Carbapenem-Resistant Enterobacteriaceae Infections: Taiwan Aspects

Carbapenem-resistant Enterobacteriaceae (CRE), a major resistance concern emerging during the last decade because of significantly compromising the efficacy of carbapenem agents, has currently become an important focus of infection control. Many investigations have shown a high association of CRE infections with high case-fatality rates. In Taiwan, a few surveys observed that a significant proportion (29–47%) of the CR-Klebsiella pneumoniae isolates harbored a plasmidic allele encoding K. pneumoniae carbapenemases (KPC, especially KPC-2). A significant increase in the number of oxacillinase (OXA)-48-like carbapenemases among CR-K. pneumoniae isolates was observed between 2012 and 2015. By striking contrast, isolates of CR-Escherichia coli and CR-Enterobacter species in Taiwan had a much lower percentage of carbapenemase production than CR-K. pneumoniae isolates. This differs from isolates found in China as well as in the India subcontinent. Apart from the hospital setting, CRE was also cultured from the inpatients from communities or long-term care facilities (LTCF). Therefore, implementation of regular CRE screening of LTCF residents, strict disinfectant use in nursing homes and hospital settings, and appropriate control of antibiotic prescriptions is suggested to alleviate the spread of clinical CRE isolates in Taiwan. Although there are some promising new antibiotics against CRE, such as ceftazidime-avibactam, meropenem-vaborbactam, aztreonam-avibactam and cefiderocol, these agents are not available in Taiwan currently. Therefore, in order to effectively decrease case-fatality rates among patients with the infections owing to carbapenemase-producing CRE isolates, combination antibiotic schemes, including colistin (or amikacin) and/or tigecycline in combination with an anti-pseudomonal carbapenem agent, remain the mainstay for treating clinical CRE infections

Antimicrobial Drug Resistance in Taiwan

Antimicrobial resistance is a major global health threat associated with high mortality rates and high medical costs. Geographic variations in resistance profiles of bacterial and fungal pathogens have had a considerable impact on antimicrobial prescription. In Taiwan, there is an alarmingly high prevalence of penicillin-resistant Streptococcus pneumoniae, multidrug-resistant and extensively drug-resistant (XDR) Pseudomonas aeruginosa and Acinetobacter baumannii, extended-spectrum β-lactamase-producing Klebsiella pneumoniae, penicillin- and fluoroquinolone-resistant Neisseria gonorrhoeae, and azole-resistant Candida species. In addition, the emergence of XDR Mycobacterium tuberculosis has illustrated the need for regular monitoring of the resistance profiles of clinical isolates. A few clones of XDR A. baumannii and methicillin-resistant Staphylococcus aureus of unique sequence type (ST 59) have disseminated in Taiwanese hospital settings. Besides, the existence of a transposon-harboring carbapenemase gene has been verified in XDR P aeruginosa strains throughout Taiwan. An end to the worsening trends in the emergence of antimicrobial resistance will require continuous survey of resistance data from clinical isolates and effective implementation of strict infection control policies in healthcare settings and animal husbandry

Cryptococcemia: clinical feature and prognostic factors

BACKGROUND: Limited data are available on the clinical significance of cryptococcaemia, which occurs in 10-30% of patients with cryptococcal diseases. AIM: To describe the clinical features of cryptococcaemia and identify its prognostic factors. STUDY DESIGN: Retrospective cohort study . METHODS: All adult patients with Cryptococcus neoformans isolated from blood culture at the National Taiwan University Hospital, Taipei, 1981- 2001, were included. Demographic and clinical information was obtained from medical records. RESULTS: Fifty-two patients were diagnosed and treated for cryptococcaemia. Acquired immunodeficiency syndrome (24/52, 46 %), immunosuppressive therapy (12/52, 23% ) and decompensated liver cirrhosis (11/52, 21%) were the three major predisposing conditions. Forty -two patients (81% , n=52) had sepsis, including four patients with septic shock, when blood cultures were obtained. Of the 38 patients in whom lumbar puncture was done, cerebrospinal fluid culture showed meningeal involvement in 32 (84%). The 30-day fatality rate was 37%. Liver cirrhosis , septic shock at presentation, an initial APACHE II score >/=20, age >/= 60 years and female gender were associated with mortality under univariate analysis. Starting antifungal therapy within 48 h after blood culture was associated with improved survival. Under multivariate analysis, liver cirrhosis remained a strong independent predictor of mortality at 30 days after blood culture (HR 16.3, 95%CI 2.6-101.7, p=0.003). DISCUSSION: Patients with cryptococcaemia have a high risk of mortality within 30 days . Sepsis and meningeal involvement are common. Those with liver cirrhosis have a particularly poor prognosis

Nationwide Surveillance of Antimicrobial Resistance among Haemophilus Influenzae and Streptococcus Pneumoniae in Intensive Care Units in Taiwan

