Intensive Care Units In Taiwan Research Articles

Carbapenem susceptibility among Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae isolates obtained from patients in intensive care units in Taiwan in 2005, 2007, and 2009

To investigate the evolutionary trends in non-susceptibility of carbapenems against the isolates of Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae from patients hospitalized in intensive care units (ICUs) of major teaching hospitals throughout Taiwan during 2005–2009, we applied the breakpoints of MICs recommended by Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing in 2013. Escalations in imipenem MIC levels for overall E. coli and E. cloacae isolates and extended-spectrum β-lactamase (ESBL)–producing K. pneumoniae isolates were noted during this period. The overall MIC levels against imipenem and meropenem for subgroups of ESBL producers of 3 Enterobacteriaceae species were significantly higher than those of respective overall groups in 2007 and 2009. Compared with meropenem, we found that significant evidence of imipenem MIC creep and evidence of extraordinarily high rates of non-susceptibility to ertapenem among isolates of 3 species in 2009 existed. The prominent rises in rates of ertapenem non-susceptibility for ESBL-producing E. coli and K. pneumoniae during 2005–2009 and rate of ESBL positivity for E. cloacae between 4years were notably found. Based on our findings, ertapenem should be used cautiously in management of the ICU infections caused by these potentially ESBL-producing Enterobacteriaceae isolates in Taiwan.

Prevalence and Molecular Characterization of Staphylococcus aureus Colonization among Neonatal Intensive Care Units in Taiwan

Background:Staphylococcus aureus, particularly methicillin-resistant (MRSA), is an important pathogen in neonatal intensive care units (NICUs). Carriage of S. aureus is a significant risk factor for subsequent infection. Objectives: To determine the current status of MRSA prevalence among NICU-hospitalized infants in Taiwan, we conducted this pilot island-wide survey. Methods: On two designated dates in 2011, each patient who stayed in the NICUs of 7 participating hospitals was included. Nasal and umbilical swabs were obtained and sent for detection of S. aureus. The prevalence and risk factors for MRSA carriage were analyzed. MRSA strains were tested for antimicrobial susceptibility and underwent molecular characterization. Results: A total of 251 subjects were included. The overall prevalence of S. aureus and MRSA carriage was 13 and 4.4%, respectively. Previous skin and soft tissue infection was the only predictor in multivariate analysis (OR 40.36; 95% CI 2.32-702.64; p = 0.011). Among 11 MRSA isolates, 3 pulsotypes were identified, with one major type (73%). Nine isolates carried a type IV staphylococcal chromosomal cassette, and 2 carried the type V_T. All but one MRSA isolate belonged to linage sequence type 59, the community clone in Taiwan. Conclusions: On a designated date, 4.4% of the infants staying in NICUs in Taiwan carried almost genetically identical community strains of MRSA. MRSA colonization in these infants was significantly associated with previous skin and soft tissue infection.

Taiwanese Parents' Experience of Making a “Do Not Resuscitate” Decision for Their Child in Pediatric Intensive Care Unit

The purpose of this project was to explore the parental experience of making a "do not resuscitate" (DNR) decision for their child who is or was cared for in a pediatric intensive care unit in Taiwan. A descriptive qualitative study was conducted following parental signing of a standard hospital DNR form on behalf of their critically ill child. Sixteen Taiwanese parents of 11 children aged 1 month to 18 years were interviewed. Interviews were recorded, transcribed, analyzed and sorted into themes by the sole interviewer plus other researchers. Three major themes were identified: (a) "convincing points to sign", (b) "feelings immediately after signing", and (c) "post-signing relief or regret". Feelings following signing the DNR form were mixed and included "frustration", "guilt", and "conflicting hope". Parents adjusted their attitudes to thoughts such as "I have done my best," and "the child's life is beyond my control." Some parents whose child had died before the time of the interview expressed among other things "regret not having enough time to be with and talk to my child". Open family visiting hours plus staff sensitivity and communication skills training are needed. To help parents with this difficult signing process, nurses and other professionals in the pediatric intensive care unit need education on initiating the conversation, guiding the parents in expressing their fears, and providing continuing support to parents and children throughout the child's end of life process.

A population-based analysis of children with pneumonia among intensive care units in Taiwan

Pneumonia is a major diagnosis in children that requires intensive care and is a major cause of mortality in critically ill children. A survey on current epidemiology and case fatality-associated conditions is crucial for the care of critically ill children with pneumonia in an intensive care unit (ICU). The sex, age, seasonality of admission, area of distribution, and case fatality rate of children younger than 18 years who had pneumonia and were admitted to an ICU during the period 2006-2010 were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan. The enrolled children were grouped by age (0-2 years, 3-5 years, 6-11 years, and 12-17 years). The need for invasive procedures such as endotracheal tube (ET) insertion, mechanical ventilation (MV), tracheostomy, central venous catheter (CVC) insertion, chest tube insertion/drainage, chest surgery, and extracorporeal membranous oxygenation (ECMO) were analyzed to clarify their association with case fatality in critically ill children with pneumonia. Of the 12,577 children enrolled, 7131 (56.7%) were boys and 5446 (43.3%) were girls. The younger age groups had more cases of pneumonia, but less often required invasive procedures. Children 0-2 years old (n = 6083) accounted for approximately one-half (48.4%) of all enrolled children. This group had the lowest case fatality rate (3.1%; 187/6083 children) and lowest need for invasive procedures (31.1%; 1892/6083 children), whereas children in the 12-17 year-old group had the highest case fatality rate (9.9%; 140/1417 children) and the highest need for invasive procedures (59.8%; 847/1417 children) (p < 0.001). The percentage of pneumonia cases was highest in the spring (30.1%) and lowest in the summer (21.7%). The invasive procedures associated with case fatality were ET/MV (OR, 14.31; p < 0.001), CVC insertion (OR, 7.46; p < 0.001), ECMO intervention (OR, 4.59; p < 0.001), and chest tube insertion/drainage (OR, 1.87; p < 0.001). The number of cases of pneumonia that required ICU admission was greater among younger children than among older children. Factors associated with the higher case fatality rate included older age at presentation, the need for invasive procedures (e.g., ET/MV, CVC insertion, chest tube insertion/drainage, and ECMO), underlying comorbidities and complications.

Association of Renal Biomarkers with 3-Month and 1-Year Outcomes among Critically Ill Acute Stroke Patients

BackgroundThe comparative relationships of widely recognized biomarkers of renal injury with short-term and long-term outcomes among critically ill acute stroke patients are unknown. We evaluated the impact of baseline albuminuria [urine albumin-creatinine ratio (UACR)≥30 mg/g] or low estimated glomerular filtration rate (eGFR<60 ml/min per 1.73 m2) on stroke patients admitted to the intensive care unit (ICU).MethodsWe reviewed data on consecutive stroke patients admitted to a hospital ICU in Taiwan from September 2007 to August 2010 and followed-up for 1 year. Baseline UACR was categorized into <30 mg/g (normal), 30–299 mg/g (microalbuminuria), and ≥300 mg/g (macroalbuminuria), while eGFR was divided into ≥60, 45–59, and <45 ml/min per 1.73 m2. The outcome measure was death or disability at 3-month and 1-year after stroke onset, assessed by dichotomizing the modified Rankin Scale at 3–6 versus 0–2.ResultsOf 184 consecutive patients, 153 (83%) met study entry criteria. Mean age was 67.9 years and median admission NIHSS score was 16. Among the renal biomarkers, only macroalbuminuria was associated with poorer 3-month outcome (OR 8.44, 95% CI 1.38 to 51.74, P = 0.021) and 1-year outcome (OR 18.06, 95% CI 2.59 to 125.94, P = 0.003) after adjustment of relevant covariates. When ischemic and hemorrhagic stroke were analyzed separately, macroalbuminuria was associated with poorer 1-year outcome among ischemic (OR 17.10, 95% CI 1.04 to 280.07, P = 0.047) and hemorrhagic stroke patients (OR 1951.57, 95% CI 1.07 to 3561662.85, P = 0.048), respectively, after adjustment of relevant covariates and hematoma volume.ConclusionsPresence of macroalbuminuria indicates poor 3-month and 1-year outcomes among critically ill acute stroke patients.

Relationship between the distribution of cefepime minimum inhibitory concentrations and detection of extended-spectrum β-lactamase production among clinically important Enterobacteriaceae isolates obtained from patients in intensive care units in Taiwan: Results from the Surveillance of Multicenter Antimicrobial Resistance in Taiwan (SMART) in 2007

The data on susceptibility of important cephalosporins against four Enterobacteriaceae members producing potential extended-spectrum β-lactamase (ESBL) collected from Taiwanese intensive care units are lacking. Minimum inhibitory concentrations (MICs) of cefotaxime, ceftazidime, and cefepime were determined using agar dilution method, against Escherichia coli (n = 344), Klebsiella pneumoniae (n = 359), Enterobacter cloacae (n = 103), and Proteus mirabilis (n = 78). Susceptibilities of these isolates to three cephalosporins were assessed according to MIC breakpoints recommended by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in 2013. The double-disk synergy test using disks containing cefepime (30 μg) with or without clavulanate (10 μg) was applied to confirm production of ESBL for isolates with cephalosporin MIC ≥ 2 μg/mL. A total of 175 isolates were verified as ESBL producers. The rates of cefepime susceptibility among the ESBL-producing isolates, according to CLSI (EUCAST) criteria, were 56.7% (22.4%) for E. coli, 61.3% (12.0%) for K. pneumoniae, 57.9% (31.6%) for E. cloacae, and 71.4% (7.1%) for P. mirabilis. Using different cefepime MIC breakpoints (MICs ≥ 16 μg/mL recommended by CLSI criteria and ≥ 2 μg/mL by EUCAST criteria) to define nonsusceptibility, we found that both criteria were poorer at predicting ESBL producers among K. pneumoniae and E. cloacae than among the other two species. In addition, we also found that the cefepime MIC level of 1.0 μg/mL best distinguished non-ESBL- from ESBL-producing K. pneumoniae and E. cloacae. To detect ESBLs, CLSI should revise the cefepime MIC breakpoint against Enterobacteriaceae.

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≥4mg/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≥8mg/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≥4mg/L.

Abstract TP235: Higher Urine Albumin-Creatinine Ratio is an Independent Predictor of Outcome among Critically Ill Acute Stroke Patients

Background: Albuminuria [urine albumin-creatinine ratio (UACR) ≥ 30 mg/g] and low estimated glomerular filtration rate (eGFR &lt; 60 ml/min per 1.73 m 2 ) have been separately associated with poor short-intermediate term outcomes after an index stroke. However, few studies have assessed the impact of both these indices of kidney dysfunction in the same acute stroke patient population; and especially not among critically ill stroke patients. We investigated the role of baseline UACR and eGFR as prognosticators for stroke patients admitted to the intensive care unit (ICU). Methods: We enrolled consecutive stroke patients admitted to a hospital ICU in Taiwan from September 2007 to August 2010 and followed-up for 1 year. UACR and eGFR were recorded at baseline. The primary outcome was poor functional outcome (mRS 3-6) at 1 year. Additional analyses subcategorized UACR into 30-299 and ≥ 300 mg/g, eGFR into 45-59 and &lt; 45 ml/min per 1.73 m 2 , and stroke into ischemic and hemorrhagic stroke. Multivariable modeling adjusted for confounders. Results: There were 188 patients met entry criteria. Compared to patients with normal kidney function, patients with higher UACR had poorer 1-year functional outcomes whether they had normal eGFR (OR 2.76, 1.03-7.44, p=0.044) or low eGFR (OR 8.49, 2.84-25.39, p&lt;0.001). Patients with low eGFR but normal UACR did not have poorer functional outcomes (OR 0.73, 0.19 to 2.90, p=0.685) (Table). Additional analyses showed that poor functional outcome was driven by baseline macroalbuminuria (OR 16.66, 2.58 to 107.64, p=0.003) vs. microalbuminuria (OR 2.01, 0.64 to 6.30, p=0.233). Separate analyses for ischemic and hemorrhagic stroke were similar to the overall findings. Conclusions: Higher baseline UACR, especially in the macroalbuminuric range, is an independent predictor of poor 1-year functional outcome among critically ill acute stroke patients regardless of stroke type. Baseline low eGFR does not appear to be a prognosticator in these patients.

Exposure to di(2-ethylhexyl) phthalate in premature neonates in a neonatal intensive care unit in Taiwan

Neonates are exposed to high levels of di(2ethylhexyl) phthalate through numerous medical procedures in the neonatal intensive care unit. Our aim was to assess the contribution of specific medical devices to the di(2-ethylhexyl) phthalate exposure of neonates. Prospective. University hospital. We recruited 32 premature neonates, 20 with very low birth weight (<1500 g) and 12 with low birth weight (<2500 g), and 31 controls at a neonatal intensive care unit from a medical center in central Taiwan. Interventions were based on a clinical need and used standard materials and devices, including endotracheal tubes, continuous positive airway pressure, oxygen hood, intravenous injection, intralipid injection, blood transfusion, orogastric tubes, nasogastric tubes, umbilical venous catheterization, umbilical arterial catheterization, chest tube, and isolate. We recorded the medical procedures of each subject, collected their urine samples, and determined the urinary concentration of three metabolites of di(2-ethylhexyl) phthalate using reversed-phase high-performance liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry. Median levels of di(2-ethylhexyl) phthalate metabolites in premature neonates treated with an endotracheal tube and orogastric tube or nasogastric tube were significantly higher than those not treated with an endotracheal tube, orogastric tube, or nasogastric tube. Median levels of di(2-ethylhexyl) phthalate metabolites in premature neonates treated with intravenous injection were ≥ 2-fold higher than those of healthy controls who received intravenous injections (p = .01). Median levels of three di(2-ethylhexyl) phthalate metabolites were similar in very-low-birth-weight and low-birth-weight neonates. These data suggest that polyvinyl chloride-containing devices are the major defining factor in di(2-ethylhexyl) phthalate exposure levels in neonates in the neonatal intensive care unit. We urge the use of polyvinyl chloride-free or alternative materials in medical devices, especially for endotracheal tubes, orogastric tubes, nasogastric tubes, and intravenous tubing in the neonatal intensive care unit. The health effects of high di(2-ethylhexyl) phthalate exposure on premature neonates in the neonatal intensive care unit is worthy of further investigation.

The nursesʼ experiences of providing spiritual care in an intensive care unit in Taiwan

International Journal of Evidence-Based Healthcare: September 2012 - Volume 10 - Issue 3 - p 259

The attitudes of neonatal professionals towards end-of-life decision-making for dying infants in Taiwan

The purposes of research were to describe the neonatal clinicians' personal views and attitudes on neonatal ethical decision-making, to identify factors that might affect these attitudes and to compare the...

Cultural Practices and End-of-Life Decision Making in the Neonatal Intensive Care Unit in Taiwan

The purpose of this research was to describe conditions of decision making for dying infants and cultural effects on the process of infant death in the neonatal intensive care unit. A retrospective chart review was used in this research. Fifty charts were reviewed; the major cause of death for the research subjects was complications of prematurity (52%). Eighty-two percent of the charts documented a do not resuscitate order, and 16% of parents allowed discontinuation of ventilator support when they realized the futility of continued care. In 30 nursing records, parents and their dying infants were offered a quiet place in which to grieve. In 10 cases, nurses accompanied these parents and allowed them to express their emotions. Research findings showed great outward expression of religion at the time of death. Various cultural issues affected both the grieving process of the families and the dying process of their infants.

Efficacy of controlling night‐time noise and activities to improve patients’ sleep quality in a surgical intensive care unit

The aim of the study was to test the efficacy of sleep care guidelines for controlling night-time noise and improving sleep quality of patients in a surgical intensive care unit. Poor sleep quality places critically ill patients at greater risk for infection, complications and mortality. Environmental stimuli such as noises, continuous lighting and frequent care-related activities in an intensive care unit interfere with patients' sleep. The study used a quasi-experimental design. Sixty surgical patients were recruited from an intensive care unit in Taiwan during December 2007-May 2008. The control group received the usual care, and the experimental group was cared for by nurses who followed the sleep care guidelines for noise and light reduction. Data were collected on noise level and sleep quality using the Sleep in the Intensive Care Unit Questionnaire, the Richards Campbell Sleep Questionnaire and a decibel meter. The results showed that both the peak sound level (χ(2) = 50.1, p < 0.001) and average noise level (χ(2) = 46.5, p < 0.001) were reduced significantly, after implementing the guidelines. The perceived noise (t = -2.07, p = 0.046) and sleep interruptions from care-related activities (t = 5.282, p < 0.001) and noises (t = 4.361, p < 0.001) were all significantly lower in the experimental group than in the control group. The experimental group also reported better sleep quality (t = -2.28, p = 0.027) and sleep efficiency (t = -2.03, p = 0.047) than did the control group. These results support the efficacy of the guidelines for controlling night-time noise and care activities to improve patients' sleep quality. Nurses should try to reduce external environmental stimuli and maintain an almost undisturbed period between midnight and 5:00 a.m. to enhance patients' sleep in a surgical intensive care unit.

Do-not-resuscitate orders for critically ill patients in intensive care

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients' preferences about DNR are elicited and honored.

Impact of Active Surveillance and Contact Isolation on Transmission of Methicillin-resistant Staphylococcus aureus in Intensive Care Units in an Area With High Prevalence

Previous research has suggested that active surveillance and early initiation of contact isolation (ASI) can control the nosocomial spread of methicillin-resistant Staphylococcus aureus (MRSA), especially among intensive care unit (ICU) patients. However, these interventions have never been implemented in Taiwan. This study was conducted from September 2005 to October 2006 to evaluate the effect of ASI on the spread of MRSA in two medical centers in Taiwan with a high prevalence of MRSA. One ICU from each hospital was selected as a study site. In phase I (the first 6 months), only active surveillance was introduced. In phase II (the final 6 months), ASI for patients who had positive MRSA cultures was implemented. The incidence of acquiring MRSA during ICU stay did not differ significantly during phases I and II in hospital A (p = 0.940) and hospital B (p = 0.810). The independent risk factors for acquiring MRSA in the ICU were length of stay and presence of respiratory tract diseases. This study demonstrated that, given the current resource limitations, ASI alone could not reduce MRSA transmission in two ICUs in Taiwan, where the MRSA prevalence was high.

Association between Contaminated Faucets and Colonization or Infection by Nonfermenting Gram-Negative Bacteria in Intensive Care Units in Taiwan

This study was designed to determine the strength of the association between the isolation of nonfermentative gram-negative bacilli (NFGNB) from tap water faucet aerators and the prevalence of colonization or infection of patients in intensive care units (ICUs). Surveillance cultures were obtained during a 4-month period from 162 faucet aerators located in seven different ICUs. The prevalence of colonization or infection of ICU patients with NFGNB was determined by prospective surveillance during the same period. Fifty four (33%) of the faucet aerators contained NFGNB. Among the 66 NFGNB isolated from faucet aerators, the most frequently encountered ones were Sphingomonas paucimobili (26 isolates), Pseudomonas aeruginosa (14 isolates), Chryseobacterium meningosepticum (13 isolates), Achromobacter xylosoxidans (6 isolates), Burkholderia cepacia (4 isolates), and Stenotrophomonas maltophilia (3 isolates). Acinetobacter baumannii was not recovered. The most common NFGNB isolated from ICU patients were P. aeruginosa and A. baumannii. There was a significant correlation between the overall prevalence of NFGNB in faucet aerators and their prevalence in exposed ICU patients (Spearman r = 0.821, P = 0.02). There was also a significant correlation between the prevalence of C. meningosepticum in faucet aerators and its prevalence among ICU patients (Spearman r = 0.847, P = 0.016). The electrokaryotypes of four clinical isolates of C. meningosepticum were similar to those of faucet isolates. Measures directed at making the water supply safe may prevent infection by C. meningosepticum and other waterborne pathogens.

Should we discharge comatose patients from intensive care to die in their own bed at home after withdrawal of mechanical ventilation?

