Guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents: the recommendations of the Thai AIDS Society (TAS) 2008.

BACKGROUND: More than 100,000 patients have been treated, since the implementation of the National Universal Coverage for antiretroviral therapy (ART) in Thailand Although there are several comprehensive guidelines available internationally, there is a need to have guidelines that can be implemented in Thailand. MATERIAL AND METHOD: The guidelines were developed by a panel of 17 members who are the experts on HIV research and/or HIV patient care and appointed without incentive by the Thai AIDS Society (TAS). The recommendations were based on evidences from the published studies and availability of antiretroviral agents. Published studies that are relevant and applicable to Thailand in particular have been taken into consideration. RESULTS: The recommendations include: when to start ART; what to start; how to monitor the therapy; adverse effects and its management; diagnosis of treatment failure; and antiretroviral treatment options in patients with treatment failure. ART in special circumstances, i.e., patients with co-infection of tuberculosis or hepatitis B virus, is also included Appropriate level of CD4+ T-cell count to start ART among Thai patients has been considered carefully. The authors recommend to start ART at CD4+ T-cell count < 200 cells/mm3. CONCLUSION: ART should be initiated in adults and adolescents HIV-1 infected patients with a history of HIV-related illness or AIDS or with a CD4+ T-cell count <200 cells/mm3. For treatment-naive patients, the preferred initial therapy is a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. CD4' T-cell count and viral load should be monitored for at least twice and once a year, respectively. Proper management of antiretroviral-related toxicity and enhancement of adherence are crucial for the long-term success of ART.

A rapidly fatal case of Panton-valentine leukocidin positive Staphylococcus aureus necrotizing pneumonia in an HIV-infected patient.

This article reports a rare case of necrotizing pneumonia caused by Panton-Valentine leukocidin (PVL) positive Staphylococcus aureus in an HIV-infected patient presenting with severe back pain and rash. The back pain progressed to excruciating abdominal pain which was misleading, resulting in an investigation on intraabdominal conditions. He developed massive hemoptysis and died within 2 days of the first clinical symptoms. Recognizing the emergence of PVL-producing S. aureus is important in both immunocompetent and immunocompromised patients. This organism was transmitted from his wife.

Effect of changes in diagnosis and management of active infective endocarditis on the clinical outcome at Srinagarind Hospital.

BACKGROUND: In recent years, diagnostic methods and treatment of infective endocarditis (IE) have been improved. It is not known whether the clinical outcome is any better. OBJECTIVE: To assess the effect of changes on the clinical outcomes of IE patients. MATERIAL AND METHOD: The authors performed a retrospective study comparing IE patients hospitalized at Srinagarind hospital during the period from 1/1/1990 to 31/12/2002. The authors classified the patients according to the period of diagnosed from 1990 to 1993 (n=57), 1994 to1997 (n=71), and 1998 to 2002 (n=72) cohorts. RESULTS: There were two hundred IE patients in the present study. Mean age and degenerative heart disease were increasing. Operative and in-hospital mortality were decreasing. Overall survival rate was 81% at the first year 60% at 5 years, 55% at 12 years in surgically treated patients, with 30-day mortality in 27.1% mostly from the 1990 to 1993 cohort. In medically treated IE, overall the survival rate was 37% in the first year, 32% at 5 years, 20% at 12 years, with 30-day mortality in 72.86% mostly in the 1990 to 1993 cohort. Early surgical intervention, improved long-term survival rates (hazard ratio 0.23; 95% CI 0.14-0.37), severe congestive heart failure (hazard ratio 1.87; 95% CI 1.17-2.99) and renal failure (hazard ratio 4.10; 95% CI 2.05-7.84) are the predictors of mortality by multivariate analysis. Survival rate from 1998 to 2002 cohort was 85%, 1994 to 1997 cohort was 54% and 1993 to 1990 cohort was 27% at 1-year (p < 0.001). CONCLUSION: The data indicated that the changing clinical outcome of this disease, reflected improvements in diagnostic method and treatment. Although IE remains a serious condition characterized by significant morbidity and mortality, the overall survival rate has significantly improved over time. The authors therefore, believe that early diagnosis and prompt treatment both medical or surgical interventions will improve the outcome of IE patients.

Factors associated with treatment outcomes in pulmonary tuberculosis in northeastern Thailand.

Tuberculosis and HIV/AIDS are both prevalent in Southeast Asia and Thailand. Factors related to treatment outcomes in smear-positive pulmonary tuberculosis were evaluated in 226 adult Thai patients. Of these, 31% had a cure or a completion of therapy, 7% had treatment failure or death, and 31% had treatment interruption. The prevalence of co-morbid diseases was 52%, including 19% with HIV. Sputum cultures for Mycobacteria were carried out in 86 cases (38%), 36 of these (42%) were culture positive for Mycobacterium tuberculosis. The rate of drug resistance was 14% (5/36) of culture proven tuberculosis and the mortality rate was 4.6% (7/153) of patients with known outcomes. Of the 7 fatalities, 3 were HIV positive and 1 had multi-drug resistant tuberculosis. Factors that were significantly associated with treatment failure/death were old age (OR 44.1; 95% Cl 2.0-983.7), HIV co-infection (OR 27.5; 95% Cl 1.3-560.0), and previously treated tuberculosis (OR 9.7; 95% Cl 1.6-59.1). These high rates of drug resistance and treatment failure in this area suggest that initial sputum cultures and drug susceptibility testing for Mycobacteria should be performed in all patients who have been previously exposed to anti-tuberculous drugs, and HIV testing should be performed on all patients with tuberculosis.

The efficacy of fluconazole 600 mg/day versus itraconazole 600 mg/day as consolidation therapy of cryptococcal meningitis in AIDS patients.

Cryptococcal meningitis is one of the major complications affecting the central nervous system of patients suffering from AIDS. The results of treatment, when following current recommendation are still unsatisfactory. OBJECTIVE: This study aimed to evaluate the efficacy of a higher than recommended dose of oral fluconazole and itraconazole as consolidation therapy for cryptococcal meningitis in AIDS patients. DESIGN AND METHOD: HIV infected patients with primary cryptococcal meningitis, who had been treated initially with amphotericin B for 2 weeks were included in this study. They were randomized into two groups, to receive either fluconazole 600 mg daily or itraconazole 600 mg daily for 10 weeks. The response towards the two different treatments was clinically defined to be successful, if after 10 weeks of treatment no clinical symptoms and signs of meningitis remained and the cerebrospinal fluid (CSF) fungal culture was negative. RESULTS: The trial was performed from April 1999 to April 2000 at Srinagarind Hospital, Khon Kaen, Thailand. At the beginning of the trial 44 cases were selected, but only 35 patients proved to be suitable for the final evaluation of the study. Out of those, 19 cases were assigned to the fluconazole and 16 cases to the itraconazole group. Ten weeks after treatment, all patients clinically recovered completely. The CSF sterilization rate for the fluconazole group and for the itraconazole group were 100 and 94 per cent respectively. The Fisher's exact test showed no significant difference in the CSF sterilization rate between both groups (p = 0.26). CONCLUSION: The result of this study indicates that treatment with either 600 mg per day of fluconazole or itraconazole as consolidation treatment have the same efficacy for AIDS patients suffering from cryptococcal meningitis. The results of this study also suggest, comparing the result of this trial with the results of similar trials published somewhere else, that treatment with the higher doses may be superior to treatment regimens using lower doses, as can be judged from the clinical outcome and the results of the mycological cultures.

A randomized, open-label, comparative trial of BID and TID dosing of saquinavir enhanced oral formulation as part of a triple therapy for advanced AIDS patients.

OBJECTIVE: To compare the efficacy and safety of 1,400 mg BID and 1,200 mg TID of saquinavir soft gel given with zidovudine and lamivudine in antiretroviral-naïve, advanced AIDS patients. METHOD: A randomized, open-label study conducted at a university hospital. RESULTS: Forty cases were enrolled in the study, 20 cases in each group. The mean CD4 cell count was 29 cells/mm3. The mean log10 HIV-1 RNA was 5.27 copies/mL. Using an on-treatment analysis, the reduction in plasma log10HIV-1 RNA of BID and TID groups was not statistically significant at -2.44 vs -2.60 copies/mL (-0.16, 95% CI -0.63 to 0.30; p= 0.48). The mean increase in CD4 cell counts was not statistically significant at +144 and +159 cells/mm3 (11, 95% CI -75 to 97; p=0.79). CONCLUSION: The preliminary data suggests that in antiretroviral-naïve, advanced AIDS patients, 1,400 mg BID of saquinavir soft gel given with two nucleoside analogues might be as effective as the standard 1,200 mg TID.

Clinical outcome of native valve infective endocarditis in Khon Kaen: 1990-1999.

OBJECTIVE: To compare the survival of infective endocarditis (IE) patients following different treatment strategies and to determine the predictors of patient survival. BACKGROUND: IE is a life-threatening infectious disease that is often difficult to manage. Studies on long-term outcome are limited. METHOD: Data on 152 patients with IE from 1990 to 1999 were collected from two hospitals. The main outcome is death after definite diagnosis of native valve IE. RESULTS: The overall case fatality rate was 38 per 100 patient-years. Survival curves showed better survival for patients treated with surgery compared with patients treated medically (p <0.0001). Survival rate at year 1 was 72 per cent for surgically treated patients and 33 per cent for medically treated patients. Five-year survival rates were 66 per cent and 27 per cent in the two groups, respectively. Based on Cox proportional hazards regression analysis, surgery to be an independent predictor of survival (relative risk [RR] = 0.23; 95% confidence interval [CI] 0.14 to 0.39, p < 0.0001), while the presence of congestive heart failure (RR = 2.55; 95% CI 1.61 to 4.02, p < 0.0001), and being male (RR = 1.76; 95% CI 1.04 to 2.82, p <0.05) were independent predictors of mortality. CONCLUSION: Patients with native valve endocarditis have a high long-term mortality rate. The most common types of cardiac death are post-operative and sudden death. Surgical treatment was the preventive factor of mortality.

Infective endocarditis: prevalence, characteristics and mortality in Khon Kaen, 1990-1999.

OBJECTIVE: To update the prevalence, characteristics and mortality of infective endocarditis in a tertiary care hospital in Khon Kaen, Thailand. BACKGROUND: Numerous studies have shown that the prevalence and course of infective endocarditis remain unchanged inspite of the advance in treatment, diagnosis and of prophylactic recommendations. METHOD: The authors identified 160 patients from 1990-1999 with 86 per cent definite and 14 per cent possible endocarditis based on the Duke criteria. Data were collected from two tertiary care hospitals. RESULTS: The prevalence was 4 patients per 1,000 hospital admissions. The mean age of the 106 male and 54 female patients was 39+/-16 years. Twenty-four percent of the patients had no previously known heart disease. Native valve endocarditis was present in 95 per cent and prosthetic valve endocarditis was diagnosed in 5 per cent. Infective endocarditis was located on the aortic valve in 42 per cent, the mitral valve in 43 per cent, both mitral and aortic valves in 9 per cent and the tricuspid valve in 8 per cent. The infective organism was identified in only 62 per cent of cases. Streptococci was the most common in 43 per cent, followed by Staphylococci in 16 per cent. During the first month after admission, 45 per cent of the patients underwent surgery. In-hospital mortality was 25 per cent. CONCLUSION: Despite improved diagnostic techniques and aggressive surgical therapy, infective endocarditis remains a serious problem associated with a high mortality in Khon Kaen.