A nationwide susceptibility surveillance of Streptococcus pneumoniae and Haemophilus influenzae isolates collected from patients treated at the intensive care units (ICUs) of ten Taiwanese major teaching hospitals was conducted from September 2005 through November 2005. High rates of resistance (intermediate/resistant) of S. pneumoniae to penicillin (85% resistance), ceftriaxone (46%/20%), and cefepime (43%/15%) by meningitis criteria, and in contrast, non-susceptibilities (intermediate/resistant) to penicillin (0%/0%), ceftriaxone (20%/0%) and cefepime (15%/0%) by non- meningitis criteria were noted (p values < 0.05) by the Clinical and Laboratory Standards Institute 2008. Resistant rate of S. pneumoniae to azithromycin was also high (63%). S . pneumoniae isolates were significantly more susceptible to ertapenem (87%) than to imipenem (39%) and meropenem (44%) (p values < 0.05). Rates of non-susceptibilities of H. influenzae isolates to ampicillin and cefaclor were high (55 % and 45%, respectively). No beta-lactamase-negative ampicillin-resistant (BLNAR) H. influenzae isolates were found. Imipenem has a notably higher MIC90 value (8 mu g/ml) for H. influenzae than that of the other two carbapenems. Tigecycline showed good in vitro activities against these two respiratory pathogens. High rates of resistance among isolates of S. pneumoniae and H. influenzae continue to exist in the ICUs of Taiwan

Nationwide Surveillance of Antimicrobial Resistance among Non- Fermentative Gram-Negative Bacteria in Intensive Care Units in Taiwan: Smart Programme Data 2005

A nationwide surveillance of the antimicrobial susceptibilities of glucose non-fermentative Gram-negative bacteria isolates was conducted from 1 September 2005 to 30 November 2005 in Taiwan. A total of 456 isolates were recovered from patients hospitalised in the Intensive Care Units (ICUs) of ten major teaching hospitals. Rates of resistant pathogens , such as ciprofloxacin-resistant Pseudomonas aeruginosa (19%) and imipenem-resistant Acinetobacter baumannii (25%), were higher than those reported in 2000 (8% and 22%, respectively). Increased rates of isolates with resistant phenotypes correlated with prolonged length of ICU stay (48 h to ≤7 days vs. >7 days) for ceftazidime-non-susceptible P. aeruginosa (20.0% and 29.7%, respectively), imipenem-non-susceptible P. aeruginosa (4.0% and 13.5%, respectively) and imipenem-non- susceptible A. baumannii (15.4% and 29.8%, respectively), but not for ciprofloxacin- resistant P. aeruginosa. Alarming rates of emergence of extensively drug- resistant (XDR) A. baumannii (15%) and XDR P. aeruginosa (1.8%) were found , particularly among those isolates that were not susceptible to tigecycline and colistin. Interhospital dissemination of some clones of XDR A. baumannii in different ICUs was also noted. This study illustrates the crucial nature of continuous nationwide surveillance of resistant pathogens and implementation of effective strategies for ICU infection control and antibiotic restriction

Carbapenem susceptibilities and non-susceptibility concordance to different carbapenems amongst clinically important Gram-negative bacteria isolated from intensive care units in Taiwan: Results from the Surveillance of Multicentre Antimicrobial Resistance in Taiwan (SMART) in 2009

To investigate the in vitro susceptibilities to various carbapenems amongst clinical Gram-negative bacteria isolated from patients in intensive care units of ten major teaching hospitals in Taiwan in 2009, a survey was conducted to determine the minimum inhibitory concentrations (MICs) of ertapenem, imipenem, meropenem and doripenem against isolates of Enterobacteriaceae (n = 594), Pseudomonas aeruginosa (n = 185), Acinetobacter baumannii (n = 192) and Burkholderia cepacia (n = 23) using the agar dilution method. Susceptibilities were determined according to 2009, 2011 and 2012 MIC breakpoints recommended by the CLSI as well as 2012 MIC breakpoints recommended by EUCAST. Based on CLSI 2012 criteria, the ertapenem susceptible rate was 93%, 81%, 68% and 92% for Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae and Serratia marcescens, respectively. All Proteus mirabilis and Morganella morganii isolates were susceptible to ertapenem; however, 64% of P. mirabilis and all M. morganii isolates were non-susceptible to imipenem. Meropenem and doripenem had better activities than imipenem against ertapenem-non-susceptible Enterobacteriaceae isolates. E. coli, K. pneumoniae and E. cloacae with ertapenem MICs &gt;= 4 mg/L were synchronously not susceptible to imipenem, meropenem and doripenem. Imipenem susceptibility was 65% and 29% for P. aeruginosa and A. baumannii, respectively. Additionally, P. aeruginosa and A. baumannii isolates with imipenem MICs &gt;= 8 mg/L were also not susceptible to meropenem and doripenem. These data provide a better understanding of choosing appropriate carbapenem agents to treat infections caused by ertapenem-non-susceptible Enterobacteriaceae as well as P. aeruginosa and A. baumannii isolates with imipenem MICs &gt;= 4 mg/L. (C) 2013 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved