt RoadTaipei 106, 106Taiwan Ing Lee Kaohsiung Chang Gung Memorial Hospital ( email ) Chwan-Chuen King National Taiwan University ( email ) Download This Paper Open PDF in Browser Please enable JavaScript to view the comments powered by Disqus. 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Objectives: The trailing effect of Candida species is a phenomenon characterized by reduced but persistent growth at antifungal concentrations above the MIC. We assessed the impact of trailing growth on the persistence of Candida albicans candidemia in patients receiving fluconazole (FLC) therapy. Methods: We retrospectively investigated candidemia isolates at three hospitals in southern Taiwan between 2013 and 2020. Patients treated with FLC for FLC-susceptible C. albicans candidemia were enrolled. The degree of trailing was determined as the average growth above the MIC divided by the measured growth at the lowest drug concentration using the EUCAST method and classified into four categories: residual (0.1-5%), slight (6-10%), moderate (11-15%), and heavy trailers (>15%). Results: Among isolates from 190 patients, the proportions of heavy trailers at 24 hours, 48 hours, and 72 hours were 63.7% (121/190), 63.2% (120/190), and 74.7% (142/190), respectively. Persistent candidemia was observed in 17 (8.9 %) patients. The proportion of persistent C. albicans candidemia in heavy trailing isolates at 48 hours was higher than in isolates without heavy trailing (13.3% [16/120] vs. 1.4% [1/70], p = 0.007). A multivariate analysis showed that immunosuppression (OR = 7.92; 95% CI: 2.38-26.39, p = 0.001), hospitalization days after the index date of C. albicans identification (OR = 1.03; 95% CI: 1.01-1.05, p = 0.011), and heavy trailing isolates at 48 hours (OR = 10.04; 95% CI: 1.27-79.88, p = 0.029) were independent factors for persistent candidemia. Discussion: The current study revealed that heavy trailing in C. albicans isolates is associated with persistent candidemia in patients receiving FLC treatment.

BackgroundDengue virus serotype 2 (DENV-2) was the major serotype in the 2015 dengue outbreak in Taiwan, while DENV-1 and DENV-3 were dominant between 2005 and 2014. We aimed to investigate whether DENV-2 contributed to disease severity and mortality in the outbreak in Kaohsiung city, Taiwan.MethodsWe collected serum samples from dengue patients to detect the presence of DENV and determine the serotypes by using quantitative reverse transcription-polymerase chain reaction. Our cohorts comprised 105 DENV-1-infected cases and 1,550 DENV-2-infected cases. Demographic data, DENV serotype, and comorbidities were covariates for univariate and multivariate analyses to explore the association with severity and mortality.ResultsThe results suggested that DENV-1 persisted and circulated, while DENV-2 was dominant during the dengue outbreak that occurred between September and December 2015. However, DENV-2 did not directly contribute to either severity or mortality. Aged patients and patients with diabetes mellitus (DM) or moderate to severe chronic kidney disease (CKD) had a higher risk of developing severe dengue. The mortality of dengue patients was related to a higher Charlson comorbidity index score and severe dengue. Among DENV-2-infected patients and older patients, preexisting anti-dengue IgG, DM, and moderate to severe CKD were associated with severe dengue. Moreover, female sex and severe dengue were associated with a significantly higher risk of death.ConclusionsOur findings highlight the importance of timely serological testing in elderly patients to identify potential secondary infections and focus on the meticulous management of elderly patients with DM or moderate to severe CKD to reduce dengue-related death.

Global travel and climate change have drastically increased the number of countries with endemic or epidemic dengue. The largest dengue outbreak in Taiwan, with 43,419 cases and 228 deaths, occurred in 2015. Practical and cost-effective tools for early prediction of clinical outcomes in dengue patients, especially the elderly, are limited. This study identified the clinical profile and prognostic indicators of critical outcomes in dengue patients on the basis of clinical parameters and comorbidities. A retrospective cross-sectional study was conducted in a tertiary hospital from 1 July 2015 to 30 November 2015. Patients diagnosed with dengue were enrolled, and the initial clinical presentations, diagnostic laboratory data, details of the underlying comorbidities, and initial management recommendations based on 2009 World Health Organization (WHO) guidelines were used to evaluate prognostic indicators of critical outcomes in dengue patients. Dengue patients from another regional hospital were used to evaluate accuracy. A group B (4 points) classification, temperature < 38.5 °C (1 point), lower diastolic blood pressure (1 point), prolonged activated partial thromboplastin time (aPTT) (2 points), and elevated liver enzymes (1 point) were included in the scoring system. The area under the receiver operating characteristic curve of the clinical model was 0.933 (95% confidence interval [CI]: 0.905–0.960). The tool had good predictive value and clinical applicability for identifying patients with critical outcomes.

Background: Accurately identifying risk factors that predict fatality in dengue is crucial for patient triage and clinical management. Our objective was to identify predictors of death associated with dengue and investigate the clinical characteristics and risk factors among patients with chronic kidney disease (CKD) who died from dengue. Methods: A multicenter longitudinal observation study conducted from 2008 to 2019. Results: A total of 1272 patients (113 who died and 1186 who recovered) diagnosed with dengue were included. Old age, CKD, and an elevated white blood cell count at hospital presentation were identified as independent predictors of in-hospital mortality among individuals infected with the dengue virus. In a subgroup analysis of 138 patients with CKD infected with dengue virus, 64 (46.3%) patients died, with 46 (33.3%) patients dying within 7 days after symptom onset. Among 64 fatal dengue patients with CKD, 34.4% were in stages 2 and 3 of kidney disease, 51.5% were in stages 4 and 5, and 14.1% had end stage renal disease as per the classification by Kidney Disease Improving Global Outcomes. Multivariate analysis revealed that initial altered consciousness, pulmonary edema, and leukocytosis during hospitalization were independently associated with in-hospital mortality in CKD patients infected with the dengue virus. Leukocytosis during hospitalization and severe hepatitis were independent risk factors for death within 7 days after dengue illness onset in CKD patients. Conclusions: This study offers valuable insights into predictors linked to fatality in dengue and reinforces the importance of optimizing patient triage to improve the quality of care.

Malaria was eradicated in Taiwan in 1952; however, imported malaria cases are reported every year. The subtropical climate in Taiwan permits mosquito propagation and possible outbreaks of mosquito-borne diseases. The aim of this study was to investigate travelers' compliance and side effects of malaria prophylaxis to prevent a malaria outbreak in Taiwan. In this prospective study, we enrolled travelers who visited our travel clinic before going to malarious areas. A total of 161 questionnaires were collected and analyzed. Associations between the occurrence of side effects and compliance with antimalarial drugs were analyzed. Adjusted odds ratios were calculated after adjusting for potential risk factors in multiple logistic regression analysis. Of the 161 enrolled travelers, 58 (36.0%) reported side effects. Insomnia, somnolence, irritability, nausea, and anorexia were associated with poor compliance. Mefloquine was not associated with more neuropsychological side effects than doxycycline. Multiple logistic regression analysis showed that chemoprophylaxis compliance was affected by a younger age, visiting friends and relatives, visiting the travel clinic more than 1 week before the trip, and preferring to use the same antimalarial regimen on the next trip. Our findings could provide information to travelers besides labeled side effects to improve compliance with malaria prophylaxis and consequently help to prevent malaria outbreaks in Taiwan.

Dengue is considered to be an endemic disease in Taiwan, and a strong association between the COVID-19 epidemic and a reduced risk of dengue has been reported in endemic areas.1 A total of 34,722 cases of dengue local to Kaohsiung City were recorded from 2014 to 2015, however no local dengue cases were reported in 2020 or 2021.2 We believe that the major reason for the absence of locally transmitted dengue cases is due to border control. During the COVID-19 pandemic, strict border control policies have been implemented in Taiwan, including 14 days quarantine at an appointed location. Approximately 29 million inbound passengers arrived in Taiwan in 2019 compared to around 4 million in 2020,3 and this has reduced the number of imported cases of dengue in Taiwan. Another reason for the absence of locally transmitted dengue cases may be because the Kaohsiung City Government Health Bureau established an airport quarantine referral station in September 2016 to reduce the occurrence of dengue. Officers from the Center for Disease Control, Taiwan, test passengers who have a fever on arrival at Kaohsiung International Airport for NS1 (nonstructural protein 1), and then these passengers are transferred to neighboring hospitals by quarantine referral station personnel.4 From 2016 to 2021, a total of 49 NS1-positive cases were treated in isolation, of whom 20 were confirmed to have dengue. This helped to prevent the spread of confirmed cases in the community. In addition, migrant workers, fishermen, and crews from Southeast Asia are required to immediately (within 3 days at the latest) go to a designated medical institution for comprehensive blood screening. Those who are positive are then sent to a designated hospital in Kaohsiung City for treatment and quarantine. From 2016 to 2020, among 53,548 foreign migrant workers and fishermen, 122 were found to be NS1-positive, of whom 8 were diagnosed with dengue (6.56%), and the diagnosis rate was 0.15‰ (data from the Kaohsiung Health Bureau). Of the 53,548 foreign migrant workers and fishermen, 43,324 were foreign migrant workers (94 were NS1-positive, 6 confirmed cases [6.38%], diagnosis rate 0.138‰), and 10,224 were fishermen (28 were NS1-positive, 2 confirmed cases [7.14%], diagnosis rate 0.1956‰) (data from the Kaohsiung Health Bureau). Fewer foreign tourists, airport quarantine referrals and inbound foreign migrant workers has resulted in a significant decline in dengue cases in Kaohsiung City in the recent 5 years, and the incidence rate has also been lower than that in the north of Taiwan. This observation provides further evidence to support that imported dengue cases from other countries are the source of local dengue transmission annually, and that continuous monitoring of dengue will be important as COVID-19-related restrictions are lifted in Taiwan as an endemic area. Although screening for fever at airports can screen out symptomatic cases, those infected with dengue who are still in the incubation period may be missed. We believe that blood testing and timely screening for overseas migrant workers can help to prevent the threat of dengue in southern Taiwan. The authors declare no conflicts of interest.

[This corrects the article DOI: 10.3389/fmed.2022.869818.].

The Clinical and Laboratory Standards Institute (CLSI) revised the fluoroquinolone MIC breakpoints for Enterobacterales in 2019, based on pharmacokinetic/pharmacodynamic analyses. However, clinical evidence supporting these breakpoint revisions is limited.

Angiostrongyliasis in humans causes a range of symptoms from mild headache and myalgia to neurological complications, coma and death. Infection is caused by the consumption of raw or undercooked intermediate or paratenic hosts infected with Angiostrongylus cantonensis or via contaminated vegetables or water. We describe a cluster of cases involved in the shared meal of wild raw monitor lizard in the Lao PDR. Seven males, aged 22–36 years, reported headaches, abdominal pain, arthralgia, myalgia, nausea/vomiting, diarrhea, neurological effects and loss of appetite. Five were admitted to hospital. The final diagnosis was made by clinical presentation and case history, and positive A. cantonensis PCR for two cases. All hospitalized patients recovered fully following supportive treatment. The remaining two individuals sought local home remedies and made full recovery. Whilst most published reports concern infections via consumption of molluscs, few detailed reports exist on infections that result from the consumption of reptiles and there exists little awareness in Lao PDR. This case cluster, which originates from a single meal, highlights the potential public health risk of the consumption of raw and wild-caught meat in Lao PDR and the Southeast Asia region. Without specific diagnostics, clinical history and the consideration of recent food consumption are important when evaluating patients.

BACKGROUND:Dengue epidemics is affected by vector-human interactive dynamics. Infectious disease prevention and control emphasize the timing intervention at the right diffusion phase. In such a way, control measures can be cost-effective, and epidemic incidents can be controlled before devastated consequence occurs. However, timing relations between a measurable signal and the onset of the pandemic are complex to be discovered, and the typical lag period regression is difficult to capture in these complex relations. This study investigates the dynamic diffusion pattern of the disease in terms of a probability distribution. We estimate the parameters of an epidemic compartment model with the cross-infection of patients and mosquitoes in various infection cycles. We comprehensively study the incorporated meteorological and mosquito factors that may affect the epidemic of dengue fever to predict dengue fever epidemics.RESULTS:We develop a dual-parameter estimation algorithm for a composite model of the partial differential equations for vector-susceptible-infectious-recovered with exogeneity compartment model, Markov chain Montel Carlo method, and boundary element method to evaluate the epidemic periodicity under the effect of environmental factors of dengue fever, given the time series data of 2000-2016 from three cities with a population of 4.7 million. The established computer model of "energy accumulation-delayed diffusion-epidemics" is proven to be effective to predict the future trend of reported and unreported infected incidents. Our artificial intelligent algorithm can inform the authority to cease the larvae at the highest vector infection time. We find that the estimated dengue report rate is about 20%, which is close to the number of official announcements, and the percentage of infected vectors increases exponentially yearly. We suggest that the executive authorities should seriously consider the accumulated effect among infected populations. This established epidemic prediction model of dengue fever can be used to simulate and evaluate the best time to prevent and control dengue fever.CONCLUSIONS:Given our developed model, government epidemic prevention teams can apply this platform before they physically carry out the prevention work. The optimal suggestions from these models can be promptly accommodated when real-time data have been continuously corrected from clinics and related agents.

This study aimed to investigate the effects of multi-drug-resistant organism (MDRO) infection and other factors on the length of hospital stay (LOS) of patients in the respiratory care ward (RCW) of a regional hospital in Taiwan. In this retrospective study, we collected cases from MDRO-infected patients in the RCW from January 2016 to March 2020. The RCW comprises 13 beds in total. There were 106 infected patients, of which 42 were in the case group (infected with MDROs) and 64 were in the control group (not infected with MDROs). Clinical specimens were inoculated in a selective medium to isolate the pathogenic bacteria by standard procedures. The results showed the main factors affecting the LOS were: patients with MDRO infection, patients discharged from the RCW, and patients who underwent catheterization. The LOS of patients infected with MDROs was significantly longer than that of patients without MDRO infection (β = 0.55, 95% CI = 0.02–1.09), with the case group and the control group being 479.8 ± 546.5 and 307.3 ± 436.2 days, respectively. Infection with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was associated with a longer LOS than other MDRO strains. These findings have important implications for infection control in RCW and in better tracking the health of patients.

Background: Intracranial hemorrhage (ICH) or infarction in dengue cases is rare but very challenging for clinicians. We report these uncommon complications of dengue patients and focused on the significant factors associated with ICH or infarction in dengue patients. Methods: This investigation was a retrospective study of 182 adult dengue patients who received brain computed tomography at three Taiwan hospitals during the 2014 and 2015 dengue outbreaks. This included 13 hemorrhage cases, 26 infarction cases and 143 cases without brain infarction or hemorrhage. Results: Among them, 13 (7.14%) suffered from ICH (6 had subdural hemorrhage, 3 had subarachnoid hemorrhage, 1 had subdural and subarachnoid hemorrhage, and 3 had intracerebral hemorrhage) and 26 (14.3%) had brain infarction. The overall mortality rate was 4/13 (30.8%) in the ICH group and 3/26 (11.5%) in the infarction group. The significant variables from the univariate analysis, including difference between 2014 and 2015, age, history of cerebrovascular accident, bone pain, arthralgia, dizziness, altered consciousness, and a higher Charlson comorbidity score. Multivariate analysis revealed that significant risk factors for ICH/infarction in dengue cases were the year of occurrence, 2014 vs. 2015 (p < 0.0001, OR = 25.027, 95% CI = 8.205-76.336 ), Charlson score >4 (p = 0.01, OR = 3.764, 95% CI = 1.364-10.386) and altered consciousness (p < 0.0001, OR = 6.3, 95% CI = 2.242-17.7). The factors physicians should notice in dengue endemic regions for brain infarction or ICH include altered consciousness and a Charlson score >4, especially in the year that a higher frequency of infarction/ICH was observed. Copyright 2021, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).