Hsien-Po Huang

Objectives: Naja atra (N. atra) envenomation and cellulitis frequently present with overlapping clinical features of acutely swollen extremities, creating a diagnostic dilemma during the early clinical course of acute limb swelling. This study investigated whether ultrasound imaging with echotexture analysis can effectively differentiate these two conditions. Methods: This retrospective cross-sectional study conducted at Taichung Veterans General Hospital included 115 ultrasound images from 84 patients categorized into three groups: confirmed N. atra envenomation (n = 45), confirmed non-snakebite cellulitis (n = 40), and controls (n = 30). Gray-level co-occurrence matrix (GLCM) features including contrast, correlation, energy, and homogeneity, along with the grayscale value and the power Doppler vascularity-to-ROI ratio, were quantitatively computed from ultrasound images. Group comparisons used generalized estimating equations to account for multiple images from the same patient, with Bonferroni correction for pairwise comparisons. Diagnostic accuracy was evaluated using receiver operating characteristic (ROC) curve analysis. Results: Significant differences among the three groups were found for contrast (p < 0.001), correlation (p < 0.001), homogeneity (p = 0.005), and the vascularity-to-ROI ratio (p < 0.001). In pairwise comparisons between N. atra envenomation and cellulitis, contrast was significantly higher (0.273 ± 0.068 versus 0.230 ± 0.040, p = 0.001) and homogeneity was lower (0.878 ± 0.020 versus 0.890 ± 0.017, p = 0.004) in the N. atra group. ROC curve analysis for discriminating N. atra envenomation from cellulitis yielded an Area Under the Curve of 0.707 (95% confidence interval, 0.591–0.824) for contrast and 0.684 (95% confidence interval, 0.568–0.800) for homogeneity. At an optimal cutoff of ≥0.243, contrast achieved 73.3% sensitivity and 70.0% specificity. Conclusions: Echotexture analysis, specifically contrast and homogeneity, may differentiate N. atra envenomation from cellulitis. These parameters may reflect the heterogeneous tissue destruction induced by venom compared to the diffuse inflammation seen in cellulitis. These proof-of-concept findings require validation in larger prospective cohorts before clinical application.

Background and Clinical Significance: Occult malignancy is an easily missed cause of prolonged fever when urinary findings suggest pyelonephritis, and repeated empirical antibiotic courses can delay tissue diagnosis. We report such a case with competing explanations for fever. Case Presentation: A 62-year-old woman had six months of intermittent fever and one month of dysuria and right flank pain despite nine outpatient antimicrobial courses. On admission, her temperature reached 40.1 °C; she had pyuria with a non-diagnostic urine culture, para-aortic lymphadenopathy on computed tomography and negative blood cultures. Fever abated during intravenous flomoxef, recurred on the seventh day, persisted after its withdrawal and subsided by hospital day 16 before cancer-directed therapy. A single naproxen dose produced only transient defervescence. Nodal biopsy revealed metastatic high-grade serous carcinoma of the tubo-ovarian type (surgical–pathological FIGO stage IIIA1; clinical stage IVB on imaging, not histologically confirmed). The cause of fever remained undetermined; tumor-associated fever, a partially treated urinary infection and flomoxef-associated drug fever were possible contributors. Conclusions: When fever persists despite empirical antimicrobials and reassessment finds no convincing bacterial infection, clinicians should consider stopping rather than escalating antibiotics in stable, non-neutropenic patients under close monitoring, consider drug fever and other non-infectious causes, and pursue prompt tissue diagnosis.

Catheter-related bloodstream infections (CRBSIs) caused by Brevundimonas diminuta are rare, and polymicrobial infections involving this organism are exceptionally uncommon. To the best of our knowledge, we describe the first reported case of polymicrobial CRBSI caused by B. diminuta and Streptococcus anginosus in a woman with a pituitary gland tumor and intracranial hypertension who was receiving intravenous treatment through an indwelling peripherally inserted central catheter (PICC). The patient made a full clinical recovery after prompt PICC removal and intravenous piperacillin–tazobactam therapy. This case emphasizes the emerging clinical significance of B. diminuta and S. anginosus as potential causes of polymicrobial bloodstream infection in patients with indwelling central venous catheters and underlines the need to consider uncommon environmental Gram-negative organisms in catheter-related infection.

Background: Outpatient Parenteral Antimicrobial Therapy (OPAT) has long been established as a safe and cost-effective alternative to inpatient care in Western healthcare systems. In contrast, its implementation across Asia has historically been fragmented and unstructured. A landmark multinational survey in 2017 identified OPAT in Asia as a “missed opportunity,” citing the lack of systematic oversight, standardized protocols, and outcome monitoring systems. Methods: This narrative review examines the evolution of OPAT in Asia over the past decade, synthesizing evidence from regional studies, national policies, and implementation models. Results: The findings demonstrate a clear shift from ad hoc infusion practices toward structured, multidisciplinary OPAT programs in several healthcare systems. These systems increasingly integrate antimicrobial stewardship principles, dedicated care teams, and reimbursement mechanisms. In parallel, innovative models, including hospital-at-home services and elastomeric pump–based continuous infusion, have expanded treatment feasibility while enabling the use of narrower-spectrum antibiotics. Despite these advances, substantial heterogeneity persists. Key barriers include the absence of unified national guidelines, limited monitoring infrastructure, workforce constraints, and regulatory restrictions in certain settings. Resource-limited regions continue to face challenges related to financing, laboratory capacity, and digital health integration. Conclusions: Overall, OPAT in Asia is transitioning from an underrecognized and inconsistently delivered service to an increasingly structured component of infectious disease care. Future priorities include standardized governance, integration with antimicrobial stewardship programs, sustainable reimbursement, digital outcome monitoring, and region-specific evidence on antimicrobial stability and safety.

Background: Pulmonary aspergillosis remains highly lethal despite modern therapy. Although polymerase chain reaction (PCR) has enhanced detection, the clinical significance of its cycle threshold (Ct) values is unclear. The key problem is the lack of validation of Ct values for assessing fungal burden or predicting outcomes, limiting their diagnostic and prognostic utility. Methods: We conducted a retrospective cohort study of 154 adult patients diagnosed with pulmonary aspergillosis at a tertiary medical center in Taiwan (2021– 2024). All patients had a positive Aspergillus PCR from a respiratory specimen. We used receiver operating characteristic (ROC) curve analysis to determine an optimal Ct cutoff for predicting 30-day all-cause mortality and multivariable logistic regression to identify independent predictors. Results: Among 154 patients (mean age 70.5 ± 13.5 years; 48.1% female), the optimal Ct cutoff for predicting 30-day mortality was 30.7 (AUC = 0.65, 95% CI 0.56– 0.73). Patients with a Ct value < 30.7 had significantly higher 30-day mortality than those with a Ct ≥ 30.7 (71.2% vs 43.1%, p = 0.002). After adjusting for clinical and laboratory confounders, a Ct value < 30.7 remained the independent predictor of mortality (adjusted OR 3.07; 95% CI 1.27– 7.39; p = 0.012). Conclusion: A low Aspergillus PCR Ct value is an independent predictor of 30-day mortality in patients with pulmonary aspergillosis. While its discriminative ability is moderate, the Ct value may serve as a valuable predictor to aid in early risk stratification, when interpreted within the overall clinical context.

Seasonal influenza remains a major threat to healthcare facilities, where introduction of the virus can cause disproportionate morbidity and mortality among high-risk inpatients. This narrative review synthesizes current evidence and practice-oriented guidance on the prevention of hospital-acquired influenza. We conducted a targeted literature search using PubMed, guideline repositories for English-language publications from 2000 to 2025, prioritizing systematic reviews, clinical trials, and authoritative guidelines. A multifaceted strategy is emphasized: annual vaccination of healthcare personnel and eligible patients; consistent implementation of standard and transmission-based precautions; attention to environmental cleaning and disinfection; and occupational-health policies that limit presenteeism and workplace exposure. Evidence demonstrates that higher healthcare personnel (HCP) vaccination coverage is associated with lower patient influenza rates and improved survival. Reliable hand hygiene, respiratory source control, early initiation of droplet precautions, and cohorting when single rooms are limited all contribute to interrupting in-facility transmission. Ensuring that ill HCP can remain off duty without penalty further reduces the likelihood of staff-to-patient spread. Collectively, these coordinated measures provide a protective framework and underscore the central role of clinicians and infection-prevention teams in sustaining influenza control within acute-care settings.

Catheter-related bloodstream infections (CRBSIs) caused by Leclercia adecarboxylata are uncommon, and polymicrobial cases are even rarer. We report the first documented case caused by co-infection with Leclercia adecarboxylata and Enterobacter cloacae complex (ECC) in a woman with breast cancer undergoing chemotherapy through an indwelling chemoport. Antimicrobial susceptibility testing revealed that both isolates were susceptible to β-lactams, quinolones, and aminoglycosides. The patient achieved complete clinical recovery following intravenous ciprofloxacin therapy and prompt removal of the chemoport. This case highlights the emerging clinical relevance of Leclercia adecarboxylata and Enterobacter cloacae complex as potential pathogens capable of causing polymicrobial bloodstream infections in immunocompromised hosts and underscores the importance of considering rare environmental Gram-negative organisms as potential causes of catheter-related infections, particularly in patients with malignancy or long-term vascular access.

We report that the implementation of a multidisciplinary team (MDT) protocol - integrating early ultrasound surveillance, prompt surgical intervention, targeted antimicrobial therapy, and optimized antivenom administration - was associated with a marked reduction the length of hospital stay and surgical burden among patients with Naja atra envenomation at a tertiary medical center in Taiwan. This approach shifts management from a reactive to a proactive strategy by enabling the early detection of tissue involvement and timely intervention.

Background: Catheter-related bloodstream infections (CRBSIs) caused by environmental organisms are uncommon, and polymicrobial cases are even rarer. Methods: We describe the first case of catheter-related bloodstream infection caused by two infrequent environmental organisms—Rhizobium radiobacter and Pseudomonas oryzihabitans—occurring as a co-infection. Results: The patient’s occupation involved frequent exposure to moist, soil-contaminated environments. Although these bacteria are often considered contaminants, they are capable of causing invasive infections such as bacteremia, which can be life-threatening. Conclusions: This case underscores the emerging pathogenic potential of R. radiobacter and P. oryzihabitans co-infection, particularly in patients with underlying malignancies or end-stage renal disease who have indwelling vascular devices, and highlights the importance of considering occupational and environmental exposures in the differential diagnosis of unusual pathogens.

Background: Pulmonary mucormycosis is a life-threatening fungal infection that primarily affects immunocompromised individuals. Underlying malignancy is a recognized risk factor for pulmonary mucormycosis, yet its independent effect on patient outcomes remains uncertain. This study aimed to evaluate the impact of underlying malignancy on the clinical characteristics and 30-day mortality of pulmonary mucormycosis. Methods: We conducted a retrospective cohort study of 163 adults with proven or probable pulmonary mucormycosis at a single center in Taiwan (2021– 2024). Clinical and laboratory variables were compared between groups. Predictors of 30-day all-cause mortality were assessed using Cox proportional hazards regression with purposeful variable selection, and proportional-hazards assumptions were verified using Schoenfeld residuals. Results: The overall 30-day mortality rate was 18.4% (30 of 163 patients). Kaplan–Meier analysis confirmed lower 30-day survival in malignancy patients (log-rank χ² = 27.08, df = 1, p < 0.0001). In multivariable analysis, malignancy (aHR 3.65, 95% CI 1.40– 9.53), neutrophil-to-lymphocyte ratio per 5 units (aHR 1.10, 95% CI 1.05– 1.22), and alkaline phosphatase per 50 U/L (aHR 1.16, 95% CI 1.00– 1.64) were independent predictors of early death. Clinically, patients with malignancy predominantly exhibited a cytopenic–immunosuppressed phenotype, whereas those without malignancy more frequently exhibited a metabolic–inflammatory profile characterized by chronic kidney disease or recent COVID-19. Conclusion: Underlying malignancy independently triples 30‑day mortality in pulmonary mucormycosis. Easily available laboratory markers—neutrophil‑to‑lymphocyte ratio and alkaline phosphatase—also stratify early risk, underscoring the need for phenotype-tailored and timely antifungal management strategies.