In an intensive care unit (ICU), mechanical ventilation(MV) and vasopressive agents (VA) are commonly usedlife-sustaining treatments. Sometimes it is decided towithdraw these treatments for reasons of futility, dispro-portion or at the request of the patient, in almost all casesresulting in death of the patient within minutes or hours.There are significant differences among countries,resulting in percentages of withdrawal of mechanicalventilation of between 1 and 10% of all ICU admissions[1–4]. The time until death seems mostly dependent onthe severity of illness and organ failure and on whichtreatments are withdrawn. After withdrawal of life-sus-taining treatment, possibly distressing symptoms canoccur, and these should be prevented and suppressed withopioids, sedatives and other medicaments. Most patientsin whom life-sustaining intensive care measures arewithdrawn die in the ICU (almost 90%) or shortly afterdischarge from the ICU on a hospital ward (approxi-mately 10%). There are only a few publicationsmentioning discharge of patients to home directly fromthe ICU in order to die [5–10]. In this issue of IntensiveCare Medicine, Huang et al. [11] report their experiencesfrom an ICU in Taiwan. The authors did a retrospectiveobservational study in a tertiary medical center. Thepatients were transported from the ICU to their homes onventilator support. Blood pressure was maintained withistered for comfort. After arrival at the patient’s home, thepatient was placed in a bed in the main hall of the house,after which mechanical ventilation was withdrawn, theendotracheal tube removed and administration of vaso-active drugs stopped. Sedatives and opiods werecontinued. Death occurred in minutes to hours. Between2003 and 2007, 969 of the patients admitted to theauthors’ ICU died, 346 (36%) of them after being dis-charged to the patient’s own home, where mechanicalventilation was withdrawn.According to the sparse literature, this practice isremarkable from the Western perspective. For example,Steinhauser et al. [12] determined the factors consideredimportant at the end of life by patients, their families, andphysicians and other care providers. They measured themain rank scores for nine preselected attributes (freedomof pain; at peace with God; presence of family, mentallyaware; treatment choices followed, finances in order; feellife was meaningful; resolve conflicts and die at home),with 1 being most important and 9 being least important.All groups ranked ‘die at home’ the least important and‘free of pain’ the most important. An analysis exploringthe quality of the dying experience on the ICU showed thatfamily members of dying patients also rank pain control asthe most important aspect for quality of dying on the ICU[13]. On the other hand, when asked directly, most peoplewould prefer to die at home in their own familiar envi-ronment. Especially patients with terminal cancer or otherchronic diseases, between a half and three quarters ofwhom would ideally choose a death at home, under aquarter actually die there. Most of them die in the hospital.But most of these patients with terminal malignantdiseases are completely conscious and would experiencebeing at home, which is not the case with most of the

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 MIC(90) value (8 microg/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.

Nationwide Surveillance of Doripenem Susceptibility among Clinical Isolates in intensive care units in Taiwan: SMART Program 2004 data

Nationwide Surveillance of Doripenem Susceptibility among Clinical Isolates in intensive care units in Taiwan: SMART Program 2004 data S.S. Jean1,∗, P.R. Hsueh2, W.S. Lee3, H.T. Chang4, M.Y. Chou5, I.S. Wang6, J.H. Wang7, C. Lin8, J.M. Shyr9, W.C. Ko10, J.J. Wu11, Y.C. Liu12, W.K. Huang13, L.J. Teng14, C.Y. Liu15 1 Departments of Intensive Care Units and Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan 2 Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan 3 Department of Internal Medicine, Taipei Municipal WanFang Hospital, Taipei, Taiwan 4 Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei County, Taiwan 5 Department of Internal Medicine, Cheng Hsin Rehabilitation Medical Center, Taipei, Taiwan 6 Department of Internal Medicine, Cardinal Tien Hospital, Taipei, Taiwan 7 Department of Internal Medicine, China Medical College Hospital, Taichung, Taiwan 8 Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan 9 Department of Clinical Pathology, Taichung Veterans General Hospital, Taichung, Taiwan 10 Department of Internal Medicine, National Cheng-Kung University Hospital, Tainan, Taiwan 11 School of Medical Technology, National Cheng-Kung University College of Medicine, Tainan, Tainan, Taiwan 12 Department of Clinical Pathology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan 13 Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan 14 School of Medical Technology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan 15 Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan