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Objectives: This study investigated the differences in epidemiological and clinical data, and antimicrobial susceptibilities among different subspecies of Mycobacterium abscessus complex (MABSC) clinical isolates at a medical school in Thailand. Methods: A total of 143 MABSC clinical isolates recovered from 74 patients were genotypically analyzed for erm(41), rrl, and rrs mutations, and antimicrobial susceptibilities were determined using a broth microdilution method. Patient characteristics and clinical outcomes were reviewed from the medical records. Results: Seventy-four patients were infected with 28/74 (37.8%) M. abscessus subspecies abscessus (MAB), 43/74 (58.1%) M. abscessus subsp. massiliense (MMA), and 3/74 (4.1%) M. abscessus subsp. bolletii (MBO). The clinical findings and outcomes were generally indistinguishable between the three subspecies. All three subspecies of MABSC clinical isolates exhibited high resistance rates to ciprofloxacin, doxycycline, moxifloxacin, TMP/SMX, and tobramycin. MAB had the highest resistance rates to clarithromycin (27.8%, 20/72) and amikacin (6.9%, 5/72) compared to MBO and MMA, with p < 0.001 and p = 0.004, respectively. In addition, the rough morphotype was significantly associated with resistance to amikacin (8.9%, 5/56), clarithromycin (26.8%, 15/56), and imipenem (76.8%, 43/56) (p < 0.001), whereas the smooth morphotype was resistant to linezolid (57.1%, 48/84) (p = 0.002). In addition, T28 of erm(41), rrl (A2058C/G and A2059C/G), and rrs (A1408G) mutations were detected in 87.4% (125/143), 16.1% (23/143), and 9.1% (13/143) of MABSC isolates, respectively. Conclusions: Three MABSC subspecies caused a variety of infections in patients with different underlying comorbidities. The drug susceptibility patterns of the recent circulating MABSC strains in Thailand were different among the three MABSC subspecies and two morphotypes. [ABSTRACT FROM AUTHOR]

Objective: Imipenem/cilastatin, a broad-spectrum antibacterial, is reserved for treatment of serious infections caused by multidrug-resistant Gram-negative bacteria. The present study was aimed to compare the effectiveness and adverse events of generic and original imipenem/cilastatin. Materials and Methods: A retrospective, multicenter, cohort, non-inferiority study of generic imipenem/cilastatin (Sianem®), and original imipenem/cilastatin (Tienam®) was carried on between November 2017 and September 2020. The centers included Srinagarind Hospital, Taksin Hospital, Nakornping Hospital, Nakhonpathom Hospital, and King Chulalongkorn Memorial Hospital. The clinically relevant data were retrieved from the medical records on day 3, 7, and 14 after enrollment. A sample size of 260 patients per arm was needed. Results: There were 214 and 227 medical and surgical patients enrolled in generic and original imipenem/cilastatin groups, respectively. Baseline characteristics of the two groups were not significantly different. Most patients were male and elderly. Comorbidity was observed in 86.6%. The average length of hospital stay was 17 days. At day 14 after enrollment, the favorable outcome in generic and original imipenem/cilastatin groups were 83.1% and 90.0%, respectively, with no statistical difference. The mortality rates were 3.4% and 2.0% in generic and original imipenem/ cilastatin groups, respectively, with no statistic difference. Serious adverse events were also not significantly different between the two groups at 0.9% and 0.4%. Conclusion: The generic imipenem/cilastatin was non-inferior to the original imipenem/cilastatin in terms of effectiveness and adverse events for the treatment of serious bacterial infections in hospitalized adult patients. [ABSTRACT FROM AUTHOR]

Background: Pythium, soil-borne plant pathogens, are in the class Oomycetes. They are not true fungi, but are related to diatom and algae. There are two human pathogens including P. insidiosum and P. aphanidermatum. To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia. Case presentation: A 47-year-old Thai woman, living in North Thailand, with ß thalassemia/hemoglobin E presented with acute recurrent arterial insufficiency of both legs. Emergent embolectomy with clot removal was performed. The pathology of the clot exhibited noncaseous granulomatous inflammation with many fungal hyphal elements. PCR identified P. aphanidermatum with 100% identity. Final diagnosis is vascular pythiosis. Unfortunately, the patient eventually expired after treatment with itraconazole, terbinafine, azithromycin, and doxycycline. Conclusions: To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia. [ABSTRACT FROM AUTHOR]

Presents a survey on the patterns of infectious diseases in Thailand. Viral diseases; Bacterial diseases; Sexually transmitted diseases; Parasitic diseases.

We describe a case of microsporidial myositis in a healthy man from Thailand. The small subunit rRNA sequence of this microsporidium is novel and has a close phylogenetic relationship with Endoreticulatus, a genus of lepidopteran microsporidia. Myositis could be caused by more genera of microsporidia than previously known. [ABSTRACT FROM AUTHOR]

The recent success in treating a human rabies patient in Milwaukee prompted the use of a similar therapeutic approach in a 33-year-old male Thai patient who was admitted in the early stages of furious rabies. He received therapeutic coma with intravenous diazepam and sodium thiopental to maintain an electroencephalographic burst suppression pattern, which was maintained for a period of 46 h, as well as intravenous ketamine (48 mg/kg/day) as a continuous infusion and ribavirin (48 to 128 mg/kg/day) via a nasogastric tube. He never developed rabies virus antibodies and he died on his 8th hospital day. At least three other patients have been treated unsuccessfully with a similar therapeutic approach. Because of the lack of a clear scientific rationale, high associated costs, and potential complications of therapeutic coma, the authors recommend caution in taking this approach for the therapy of rabies outside the setting of a clinical trial. More experimental work is also needed in cell culture systems and in animal models of rabies in order to develop effective therapy for human rabies. [ABSTRACT FROM AUTHOR]

