A surveillance study of bacteriologic profile in rhinosinusitis.

Objective: To review the types of bacteria found in rhinosinusitis and the prevalence of a beta-lactamase producing organism in a tertiary care hospital during the year 2004 and compared with our previous reports. Methods: Charts of patients who underwent endoscopic sinus surgery or maxillary antral puncture or endoscopic-guided culture at the Rhinology & Allergy Division, Department of Otolaryngology and the Department of Microbiology, Siriraj Hospital from January 2004 to December 2004 were reviewed. Information regarding the patient’s age, site of specimens, culture and sensitivity results were obtained. Results: There were 162 specimens and 29 bacterial species isolated. There were 50.4% positive aerobic cultures, gram-negative bacteria were more common than gram-positive bacteria (68.5% vs 31.5%). Common aerobes were Pseudomonas aeruginosa (16.2%), non-fermentative gram negative rod: NF-GNR (10.8%), Coagulase- negative Staphylococcus aureus :CNS (9.9%) and Klebsiella pneumoniae (9.9%).The most common anaerobes were Peptostreptococcus sp., Bacteroides fragilis and Fusobacterium sp. Conclusion: Contrary to our previous studies, gram negative organisms play a more important role than gram positive organisms. The causative pathogens of rhinosinusitis should be studied continuously because rapid progress in the development of new antimicrobial agents has a significant impact on their bacteriologic profile.

Discriminatory powers of molecular typing techniques for methicillin-resistant Staphylococcus aureus in a university hospital, Thailand.

Discriminatory powers of various molecular techniques were evaluated for typing of methicillin-resistant Staphylococcus aureus (MRSA) isolated in Siriraj Hospital, Bangkok, Thailand. Thirty MRSA isolates were randomly selected in this study. They were characterized by pulsed-field gel electrophoresis, Clal-mecA and Clal-Tn554 polymorphisms, ribotyping, and PCR-based methods including SCCmec typing, spa and coa gene polymorphism, and repeat units in hypervariable region downstream of mecA. Individual molecular typing technique distinguished those MRSA isolates into 2 to 5 types. Eleven genetic backgrounds of MRSA isolates were elucidated by combination of typing methods with trimethoprim/sulfamethoxazole (TMP/SXT) susceptibility. Combination of all typing methods including TMP/SXT susceptibility yielded a discriminatory index of 0.94. Combination of PCR-based methods and TMP/SXT susceptibility, with the discriminatory index of 0.89, is a practical typing approach suitable for rapid epidemiological investigation of MRSA isolates in a hospital setting.

Antimicrobial susceptibility of community and hospital acquired bacteria.

OBJECTIVES: To study the antibiotic susceptibility of common community- and hospital-acquired bacteria in Thailand. MATERIAL AND METHOD: Eight common bacterial pathogens were studied in 24 hospitals across Thailand in 2002-2003. Isolates of clinically proven infections were tested for their susceptibility by agar-based disc diffusion method. RESULTS: A total of 9,091 isolates of target bacteria were studied. Community and hospital acquired bacteria accounted for 54.9% and 45.1% respectively. Community acquired Escherichia coli, Klebsiella pneumoniae, Acinetobacter spp., Enterobacter spp., Staphylococcus aureus were more susceptible to antimicrobials compared to hospital acquired strains. The difference in susceptibility of community-acquired vs hospital acquired Pseudomonas aeruginosa, Coagulase-negative staphylococci and Enterococcus spp. was less impressive indicating the spread of hospital strains into the community. Bacteria isolated from the blood stream were more susceptible to antimicrobials compared to those from the lower respiratory tract, urinary tract and surgical sites. Acinetobacter spp. and Enterococcus spp. were less susceptible to antimicrobials compared to others. CONCLUSION: Decreased susceptibility to antimicrobials was found in all bacteria tested. The susceptibility to commonly used antimicrobials of community-acquired bacteria decreased to a critical level indicating the widespread resistant bacteria to the community.

Catheter-associated urinary tract infection.

OBJECTIVES: To study the incidence, risk factors, clinical outcomes and antibiotic costs of catheter-associated urinary tract infections (CAUTI) in patients with indwelling urinary catheter for one week and longer MATERIAL AND METHOD: Patients in neurology and neurosurgery wards in a teaching hospital were studied. Patients with UTI before catheterization and in whom the catheter was removed before one week were excluded. Urine cultures were done immediately after catheterization and 3 times a week there after. Patients were followed for symptoms of UTI for 1 week after catheter removal, for 4 weeks without evidence of UTI or until discharge. RESULTS: One hundred and one patients met the inclusion criteria. The incidence of CA UTI was 73.3%. High incidence of CAUTI was found in the first 2 weeks after catheterization. About one-half of the patients with CAUTI had a single episode and were symptomatic. None of the 132 episodes of CAUTI were associated with secondary bacteremia. Risk factors for CAUTI identified were prolonged catheterization and change of the catheter Nosocomial pathogens were found in urine and yeast was the commonest. Eleven patients (14.9%) with CAUTI died and only in 2, CAUTI was considered a contributory factor for mortality. The cost of antimicrobials for treating one episode of CAUTI was 8,180 baht and this rose to 49,983 baht for CAUTI associated with concurrent infections at other sites. CONCLUSION: Catheter-associated urinary tract infection was common. Uropathogens were nosocomial micro-organisms with high incidence of resistance to antimicrobials. Impacts on morbidity, mortality and costs were substantial. Better management of urinary catheter is to be explored and implemented.

Microbial contamination of antiseptics and disinfectants.

OBJECTIVE: To study the bacterial contamination of antiseptics and disinfections in-use and the risk factors for contamination. MATERIAL AND METHOD: Bacterial contamination of antiseptics and disinfectants was done by culturing in-use solutions. Eight commonly used solutions were studied: alcohol 70%, chlorhexidine 4%, and 0.5%, povidone iodine 7.5% and 10%, tincture iodine 1-2%, lysol 2% and sodium hypochlorite 0.5%. RESULTS: The following risk factors for contamination were found : preparation by unskilled personnel, improper containers and prolonged use. Contamination with bacteria were found in 1.8% of 16,142 samples tested Highest rate of contamination was found in Lysol 2%. There was no contamination of povidone iodine 10% and tincture iodine 1-2%. Bacterial contamination of antiseptics and disinfectants was highest in provincial hospitals and was not found in university hospitals. The rates of contamination correlated with the duration of use. Most bacteria isolated were those found in the environment. CONCLUSION: The contamination of in-use antiseptics and disinfectants was as high as 1.8%. Risk factors for contamination were improper preparation and prolonged use.

A study on the application of pasteurization of medical equipment.

OBJECTIVES: To study the need of pasteurization of medical equipment and the possibility of production of pasteurizer in Thailand. MATERIAL AND METHOD: The need of pasteurization of medical equipment was studied by a set of questionnaires to heads of the central sterile supply department (CSSD) and head ward nurses in 29 hospitals across Thailand. Efficacy of pasteurization was demonstrated by disinfection with an imported pasteurizer. A pasteurizer was later produced by the researchers and had it tested for efficacy in disinfection. RESULTS: There were 26 items of medical equipment that could be disinfected by pasteurization. The number of the equipment was 6.2 pieces per bed per week. