Childhood tuberculosis in southern Taiwan, with emphasis on central nervous system complications

Background/PurposeChildhood tuberculosis (TB) continues to be a major public health problem in Taiwan. Taiwan remains a highly endemic area despite neonatal Bacillus Calmette–Guérin (BCG) vaccination and the availability of anti-TB therapy. The presentation is highly variable and it is often difficult to make an accurate diagnosis. This study was designed to evaluate the demographic, clinical, and laboratory findings and outcomes of TB in children with emphasis on central nervous system (CNS) complications.MethodsThe medical records of 80 children diagnosed with TB at a medical center in southern Taiwan over the past 24 years (1988–2012) were reviewed.ResultsAmong them, 48.8% (39/80) had pulmonary TB, 27.5% (22/80) had isolated extrapulmonary TB, and 23.7% (19/80) had disseminated TB. Most infected cases were aged either < 4 years or > 12 years. TB contact history was found in 42.5% (34/80) cases. Fourteen (17.5%) of the cases had CNS involvement. The most common presentations were fever (85.7%), signs of increased intracranial pressure (71.4%), drowsiness (64.3%), and focal neurological signs (57.1%). The major radiological findings were tuberculoma (50%), basilar enhancement (41.6%), infarction (41.6%), hydrocephalus (16.6%), and transverse myelitis (16.6%). The case fatality of CNS TB was 14.3% and 21.4% had neurologic sequelae.ConclusionFindings suggest that positive exposure history and suspicious clinical presentations are important clues for further confirmatory laboratory and image studies in childhood TB. CNS TB usually presented as part of disseminated TB in children. Early diagnosis and treatment may lead to favorable outcomes in CNS TB

Long-term Characteristics of Healthcare-associated Infections in a Neonatal Intensive Care Unit

Background/PurposeHealthcare-associated infections in neonatal intensive care units (NICUs) are associated with a significant risk of morbidity and mortality. Knowledge regarding pathogens, primary sources of infection and antibiotic resistance in the NICU is essential for developing management strategies. This study aimed to analyze the long-term characteristics of healthcare-associated infections in a tertiary referral center in southern Taiwan.MethodsInfants < 30 days old, with positive blood, cerebrospinal fluid, urine or tissue fluid cultures during hospitalization in the NICU of National Cheng Kung University Hospital from July 1989 to June 2008 were included in the study.ResultsIn total, 1,417 organisms and episodes were identified during the study period. Gram-positive organisms, Gram-negative organisms and fungi constituted 923 (65.1%), 358 (25.3%) and 136 (9.6%) of the pathogens, respectively. Of the Gram-positive organisms, coagulase-negative staphylococci (51.5%), Staphylococcus aureus (34.8%) and Enterococcus spp. (6.1%) were the major pathogens; and 27% of Staphylococcus aureus isolates were oxacillin-resistant. For the Gram-negative organisms, Klebsiella pneumoniae (22%), Pseudomonas aeruginosa (21.8%), Escherichia coli (16.7%) and Enterobacter cloacae (16.7%) were dominant. Also, Candida albicans accounted for 50% of fungal infections. The most common source of infection was bloodstream infection (59.0%), and 5.6% of these were catheter-related. Skin and soft tissue infections were also frequent (26.3%).ConclusionBloodstream and skin/soft tissue infections caused by commensal species play an important role in healthcare-associated infections in the NICU. New measures should be developed in response to the changing patterns in the NICU

Historical Review of Pandemic Influenza A in Taiwan, 2009

Influenza is an important disease in children. In April 2009, human infections caused by a novel swine H1N1 virus were reported in Mexico, followed by a pandemic. As of 14 March 2010, more than 213 countries and overseas territories or communities have reported laboratory-confirmed cases of pandemic influenza H1N1 2009, including at least 16,813 deaths. This influenza pandemic is unique in many respects. Large outbreaks occurred outside the usual season for influenza infection. The virus also caused severe illnesses and deaths in younger people, with many deaths caused by severe pneumonia. A comprehensive approach to pandemic control has been launched, including infection control interventions, antiviral drugs and vaccines. Vaccination is the most efficient way to control morbidity and mortality resulting from influenza infections in humans. For the first time, an influenza vaccine against a pandemic strain became available before the winter. However, the initially smooth influenza vaccination program was disturbed by the fear of possible adverse events following immunization. In Taiwan, mistrust of the influenza vaccination has also caused significant social impacts towards the end of 2009. Lessons learned from this pandemic influenza H1N1 2009 might help health authorities and physicians shape their preparedness for the next pandemic

Enterovirus 71, One Virus and Many Stories

Enterovirus 71 (EV71) has emerged as a significant cause of brainstem encephalitis and acute flaccid paralysis in Taiwan. It may be complicated by autonomic nervous system dysregulation and pulmonary edema (PE). Cytokines in the central nervous system and systemic inflammatory responses play important roles in the pathogenesis of EV71-associated PE. Pathogenesis-based management with intravenous immunoglobulin and milrinone has been associated with reduced mortality in children with severe EV71 infections

Clinical perspectives of childhood tuberculosis in Taiwan

Tuberculosis (TB) is an important public health issue in Taiwan and worldwide. Taiwan has made major progress in combating TB in the past 40 years. However, childhood TB still constitutes a significant challenge in disease control. From January to mid December 2011, 369 new cases of pediatric TB were confirmed. The relatively low case number and variable clinical presentations made it difficult for early detection. Latent TB infections in children also pose further complexity in clinical management. Knowledge of the clinical features of active and latent TB infection is crucial for efficient TB control

Knowledge, attitude, and practice of dengue disease among healthcare professionals in southern Taiwan

Primary physicians and nurses serve as the first-line health care providers of dengue virus infection diagnosis, notification, and treatment. Knowledge, attitude, and practice (KAP) among primary healthcare professionals (HCPs) regarding dengue diseases may pace alarm and improve the outcome of dengue control. Methods: A cross-sectional survey using a structured quiz in 264 HCPs (response rate, 76%) was conducted in Tainan City in southern Taiwan. The quiz consisted of 10 questions regarding the control measures, notification, and clinical practices of dengue diseases. Scores of KAP and demographic characteristics of HCPs were analyzed. Results: One hundred thirty-four physicians and 130 nurses comprise the 264 HCP responders. Forty-three physicians (32%) and 80 nurses (61.5%) were practicing in medical centers, and they scored higher than nonmedical center peers on quizzes on notification (1.18 vs. 0.93 points, p < 0.01) but lower on control measures (3.52 vs. 3.22 points, p < 0.01). Fifty-seven physicians (42.5%) were experienced in reporting suspected dengue cases, and 13.1% of nurses had reported dengue cases. Three-fourths of HCPs failed to respond to the timing of dengue case notification, whereas nurses scored higher than physicians (0.34 vs. 0.16, p < 0.01). In addition, 57.2% of the HCPs failed to respond correctly to the timing of typical skin rashes occurring in the patients with dengue. More than half of the HCPs considered Taiwan an endemic area of dengue diseases. Conclusion: This pilot study showed a lack of acquaintance with notification timing and important clinical features of dengue among HCPs in southern Taiwan. Future continued medical/nursing education should place more emphasis on these factors to improve dengue control in this demographic area

Childhood invasive pneumococcal disease caused by non-7-valent pneumococcal vaccine (PCV7) serotypes under partial immunization in Taiwan

Emerging non-7-valent pneumococcal conjugate vaccine (PCV7) serotypes have replaced PCV7 serotypes in childhood invasive pneumococcal disease (IPD). This study was designed to describe the IPD caused by non-PCV7 serotypes under partial PCV7 immunization in Taiwan. Methods: All children <18 years of age diagnosed with IPD at National Cheng Kung University Hospital from 1998 to 2010 were enrolled. Clinical and laboratory information was collected. Pneumococcal isolates were tested for antimicrobial susceptibility and interpreted using Clinical Laboratory Standard Institute guidelines (2008). Serotypes were determined using the capsular swelling method. Results: One hundred and five patients with IPD were identified, including 75 PCV7 and 30 non-PCV7 isolates. Pneumonia (63.3%) was the leading clinical manifestation of non-PCV7 IPDs and 78.9% of pneumonia cases were associated with necrotizing pneumonia or empyema. Children with non-PCV7 IPDs had longer febrile days, required longer intensive care unit stays, and had a higher C-reactive protein level than those with PCV7 IPDs (p < 0.05). Serotype 3 is the most common non-PCV7 serotype (46.7%) and possesses the highest potential for pulmonary complications (p < 0.05, odds ratio: 0.114; 95% confidence interval, 0.013 – 0.973). Conclusion: The changing epidemiology of IPDs following the introduction of PCV7 has been noted. Expanded serotype coverage of the vaccine is warranted

Lessons learned from dengue: Focus on Taiwan

This chapter outlines the current views on dengue disease, epidemiology, treatment and prevention worldwide and with a focus on the Taiwan experience. Geographical differences in virus spread and in clinical profiles are revealed, as well as ongoing research efforts towards a safe and effective dengue vaccine