Background Catheter-associated urinary tract infection (CAUTI) is one of the most common nosocomial infections. To date, there have been no randomized controlled studies to recommend the most appropriate antiseptic solution for periurethral cleaning before indwelling urinary catheterization. This study was aimed to compare normal saline solution (NSS) and Savlon solution for periurethral cleaning before indwelling urinary catheterization in reducing catheter-associated bacteriuria. Methods A randomized controlled, noninferiority, cross-over study to determine the incidence of significant bacteriuria (SB) on day 5 after Foley catheterization, using 2 different solutions for periurethral cleaning (NSS and Savlon solutions), was carried out in all adult patients admitted in the 2 medical intensive care units (ICUs), 1 surgical ICU, 2 neurosurgical ICUs, 4 medical wards, 4 surgical wards and 1 emergency room (ER) of King Chulalongkorn Memorial Hospital, Thailand, from June 2018 to March 2019. The acceptable prespecified noninferiority margin was set to be 10%. Each solution was used alternately every 3 months in each unit. Urine culture was collected on day 1, 3, and 5 of Foley catheter. Results During the study period, there were 207 and 160 patients in the NSS and Savlon groups, respectively. 202 (55%) patients had received Foley catheterization in the emergency room. There were no significant differences in the indication, the current illness, and preexisting condition between the 2 groups. The overall incidence of SB on day 3 and 5 after catheterization was 4% and 8.2%. The incidence of CAUTI was 3.43/1,000 catheter-day. The median duration of catheterization was 5 (IQR 3, 7) days. On day 5 after catheterization, noninferiority was demonstrated for the incidence of SB with an adjusted difference of 4 (95% CI of the difference: −2.1% to 8.9%, P = 0.05). Regarding the incidence of CAUTI, there was no significant difference between the 2 groups. Conclusion To the best of our knowledge, our study was the first randomized controlled study to compare the 2 solutions for periurethral cleaning before indwelling urinary catheterization in different departments. This study demonstrates the noninferiority of NSS to Savlon solution in reducing the incidence of SB. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background and Objectives : Melioidosis is an infectious disease caused by Burkholderia pseudomallei , and it has a wide range of clinical symptoms. It is endemic in tropical areas, including Southeast Asia. Despite the availability of effective treatment, the mortality rate is still high, especially in patients presenting with septic shock. The aim of this study was to determine and explore clinical characteristics, microbiology, treatment outcomes, and factors associated with in-hospital mortality which could predict prognosis and provide a guide for future treatment. Materials and Methods : The population in this retrospective cohort study included all 262 patients with a diagnosis of melioidosis who were hospitalized at Surin Hospital, Surin, Thailand, from April 2014 to March 2017. We included patients older than 15 years with a positive culture for B. pseudomallei. Data regarding the clinical characteristics, microbiology, and treatment outcomes of the patients were collected and analyzed. The patients were divided into two groups dependent on outcome, specifically non-survival and survival. Logistic regression was performed to determine the risk factors associated with in-hospital mortality. Results : Out of the 262 patients with melioidosis during the study period, 117 (44.7%) patients died. The mean age was 57.2 ± 14.4 years, and 193 (73.7%) patients were male. The most common comorbidity was diabetes (123, 46.9%), followed by chronic kidney disease (35, 13.4%) and chronic liver disease (31, 11.8%). Four risk factors were found to be associated with in-hospital mortality, including age (adjusted odds ratio (aOR) 1.04, 95%CI: 1.01-1.07), respiration rate (aOR 1.18, 95%CI: 1.06-1.32), abnormal chest X-ray finding (aOR 4.79, 95%CI: 1.98-11.59), and bicarbonate levels (CO 2 ) (aOR 0.92, 95%CI: 0.85-0.99). Conclusions : Our study identified age, respiration rate, abnormal chest X-ray finding, and CO 2 levels are predictive factors associated with in-hospital mortality in melioidosis patients. Physicians should be aware of these factors, have access to aggressive treatment options, and closely monitor patients with these risk factors.

Mycobacterium kansasii is among the most common non-tuberculous mycobacteria causing human infections. Apart from pulmonary infection, the most common infection caused by M. kansasii is skin and soft tissue infection, and it is very rare in immunocompetent people. In this report, we present a case of a huge cutaneous abscess caused by M. kansasii A 63-year-old man living in Bangkok presented with progressive pain at the left lateral chest wall for 3 weeks and altered mentation for a few days. Examination revealed a non-tender fluctuated cutaneous mass 20×10 cm in size. An aspiration of the mass yielded 50 mL pus with many positive acid-fast bacilli. Mycobacterial PCR was positive for M. kansasii with culture confirmation. There was severe hypercalcaemia. The treatment included surgical drainage, and medical treatment consisted of isoniazid, rifampicin, ethambutol and levofloxacin, along with adequate hydration and calcitonin for hypercalcaemia. The patient gradually improved and was discharged 12 days after hospitalisation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract. Clostridium difficile infection (CDI) is one of the most common nosocomial infections in Thailand and worldwide. The clinical spectrum ranges from annoy- ing diarrhea to severe life-threatening disease. Enzyme-linked immunofluorescent assay for cytotoxins A/B (cytotoxins A/B ELFA), which has been widely used in our institute, generally is considered as having low sensitivity for diagnosis of CDI. The study was a prospective evaluation of a novel two-step diagnostic algorithm, in which the first step involved concurrent cytotoxins A/B ELFA and enzyme immunoassay for glutamate dehydrogenase (GDH EIA) for CDI, followed by PCR assay of tcdA and tcdB in samples with discordant results. Of the 91 adult patients (37 males and 54 females, mean age of 60.0 ± 19.5 years) with suspected CDI hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from December 2012 to February 2013, 22 were diagnosed with CDI by the gold standard PCR test for tcdA and tcdB, among whom 21 were positive by GDH EIA, accounting for a sensitivity of 95%. Of the 69 patients without CDI, GDH EIA was negative in 46 patients, accounting for a specificity of 67%. The positive predic- tive value (PPV), negative predictive value (NPV) and accuracy of GDH EIA was 48%, 98% and 74%, respectively, whereas sensitivity, specificity, PPV, NPV, and accuracy of cytotoxins A/B ELFA was 73%, 96%, 84%, 92% and 92%, respectively. Some 30% of specimens required the more expensive PCR assay. However, this two-step protocol detected 20% more patients with CDI than the currently used cytotoxins A/B ELFA method.

Ergotism is a toxic condition resulting from overexposure to the ergot compounds produced by various fungi of the genus Claviceps. Traditionally, such exposure was due to ingestion of infected grains, but long-term or excessive use of medications containing ergot derivatives or drug-drug interactions between these medications can result in ergotism. Ergotamine, typically used to treat migraine, has less than 5% bioavailability due to extensive first-pass metabolism by cytochrome P450 3A4 (CYP3A4). Concurrent intake of ergotamine and strong CYP3A4 inhibitors, such as the HIV protease inhibitors (PIs), can lead to clinical ergotism. A total of 13 cases of clinical ergotism in HIV-infected patients has been published since 1997 (most recently reviewed by Frohlich et al).

Background: In Thailand, acute diarrhea is one of the most common problems among ambulatory patients at the outpatient department (OPD). Overuse of antibiotics is associated with increased rates of antibiotic-resistant bacteria, unnecessary increased cost of treatment, and significant incidence of adverse effects. In Thailand, how frequently antibiotic is prescribed in adult patients with acute diarrhea is not known., Material and Method: The authors performed a retrospective study in all adult patients with acute diarrhea attending at the OPD of King Chulalongkorn Memorial Hospital, Bangkok, Thailand between August 2009 and January 2010 as ambulatory basis. All data regarding epidemiology, clinical features, and treatment were evaluated., Results: There were 390 [255 females (65.4%) and 135 males (34.6%)] patients during the study period. There were 91 (23.3%) with inflammatory diarrhea and 209 (76.7%) patients with non-inflammatory diarrhea. Only 36 (9.2%) patients had stool examination and culture results. Of 13 (36.1%) patients with positive stool cultures, four (11.1%) patients had Vibrio parahaemolyticus, two (5.7%) patients each had non-O1 Vibrio cholerae, Cryptosporidium parvum, or Plesiomonas shigelloides and V. parahaemolyticus, and one (2.9%) patient each had P. shigelloides, P. shigelloides and Salmonella, or group D Salmonella. Three hundred fifty three (90.5%) and 37 (9.5%) patients were treated by residents and faculty staffs, respectively One hundred and seventy-six (45.1%) patients received antibiotics, which included norfloxacin (128 patients, 72.7%), ciprofloxacin (34, 19.3%), ceftriaxone and ciprofloxacin (6, 3.4%), ceftriaxone (5, 2.8%), ceftriaxone and norfloxacin (2, 1.1%), amoxicillin (1, 0.6%), and ofloxacin (1, 0.6%). One hundred and forty-eight of 353 (41.9%) residents and 28 of 37 (75.7%) faculty staffs prescribed antibiotics. According to the recommendations by WHO, the rate of overuse of antibiotics was 48.9% (86 of 176 patients)., Conclusion: There is a very high rate of overuse of antibiotics in Chulalongkorn Hospital. Both attributing physician- and patient-related factors should be evaluated before implementing an effective strategy to change prescribing behavior.

Background: Central nervous system (CNS) infections are among one of the most common complications in HIV-infected patients. The present study aimed to determine the etiologies, clinical features, treatment, and outcomes of all CNS infections in HIV-infected patients., Material and Method: A retrospective study was carried out in all adult HIV-infected patients with CNS infection who were hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from January 1, 2007 to December 31, 2008. Medical records ofthe patients were identified by extensively searching the disease codes based on International Classification ofDiseases-10, all microbiological data, and all histopathological data., Results: One hundredforty eight patients were enrolled. There were 103 males (69.6%) with the mean age of 36.1 +/- 8.9 years (range 15 to 75 years). Among 93 patients with available data, the median and percentage of CD4 cell count during hospitalization were 64.0 cells/microlitre and 6% (range 1-684 cells/microlitre and 1-57%). Among 106 patients with known HIV infection, 67 patients (63.2%) had received antiretroviral therapy with the mean duration of 1.6 +/- 2.1 years. The most common CNS infection was cryptococcal meningitis (56 patients, 37.8%), followed by tuberculosis (53, 35.8%), toxoplasmosis (19, 12.8%), progressive multifocal leukoencephalopathy (6, 4.1%), varicella-zoster virus (VZV) meningitis (4, 2.7%), brain abscess (3, 2.1%), cytomegalovirus radiculomyelitis (2, 1.4%), pneumococcal meningitis (2, 1.4%), herpes simplex encephalitis, Epstein-Barr virus-related primary CNS lymphoma, and HIV-associated myelopathy (1 patient, each, 0.7%). Twenty-two patients died, accounting for the mortality rate of 14.9%. Of these 22 patients, tuberculous meningitis was the most common cause (9 patients, 16.9%), followed by cryptococcal meningitis (9, 16.1%), VZV encephalitis, Aspergillus brain abscess, herpes simplex encephalitis, and pneumococcal meningitis (1, 4.8% each)., Conclusion: To the authors' knowledge, this is the first comprehensive study in Thailand to investigate the etiologies, clinical manifestations, and outcomes of all CNS infections in AIDS patients. There are a high number of patients with tuberculosis and severe immunodeficiency in the present study. The authors' findings suggest an urgent need to actively search and treat most HIV-infected patients in the community before they become severely immunocompromised.

Background: Infections cause substantial morbidity and morbidity in neutropenic patients. In King Chulalongkorn Memorial Hospital, Gram-negative bacteria remained the most common causative pathogen of febrile neutropenia in all three studies conducted before 2002. However, Gram-positive bacteria have become more commonly isolated etiologic pathogens, and the incidence of fungal infection has been increasing since 2005., Objective: Determine the infectious etiology of fever in neutropenic patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand., Material and Method: A retrospective chart review of all medical records of febrile neutropenic patients hospitalized at Department of Medicine between January 1 and December 31, 2006 in accompanying with microbiologic, radiologic, and serologic results was analyzed., Results: There were 125 patients (61 males and 64 females) and 172 episodes of febrile neutropenia with a mean age of 46.5 +/- 18.5 years (range: 15-81 years). The three most common primary diseases associated with neutropenia were acute myeloid leukemia, non-Hodgkin's lymphoma, and acute lymphoblastic leukemia (36.6%, 33.1%, and 10.5%). Infections could be documented microbiologically and clinically in 84 episodes (48.8%), and primary bacteremia or fungemia was the most common cause of infection (40.5%). Gram-negative bacteria were the most frequently isolated pathogens (63.9%), followed by Gram-positive bacteria (29.9%) and fungi (6.2%). Escherichia coli (46.8%) and coagulase-negative Staphylococcus (27.6%) were the most common isolates among Gram-negative and Gram-positive bacteria, respectively. Among 53 episodes (30.8%) of bloodstream infections, Gram-negative bacteria were the most commonly isolated pathogens (38 episodes, 71.7%), followed by Gram-positive bacteria (19 episodes, 35.8%) and Candida tropicalis (1 episode, 1.9%). Surprisingly, invasive mold infections were noted in eight episodes (5, 1, and 2 episodes of proven, probable, and possible infections, respectively). The overall mortality was 19.2%., Conclusions: Although Gram-negative bacteria are the most common etiology of fever in neutropenic patients, the occurrence of infections caused by coagulase-negative Staphylococcus and molds has been increasing in comparison with the observations from previous studies in King Chulalongkorn Memorial Hospital. To authors knowledge, the present study is the first in Thailand to determine the occurrence of invasive fungal infections using the standard criteria recommended by EORTC/MSG.

We report a case of visceral leishmaniasis in a human immunodeficiency virus (HIV)-infected 37-year-old Thai fisherman who presented with nephritonephrotic syndrome, fever, anemia, and thrombocytopenia. Bone marrow biopsy revealed many amastigotes within macrophages. Kidney biopsy showed membranoproliferative glomerulonephritis. Polymerase chain reaction (PCR) and nucleotide sequence analysis of the internal transcribed spacer 1 of the small subunit ribosomal RNA gene in blood and kidney biopsy specimens showed Leishmania species previously described in a Thai patient with visceral leishmaniasis. Only four autochthonous cases of leishmaniasis have been reported in Thailand since 1996. To the best of our knowledge, this is the first report of autochthonous visceral leishmaniasis in an HIV-infected Thai. With an increasing number of patients with autochthonous leishmaniasis in association with the presence of potential vector, it remains to be determined whether this vector-borne disease will become an emerging infectious disease in Thailand.

We describe the first case of typhoid spondylodiscitis in Southeast Asia, and the literature were also reviewed. A 57-year-old diabetic Thai man who presented with a one-month course of progressive low back pain associated with paraparesis and bowel-bladder dysfunction. Examination revealed local tenderness over T12 area, spastic paraparesis, impaired pinprick sensation up to T12 level, and loose anal sphincter tone. Magnetic resonance imaging showed spondylodiscitis of T11 and T12 and epidural abscess causing spinal cord compression. T11 and T12 laminectomy, T11/12 discectomy, and debridement of epidural abscess were performed, and the cultures of the pus grew Salmonella Typhi. He was treated with intravenous ciprofloxacin for three weeks and was discharged from the hospital with oral ciprofloxacin and trimethoprim-sulfamethoxazole for another five months of treatment. The patient was doing well when last seen two months after discontinuation of antimicrobial treatment. In addition, a total of ten cases of typhoid spondylitis/spondylodiscitis were reviewed.

