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BackgroundRisks for subsequent multidrug-resistant gram-negative bacteria (MDRGNB) infection and long-term outcome after hospitalization among patients with MDRGNB colonization remain unknown.MethodsThis observational study enrolled 817 patients who were hospitalized in the study hospital in 2009. We defined MDRGNB as a GNB resistant to at least three different antimicrobial classes. Patients were classified into MDRGNB culture-positive (MDRGNB-CP; 125 patients) and culture-negative (MDRGNB-CN; 692 patients) groups based on the presence or absence of any MDRGNB identified from either active surveillance or clinical cultures during index hospitalization. Subsequent MDRGNB infection and mortality within 12 months after index hospitalization were recorded. We determined the frequency and risk factors for subsequent MDRGNB infection and mortality associated with previous MDRGNB culture status.ResultsIn total, 129 patients had at least one subsequent MDRGNB infection (MDRGNB-CP, 48.0%; MDRGNB-CN, 10.0%), and 148 patients died (MDRGNB-CP, 31.2%; MDRGNB-CN, 15.9%) during the follow-up period. MDR Escherichia coli and Acinetobacter baumannii were the predominant colonization microorganisms; patients with Proteus mirabilis and Pseudomonas aeruginosa had the highest hazard risk for developing subsequent infection. After controlling for other confounders, MDRGNB-CP during hospitalization independently predicted subsequent MDRGNB infection (hazard ratio [HR], 5.35; 95% confidence interval [CI], 3.72–7.71), all-cause mortality (HR, 2.42; 95% CI, 1.67–3.50), and subsequent MDRGNB infection-associated mortality (HR, 4.88; 95% CI, 2.79–8.52) after hospitalization.ConclusionsHarboring MDRGNB significantly increases patients’ risk for subsequent MDRGNB infection and mortality after hospitalization, justifying the urgent need for developing effective strategies to prevent and eradicate MDRGNB colonization.

Background Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19. Objective The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED). Methods In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers’ exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians’ total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes. Results The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes, P<.001), whereas the total evaluation time in the telemedicine group was significantly longer than that in the conventional group (12.2 minutes vs 8.9 minutes, P<.001). After controlling for potential confounders, the total exposure time in the telemedicine group was 4.6 minutes shorter than that in the conventional group (95% CI −5.7 to −3.5, P<.001), whereas the total evaluation time in the telemedicine group was 2.8 minutes longer than that in the conventional group (95% CI −1.6 to −4.0, P<.001). The mean scores of the patient questionnaire were high in both groups (4.5/5 to 4.7/5 points). Conclusions The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.

OBJECTIVE Isolation of multidrug-resistant gram-negative bacteria (MDR-GNB) from patients in the community has been increasingly observed. A prediction model for MDR-GNB colonization and infection risk stratification on hospital admission is needed to improve patient care. METHODS A 2-stage, prospective study was performed with 995 and 998 emergency department patients enrolled, respectively. MDR-GNB colonization was defined as isolates resistant to 3 or more classes of antibiotics, identified in either the surveillance or early (≤48 hours) clinical cultures. RESULTS A score-assigned MDR-GNB colonization prediction model was developed and validated using clinical and microbiological data from 995 patients enrolled in the first stage of the study; 122 of these patients (12.3%) were MDR-GNB colonized. We identified 5 independent predictors: age>70 years (odds ratio [OR], 1.84 [95% confidence interval (CI), 1.06-3.17]; 1 point), assigned point value in the model), residence in a long-term-care facility (OR, 3.64 [95% CI, 1.57-8.43); 3 points), history of cerebrovascular accidents (OR, 2.23 [95% CI, 1.24-4.01]; 2 points), hospitalization within 1 month (OR, 2.63 [95% CI, 1.39-4.96]; 2 points), and recent antibiotic exposure (OR, 2.18 [95% CI, 1.16-4.11]; 2 points). The model displayed good discrimination in the derivation and validation sets (area under ROC curve, 0.75 and 0.80, respectively) with the best cutoffs of<4 and ≥4 points for low- and high-risk MDR-GNB colonization, respectively. When applied to 998 patients in the second stage of the study, the model successfully stratified the risk of MDR-GNB infection during hospitalization between low- and high-risk groups (probability, 0.02 vs 0.12, respectively; log-rank test, P<.001). CONCLUSION A model was developed to optimize both the decision to initiate antimicrobial therapy and the infection control interventions to mitigate threats from MDR-GNB. Infect Control Hosp Epidemiol 2017;38:1216-1225.

A 36-year-old woman presented to the emergency department (ED) with sudden onset, post-micturition lower severe abdominal pain of 1 day duration. She had a history of left thyroid nodules and anemia of chronic disorder, but without any surgical history. There were no other associated symptoms such as chills, nausea, vomiting, diarrhea, constipation or hematuria. She also denied pregnancy, trauma or alcohol consumption.On examination, she was fully conscious, and her vital signs were body temperature of 37.7 °C, pulse rate of 100 beats per minute, blood pressure of 121/84 mmHg, respiratory rate of 20 breaths per minute and the oxygen saturation 99% on room air. Her abdomen was distended with diffuse rebound tenderness and hypoactive bowel sounds. The remainder of her systematic examination was unremarkable.Results of biochemical analysis showed elevated serum levels of urea nitrogen (UN) and creatinine, indicative of acute renal failure (Table 1). Other laboratory examinations, including hemogram, urinalysis and coagulation test, were within the normal ranges. Ultrasound of the abdomen demonstrated ascites and mild distended urinary bladder without hydronephrosis. Diagnostic abdominal paracentesis confirmed the presence of transudative ascites with serum-ascites albumin gradient (SAAG) value greater than 3. Additionally, spontaneous peritonitis was excluded based on normal ascitic fluid polymorphonuclear leukocyte count. Non-contrast computed tomography (CT) of the abdomen and pelvis revealed urinary bladder diverticulum with peritoneal fluid accumulation, which suggested urinary leakage. We prescribed antibiotics and inserted a Foley catheter. Notably, the abdominal distension and tenderness began to resolve, and the serum urea nitrogen and creatinine levels dramatically decreased to a normal range within 16 h (Table 1), which indicated the possibility of ruptured urinary bladder causing urinary ascites and peritoneal irritation. A CT cystography showed extravasation of contrast into the peritoneal space and confirmed the diagnosis of ruptured urinary bladder diverticulum (Fig. 1). The urologist performed a cystoscopy and laparoscopic diverticulectomy after admission and identified a 5 × 5 cm diverticulum at the left lateral wall near the bladder dome intraoperatively. The patient was discharged home on postoperative day 5 uneventfully. DiscussionSpontaneous or non-traumatic rupture of the urinary bladder is a rare, but potentially life-threatening event in adult patients. This condition is associated with certain specific predisposing factors including binge alcohol drinking, pregnancy, infection, neurologic bladder, diabetes, benign prostatic hyperplasia and postpartum complications [1]. Nevertheless, rupture of a urinary bladder from diverticulum is extremely rare, and only few cases have been reported in the literature [2]. The etiologies of urinary bladder diverticulum rupture may originate from congenital anatomic abnormality of pathological urinary bladder wall weakness, but the majority are acquired, inc...

) that extends bilaterally with basal and peripheral involvement of the lung. 1 Computed tomography (CT) has been the most widely recommended and used imaging modality for screening thus far 2 ; however, it has significant downsides, including the need for extensive sterilization of equipment after use with highly contagious COVID-19 virus, along with cost and excessive radiation. Lung ultrasonography has been previously established as an excellent method of diagnosing and monitoring pneumonia and acute respiratory distress syndrome, particularly when compared with chest radiograph, 3,4 and thus has potential as an inexpensive and effective imaging modality in the early diagnosis and monitoring of patients with COVID-19.The literature of lung ultrasonography in COVID-19 patients is scarce but promising. Huang et al 5 showed in a small preliminary study that 75% of observed patients with COVID-19 had identifiable lesions in the bilateral lower lobes. This study examined 20 patients with noncritical illness, using a 3 to 17-MHz high-frequency linear array to characterize lung lesions, and found a few identifying characteristics: numerous bilateral B lines, subpleural pulmonary consolidations, and poor blood flow. These findings were highly consistent with findings on CT. In addition, they determined that COVID-19 subpleural lesions differed significantly from similar ones observed in bacterial pneumonia, pulmonary abscess, tuberculosis, atelectasis, and cardiogenic pulmonary edema, 5 an example of which is that B lines in COVID-19 appear to be more fixed, fused, and obtuse compared with those in cardiogenic pulmonary edema. 5 Peng et al 6 also examined 20 patients with COVID-19, using lung ultrasonography, and described similar characteristic findings that typically appeared in a multilobar distribution: focal B lines were the main early feature, followed by alveolar interstitial syndrome in progressive stages, and then A lines during convalescence. Pleural effusions were rarely observed at any stage. A third preliminary study performed by Poggiali et al, 7 using ultrasonography and CT, evaluated 12 patients who presented with symptomatic COVID-19. They reported good consistency between B lines on ultrasonography and ground-glass opacities on CT in all 12 patients, with both modalities identifying organizing pneumonia in 4 of them.As observed with the early clinical evidence, lung ultrasonography in COVID-19 patients was able to identify characteristic lesions that were highly consistent with findings on CT. Although CT is still considered the preferred imaging modality, ultrasonography may be useful in evaluating for early lung changes in emergency department patients with suspected COVID-19 or in monitoring progression of confirmed cases. In resource-

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Accurate detection of anti-SARS-CoV-2 antibodies provides a more accurate estimation of incident cases, epidemic dynamics, and risk of community transmission. We conducted a cross-sectional seroprevalence study specifically targeting different populations to examine the performance of pandemic control in Taiwan: symptomatic patients with epidemiological risk and negative qRT-PCR test (Group P), frontline healthcare workers (Group H), healthy adult citizens (Group C), and participants with prior virologically-confirmed severe acute respiratory syndrome (SARS) infection in 2003 (Group S). The presence of anti−SARS−CoV−2 total and IgG antibodies in all participants were determined by Roche Elecsys® Anti−SARS−CoV−2 test and Abbott SARS-CoV-2 IgG assay, respectively. Sera that showed positive results by the two chemiluminescent immunoassays were further tested by three anti-SARS-CoV-2 lateral flow immunoassays and line immunoassay (MIKROGEN recomLine SARS-CoV-2 IgG). Between June 29 and July 25, 2020, sera of 2,115 participates, including 499 Group P participants, 464 Group H participants, 1,142 Group C participants, and 10 Group S participants, were tested. After excluding six false-positive samples, SARS-CoV-2 seroprevalence were 0.4, 0, and 0% in Groups P, H, and C, respectively. Cross-reactivity with SARS-CoV-2 antibodies was observed in 80.0% of recovered SARS participants. Our study showed that rigorous exclusion of false-positive testing results is imperative for an accurate estimate of seroprevalence in countries with previous SARS outbreak and low COVID-19 prevalence. The overall SARS-CoV-2 seroprevalence was extremely low among populations of different exposure risk of contracting SARS-CoV-2 in Taiwan, supporting the importance of integrated countermeasures in containing the spread of SARS-CoV-2 before effective COVID-19 vaccines available.