Snakebites from Taiwan habus (Protobothrops mucrosquamatus) and green bamboo vipers (Viridovipera stejnegeri) account for two-thirds of all venomous snakebites in Taiwan. While there has been ongoing optimization of antivenin therapy, the proper management of superimposed bacterial wound infections is not well studied. In this Bacteriology of Infections in Taiwanese snake Envenomation (BITE) study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with snakebites from these two snakes. We further developed a BITE score to evaluate the probability of wound infections and guide antibiotic usage in this patient population. All snakebite victims who presented to the emergency departments of seven training and research hospitals and received at least one vial of freeze-dried hemorrhagic antivenin between January 2001 and January 2017 were identified. Patient biodata, laboratory investigation results, and treatment modalities were retrieved. We developed our BITE score via univariate and multiple logistic regression analyses. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive performance of the BITE score. Out of 8,295,497 emergency department visits, 726 patients presented with snakebites from a Taiwan habu or a green bamboo viper. The wound infection rate was 22.45%, with seven positive wound cultures, including six polymicrobial infections. Morganella morganii, Enterococcus spp., Bacteroides fragilis, and Aeromonas hydrophila were most frequently cultured. There were no positive blood cultures. A total of 33.0% (n = 106) of snakebite patients who received prophylactic antibiotics nevertheless developed wound infections, while 44.8% (n = 73) of wound infection patients were satisfactorily treated with one of the following antibiotics: amoxicillin/clavulanic acid, oxacillin, cefazolin, and ampicillin/sulbactam. With the addition of gentamicin, the success of antibiotic therapy increased by up to 66.54%. The prognostic factors for the secondary bacterial infection of snakebites were white blood cell counts, the neutrophil lymphocyte ratio, and the need for hospital admission. The area under the ROC curve for the BITE score was 0.839. At the optimal cut-off point of 5, the BITE score had a 79.58% accuracy, 82.31% sensitivity, and 79.71% specificity when predicting infection in snakebite patients. Our BITE score may help with antibiotic stewardship by guiding appropriate antibiotic use in patients presenting with snakebites. It may also be employed in further studies into antibiotic prophylaxis in snakebite patients for the prevention of superimposed bacterial wound infections.

Wound necrosis and secondary infection are common complications after Naja atra bites. Clinical tools to evaluate the infection risk after Taiwan cobra bites are lacking. In this Cobra BITE study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with Taiwan cobra snakebites. Patients with wound infection lacking tissue necrosis were included in developing Cobra BITE score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis, and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients’ wounds had necrosis. As per our Cobra BITE score, the three factors predicting secondary wound infection after cobra bites are hospital admission, a white blood cell count (in 103/µL) × by neu-trophil-lymphocyte ratio value of ≥114.23, and the use of antivenin medication. The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76. This scoring system enables the assessment of wound infections after N. atra bites, and it could be modified and improved in the future for other Naja spp. bites.

Background Early diagnosis and treatment of patients with sepsis reduce mortality significantly. In terms of exploring new diagnostic tools of sepsis, monocyte distribution width (MDW), as part of the white blood cell (WBC) differential count, was first reported in 2017. MDW greater than 20 and abnormal WBC count together provided a satisfactory accuracy and was proposed as a novel diagnostic tool of sepsis. This study aimed to compare MDW and procalcitonin (PCT)’s diagnostic accuracy on sepsis in the emergency department. Methods This was a single-center prospective cohort study. Laboratory examinations including complete blood cell and differentiation count (CBC/DC), MDW, PCT were obtained while arriving at the ED. We divided patients into non-infection, infection without systemic inflammatory response syndrome (SIRS), infection with SIRS, and sepsis-3 groups. This study’s primary outcome is the sensitivity and specificity of MDW, PCT, and MDW + WBC in differentiating septic and non-septic patients. In addition, the cut-off value for MDW was established to maximize sensitivity at an optimal level of specificity. Results From May 2019 to September 2020, 402 patients were enrolled for data analysis. Patient number in each group was: non-infection 64 (15.9%), infection without SIRS 82 (20.4%), infection with SIRS 202 (50.2%), sepsis-3 15 (7.6%). The AUC of MDW, PCT, and MDW + WBC to predict infection with SIRS was 0.753, 0.704, and 0.784, respectively (p < 0.01). The sensitivity, specificity, PPV, and NPV of MDW using 20 as the cutoff were 86.4%, 54.2%, 76.4%, and 70%, compared to 32.9%, 88%, 82.5%, and 43.4% using 0.5 ng/mL as the PCT cutoff value. On combing MDW and WBC count, the sensitivity and NPV further increased to 93.4% and 80.3%, respectively. In terms of predicting sepsis-3, the AUC of MDW, PCT, and MDW + WBC was 0.72, 0.73, and 0.70, respectively. MDW, using 20 as cutoff, exhibited sensitivity, specificity, PPV, and NPV of 90.6%, 37.1%, 18.7%, and 96.1%, respectively, compared to 49.1%, 78.6%, 26.8%, and 90.6% when 0.5 ng/mL PCT was used as cutoff. Conclusions In conclusion, MDW is a more sensitive biomarker than PCT in predicting infection-related SIRS and sepsis-3 in the ED. MDW < 20 shows a higher NPV to exclude sepsis-3. Combining MDW and WBC count further improves the accuracy in predicting infection with SIRS but not sepsis-3. Trial registration The study was retrospectively registered to the ClinicalTrial.gov (NCT04322942) on March 26th, 2020.

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The occurrence of six common antibiotics in the surface water, sediment, and suspended particulate matter (SPM) of the Jiyun River, a typical river in the livestock-producing region in Beijing, northern China, was investigated. The results revealed that the antibiotics were widely distributed in the studied area. The aqueous samples were contaminated by the antibiotics, and the target antibiotics presented in highest levels were sulfonamides, with maximum concentrations of 230 and 385 ng/L for sulfadiazine and sulfamethoxazole, respectively. Oxytetracyline, one of the tetracylines, was the most frequently detected compound in the particulate phase with maximum concentration of 121 and 130 ng/g in the sediment and SPM, respectively. The total antibiotic concentration in the water was higher in the tributary than that in the main river, demonstrating that the tributaries were discharging antibiotics into the main river. In addition, the partition coefficients of sediment-water (Kp(S)) and the SPM-water (Kp(SPM)) were calculated. Overall, the Kp(S) decreases with an increase in the contents of SPM. In terms of the interaction between SPM and water, linear relationship between logarithm of Kp(SPM) (log Kp(SPM)) and the logarithm of molecular weight (log MW) was obtained, suggesting that large and heavy molecules are more likely to be attracted to suspended particulates, eventually leading to their enrichments in bed sediments.