As part of the continuing national antimicrobial surveillance, the national antimicrobial resistance surveillance thailand (NARST), data of all clinical isolates of Streptococcus pneumoniae were collected from 28 hospitals in Thailand from 2000 to 2005. Epidemiological and microbiological data were obtained and analyzed using the WHONET software program. Among all isolates tested for antimicrobial susceptibility, the rates of penicillin resistance were constantly high, ranging from 42.4% in 2000 to 47.7% in 2005. The third-generation cephalosporin resistance rate, determined by Epsilon test (E-test) in 10% to 15% of all isolates each year, ranged from 2.1% to 8.4%. The rates of erythromycin resistance ranged from 24.2% to 30.3%. Surprisingly, one isolate in 2005 was resistant to levofloxacin. The rates of multi-drug resistance ranged from 14.8% to 34.3%. In conclusion; the present (NARST) study documents remarkable increase of penicillin, erythromycin, and multi-drug resistance rates in Thailand, especially among isolates from the North, the Center, the East, and Bangkok; from university hospitals; from young children; and from non-sterile specimens.

In this overview, the authors summarize the antimicrobial susceptibility patterns of important Gram-positive bacteria from the National Antimicrobial Resistance Surveillance Thailand (NARST) program between 2000 and 2005 as well as the clinical implications. This collaborative network program was funded by the World Health Organization, and involved 33 hospitals throughout Thailand. There are rising trends of drug-resistant S. pneumoniae (DRSP), ampicillin-resistant enterococci, but a constant occurrence of methicillin-resistant S. aureus (MRSA) was noted during this period. The rates of penicillin and erythromycin resistances of S. pneumoniae were constantly high, ranging from 42.5% to 47.7% and 24.6% to 31.1%, respectively, whereas the rates of cefotaxime resistance were quite low, ranging from 2.1% to 8.4%. The rates of multidrug-resistant (MDR) S. pneumoniae ranged from 14.8% to 34.3%. Of all S. aureus isolates, MRSA comprised 24% to 27%, and vancomycin resistance rates of these MRSA isolates ranged from 0.1% to 0.8%. The antimicrobial resistance rates of methicillin-susceptible S. aureus isolates were very low. The rates of ampicillin and high-level gentamicin resistances of E. faecium from 2000 to 2005 have been significantly increasing from 52% to 84.1%, and from 46.9% to 75%, respectively, but vancomycin resistance was stable at the rates between 0.4% and 1.9%. In conclusions, antimicrobial resistance rates of important Gram-positive bacteria have been increasing in Thailand. All local, national, and international surveillance data will help to set the strategic plan for control and treatment of these resistant organisms. Appropriate and accurate microbiological procedures regarding the collection and transportation of clinical specimens as well as the identification of these emerging resistant organisms are urgently needed, in collaboration with other concerned sectors.

Objective: To determine the prevalence, clinical epidemiology, and antimicrobial susceptibility of Pseudomonas aeruginosa in Thailand from 2000 to 2005., Material and Method: Using WHONET data from 28 hospitals participating in the National Antimicrobial Resistance Surveillance Thailand (NARST) program, all data were reviewed and analyzed for the prevalence, clinical epidemiology, and antimicrobial susceptibility of clinical isolates of P. aeruginosa from 2000 to 2005., Results: During the six-year surveillance, the prevalence of P. aeruginosa in clinical isolates was constant among 28 hospitals. The most common sites of isolation included sputum, pus, and urine. The most active antimicrobials were netilmicin (88% to 90.8%), cefoperazone/sulbactam (85.1% to 89.5%), imipenem (84.6% to 87.2%), and meropenem (84.5%). The resistance to ceftazidime was very high, ranging from 24.6-27.4%. The prevalence of multidrug-resistant (MDR) P. aeruginosa (resistance to amikacin, ciprofloxacin, and ceftazidime) was constant. Some hospitals in Central and Eastern regions had the prevalence of MDR up to 20% to 30% of the isolates., Conclusion: According to NARST data, the antimicrobial resistance rates of P. aeruginosa remains constant with the exception of relatively high rates in ceftazidime. The prevalence of MDR P. aeruginosa is generally low with a moderately high prevalence in some hospitals.

Background: Currently, in established antibiotic era, there is a widespread and increasing use of broad-spectrum antibiotics. Clostridium difficile, one of the troublesome intruders, flourishes when normal gut flora is altered by antibiotics. C. difficile is recognized as a frequent and leading cause of antibiotic-associated diarrhea and colitis. It causes substantial morbidity and mortality in hospitalized patients., Objective: The present study was aimed at determining patient characteristics, clinical features, treatment, and outcomes of C. difficile-associated disease (CDAD) in hospitalized patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand., Material and Method: From 2002 to 2005, 88 patients with positive latex immunoassay for C. difficile toxin A were identified. Data from medical records of 56 patients were available for analysis., Results: Of 56 patients, there were 28 males and 28 females, with the mean age of 47.39 years (range: 4 months to 93 years). 50 (89.3%) patients had underlying illnesses with hematological malignancies (14 patients, 25%) and solid tumors (15 patients, 26.8%) being the most common. All patients had a history of antibiotic use including current (17 patients, 30.4%), recent (16 patients, 28.6%), or both current and recent uses (23 patients, 41.1%). Cephalosporins and carbapenems were the two most commonly prescribed antibiotics. 25 (44.6%) patients were receiving either omeprazole or ranitidine. 12 (21.4%) patients had received chemotherapy within two months before CDAD diagnosis. Of 50 stool specimens examined, only 26 (52%) had white or red blood cells. Colonoscopy was performed in only three patients, and pathological findings revealed non-specific colitis. Oral metronidazole, intravenous metronidazole, and vancomycin were prescribed for CDAD treatment in 38 (67.9%), 4 (7.1%), and 2 (3.6%) patients, respectively. 8 (14.3%) patients had no specific treatment, and the offending antibiotic was not discontinued in three of them. An overall initial response rate was 66.7%. 2 patients relapsed after metronidazole treatment., Conclusion: The present study is the first in Southeast Asia to describe the decreased initial response rate of metronidazole treatment of CDAD. The reasons for this relatively poor response in the presented patients need to be determined in a future study.

Background: Urinary tract infection (UTI) is common in spinal cord injured patients. The authors investigated the epidemiology of bacteria associated with UTI to select an appropriate antibiotic for empirical treatment of UTI before obtaining a bacterial culture., Objective: To determine the prevalence, as well as the causative bacteria and their susceptibility pattern of urinary tract infection in spinal cord injured patients hospitalized to the Rehabilitation Center, Thai Red Cross Society, Samutprakarn, Thailand from January 2001 to December 2005., Material and Method: A retrospective chart review of 76 spinal cord injured patients., Results: Of all spinal cord injured patients, there were 50 males and 26 females, with the average age of 44.70 years. The average length of hospitalization was 104.5 days. 71.2% of the patients needed intermittent catheterization for bladder drainage, and only 2.7% had suprapubic cystostomy. None of patient had indwelling catheterization. Forty-six patients had 68 episodes of UTI (60.52%). Eighteen patients had recurrent UTI (14 patients had two episodes and four patients had three episodes). E. coli was the most common isolated pathogen (74.36%) followed by K. pneumoniae (12.82%), E. faecalis (5%) and P. mirabilis (5%). Most gram-negative pathogens were susceptible to amikacin and third generation cephalosporins. The susceptibility of these organisms to cotrimoxazole, amoxicillin/clavulanate, and ciprofloxacin were in the range of 34.6-60.0%, 44.0-50.0% and 25.9-50.0%, respectively., Conclusion: Urinary tract infections were commonly observed among spinal cord injured patients in the presented institution. E. coli was the most common isolated pathogen. Surprisingly, most gram-negative pathogens were resistant to cotrimoxazole, amoxicillin/clavulanate, and ciprofloxacin. An antibiotic of choice for UTI in our patients should be aminoglycoside or third generation cephalosporins.

Background: The most common endocrine disorder in patients with human immunodeficiency virus (HIV) is adrenocortical dysfunction. The prevalence of adrenal insufficiency in patients with AIDS is unclear; partly due to different tests, doses of adrenocorticotrophic hormone (ACTH), and criteria used. In addition, there is controversy regarding the assessment of adrenal insufficiency in patients with and without critical illness., Objective: To help clarify the prevalence of adrenal insufficiency in patients with AIDS both in critical and non-critical illness, the authors compared the prevalence based on the high-dose ACTH stimulation test., Material and Method: There were 26 patients with AIDS (19 males and 7 females) with a mean age of 33.6 years (range: 22-46 years). Twelve and 14 patients were in critical and non-critical illness, respectively., Result: Overall, the prevalence of adrenal insufficiency was 19.2% (5 of 26) and 30.8% (8 of 26) when a peak stimulated cortisol level of < 18 microg/dL and < 25 microg/dL was defined, respectively. The prevalence was 8.3% and 28.6% in critically and non-critically ill patients; respectively, when a peak stimulated cortisol level of < 18 microg/dL was defined. Finally, when a peak stimulated cortisol level of < 25 microg/dL was defined, the prevalence was 16.7% and 42.9% in critically and non-critically ill patients, respectively., Conclusion: Adrenal insufficiency in patients with AIDS is more prevalent than those without HIV infection, no matter what criteria of cortisol response after ACTH test are defined An adrenal testing should be performed in all hospitalized patients with AIDS, both in critical and non-critical illness.

Animal studies and case series have demonstrated the dose-dependent efficacy and long half-life of amphotericin B deoxycholate (ABd), providing the rationale for our randomized controlled study to compare once-daily (OD) (1 mg/kg) and alternate-d (AD) (2 mg/kg) administration of ABd in the treatment of cryptococcal meningitis in patients with AIDS hospitalized at King Chulalongkorn Memorial Hospital, Thailand, from 2003 to 2004. Of 28 patients, 15 and 13 received OD and AD administration, respectively. There was no significant difference between the 2 groups regarding the demography, clinical features, and laboratory data. After 2 weeks of the intensive-phase treatment, there was no significant difference in the clinical response between the OD (80%) and AD (76.9%) groups. Mycological response was observed in 33.3% and 10% of patients in the OD and AD groups, respectively (p = 0.3). There was no difference in nephrotoxicity and infusion-related events. In conclusion, this is the first randomized controlled study comparing OD and AD administration of ABd in the treatment of cryptococcal meningitis. Although our study was not sufficiently powered to draw conclusions on clinical efficacy and toxicities, the results are encouraging and should warrant further clinical trials evaluating the efficacy and adverse effects with a larger sample size.

Background: Nontuberculous mycobacteria (NTM) can cause infections in both human immunodeficiency virus (HIV)-infected and HIV-noninfected patients. The incidence of NTM infections has been increasing since the acquired immunodeficiency syndrome (AIDS) epidemics. However, the epidemiologic and clinical data of NTM infections in Thailand are limited., Objective: Determine the epidemiology, clinical manifestations, treatment, and outcome of NTM infections in King Chulalongkorn Memorial Hospital from January 2000 to December 2003., Material and Method: One hundred and fourteen patients had positive NTM cultures; however, complete medical records were available in only 103 (90.3%) patients., Results: There were 71 (68.9%) HIV-infected patients, and 38 (87%) of them had the CD4 counts of < 200 cells/microL (range 4-360). Among HIV-infected patients, the most common previous opportunistic infections included tuberculosis (36.6%), Pneumocystis jirovecii pneumonia (25.3%), cryptococcal meningitis (15.5%), penicilliosis (5.6%), and cytomegalovirus infection (5.6%). Most patients presented with prolonged fever (67%), chronic cough (54.4%), lymphadenopathy (52.4%), weight loss (50.5%), or chronic diarrhea (31%). The clinical manifestations included disseminated (17.4%) and localized (82.6%) infections. The localized infection included pulmonary infection (82.3%), followed by gastrointestinal infection (34.1%), skin infection (12.9%), lymphadenitis (8.2%), genitourinary tract infection (2.4%), central nervous system infection (2.4%), and keratitis (1.2%). Mycobacterium avium complex (MAC) was the predominant species (48.5%), followed by M. kansasii (19.4%), and rapidly growing mycobacteria (16.4%). Diffuse reticular infiltration was most commonly observed on chest radiography (53.4%). Abnormal laboratory findings included anemia (48.5%), hyponatremia (42.7%), and elevated alkaline phosphatase (39.8%). The overall mortality rate was 34.8% (45.9% and 11.1% in HIV- and HIV-noninfected patients)., Conclusion: A diagnosis of NTM infection requires a high index of suspicion in patients especially with AIDS or immunocompromised status who present with prolonged fever, with or without organ-specific symptoms and signs. Therefore, clinical specimens must be sent for mycobacterial cultures for a definite diagnosis, a determination of the species of NTM, and an appropriate management. In addition to four standard antituberculous drugs, clarithromycin should be added for the treatment of MAC in patients with AIDS who presented with disseminated opportunistic infections before obtaining the microbiologic results.

Background: Pythiosis is an emerging and life-threatening infectious disease in humans and animals that is caused by the pathogenic oomycete Pythium insidiosum. Human pythiosis is found mostly in Thailand, although disease in animals has been increasingly reported worldwide. Clinical information on human pythiosis is limited, and health care professionals are unfamiliar with the disease, leading to underdiagnosis, delayed treatment, and poor prognosis., Methods: To retrospectively study the clinical and epidemiological features of human pythiosis, we analyzed clinical data from patients with pythiosis diagnosed during the period of January 1985 through June 2003 at 9 tertiary care hospitals throughout Thailand., Results: A total of 102 cases of human pythiosis were documented nationwide. A substantial proportion (40%) of cases occurred in the last 4 years of the 18-year study interval. Clinical presentations fell into 4 groups: cutaneous/subcutaneous cases (5% of cases), vascular cases (59%), ocular cases (33%), and disseminated cases (3%). Almost all patients with cutaneous/subcutaneous, vascular, and disseminated pythiosis (85%) had underlying thalassemia-hemoglobinopathy syndrome. Most ocular cases (84%) were associated with no underlying disease. A majority of the patients were male (71%), were aged 20-60 years (86%), and reported an agricultural occupation (75%). Regarding treatment outcomes, all patients with disseminated infection died; 78% of patients with vascular disease required limb amputation, and 40% of these patients died; and 79% of patients with ocular pythiosis required enucleation/evisceration., Conclusions: Here, we report, to our knowledge, the largest case study of human pythiosis. The disease has high rates of morbidity and mortality. Early diagnosis and effective treatment are urgently needed to improve clinical outcomes. Because P. insidiosum is distributed worldwide and can infect healthy individuals, an awareness of human pythiosis should be promoted in Thailand and in other countries.

Brucellosis remains a major zoonotic disease worldwide. It has never been reported at King Chulalongkorn Memorial Hospital (KCMH). The authors describe the first case of brucellosis in KCMH, and also review all previous reports in Thailand. The presented case was a 52-year-old Thai man, living in Phetchabun Province, who was diagnosed with idiopathic pulmonary fibrosis two years prior to admission. He presented with prolonged fever, dry cough, weight loss of eight kg over three months, hepatosplenomegaly, and pancytopenia. Blood and bone marrow cultures grew Brucella melitensis at 72 hours of incubation. A slide agglutination (Rose Bengal) test was also positive for Brucella antibody. He had been exposed to contaminated placenta of his goats that had spontaneous abortion in the past few months before his illness. The patient was successfully treated with gentamicin, doxycycline, and rifampicin. Clinicians should have a high index of suspicion when evaluating patients presenting with prolonged fever and having an exposure risk of brucellosis.

Rapidly growing mycobacteria (RGM) have emerged as important human pathogens that can cause a variety of diseases. Thirty isolates of the pathogenic RGM were recovered from patients who attended King Chulalongkorn Memorial Hospital during 1997 and 2003. There were 16 isolates of Mycobacterium chelonae, ten isolates of M. fortuitum and four isolates of M. abscessus. Clinical data was available in only nine patients (five males and four females) including six M. chelonae, two M. abscessus, and one M. fortuitum. The mean age was 37 years (range: 13-62 years). The associated conditions were present in five patients including two diabetes, one HIV infection, one pregnancy, one SLE and one chronic renal failure. A wide spectrum of clinical features was observed. These included two chronic pulmonary infections, two post-traumatic wound infections, two disseminated infections, one lymphadenitis, one keratitis and respiratory colonization. AFB staining was positive in six patients (66.67%). The MIC of one M. chelonae and one M. abscessus were determined by Epsilon test. For M. chelonae, the MIC of clarithromycin, amikacin, ciprofloxacin, sulfamethoxazole and imipenem were 0.25, 2.0, 1.00, > 64, and 0.54 microg/ml, respectively. For M. abscessus, the MIC of clarithromycin, amikacin, ciprofloxacin, tetracycline and sulfamethoxazole were 0.016, 0.016, 0.038, > 16 and 0.002 microg/ml, respectively. Six of eight patients (75%) were initially treated with four first-line antituberculous drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) before obtaining the culture result. Of these, three patients with pulmonary and disseminated infections improved after a prolonged course of these combinations. The patients improved after switching to specific anti-RGM antibiotics. One patient died after 10 months of therapy of four anti-tuberculous drugs. One patient with post-traumatic wound infection was cured with surgical debridement and dicloxacillin. One patient improved after treatment as acute bronchitis with oral amoxicillin. An extensive review of the literature of RGM infections in Thailand is also presented.

Background: The aim of our study is to describe the unusual clinical manifestations of smooth-muscle tumors (SMTs) in patients with acquired immunodeficiency virus (AIDS) and to demonstrate the association between Epstein-Barr virus (EBV) infection and SMTs., Methods: Nine patients with AIDS and SMTs were characterized at Chulalongkorn Hospital (Bangkok, Thailand) from 2001 through 2003. Tumor tissues suitable for immunohistochemical analysis and in situ hybridization were assayed for SMTs and EBV, respectively. Plasma and serum samples were tested for EBV by real-time quantitative polymerase chain reaction and serologic analysis., Results: The study included 8 adults and 1 child (3 males and 6 females). All patients had CD4 cell counts of <200 cells/microL. By the end of the study, 3 patients had died, and 6 patients had survived. The sites of SMTs were the epidura (5 intracranial and 4 intraspinal SMTs), vocal cords (2), adrenal glands (2), abdominal wall (2), iris (1), liver (1), lung (1), orbit (1), and thigh (1). Seven patients had multicentric SMTs involving intracranial sites only (4 SMTs), extra- and intracranial sites (3), or extracranial sites only (2), which occurred either concurrently or sequentially. We found evidence of EBV infection, as determined by in situ hybridization, in all SMTs. Furthermore, EBV DNA was detectable in plasma samples from 2 patients. The results of serologic analysis were consistent with past EBV infection., Conclusions: SMTs in patients with AIDS typically arise in multiple and very unusual sites that are not often observed in SMTs among immunocompetent individuals. Our series also suggests association between EBV infection and SMTs in patients with AIDS. The exact role of EBV in smooth-muscle oncogenesis awaits further study.

Streptococcus suis may be the second most common cause of adult streptococcal meningitis. The clinical and epidemiological data of S. suis meningitis are occasionally reviewed. To date, there have been only two large case series from Hong Kong and the Netherlands. We describe twelve cases of S. suis meningitis who were admitted to Chulalongkorn University Hospital, Bangkok, during a 6-year period between 1997 and 2002. A comparative review of case reports of S. suis meningitis in Thailand, Hong Kong, and the Netherlands is presented and revealed no significant differences between the three series. However, the cases from Thailand and Hong Kong had a significantly greater number of associated skin and soft tissue infections. Clinically, S. suis meningitis may appear acute or with a more chronic course.

Adenovirus (AdV) infections are prevalent in bone marrow transplant patients, usually associated with significant morbidity and mortality. Hemorrhagic cystitis (HC) is a major complication mainly attributed to this virus. The authors report a case of AdV HC in a myelodysplastic patient undergoing peripheral blood stem cell transplantation. The diagnosis was confirmed by positive urine AdV antigen using indirect immunofluorescence assay. The patient gradually improved after adequate hydration, supportive treatment and reduced dose of cyclosporine, and was discharged on the ninth day of hospitalization. To the authors' knowledge, this is the first case of AdV HC in stem cell transplantation in Southeast Asia.

The authors describe the first indigenous case of hepatic hydatid disease in Thailand. A 58-year-old female presented with progressive right upper quadrant abdominal discomfort over a 6-month period. Ultrasonography and computed tomography showed a solitary cystic lesion 11 x 12 x 13 centimeter in size at the left lobe of the liver. She had never been abroad and had no livestock exposure. The first operation was complicated by spillage of the parasite which required a combination of albendazole and praziquantel and a second operation for intracystic instillation of hypertonic saline solution. Unfortunately, uncontrolled generalized seizures developed due to severe hypernatremia. She never regained consciousness and expired 3 weeks after admission. In addition, the authors also reviewed previous reports of hydatid disease in Thailand. To date, only 9 cases have been reported since 1932.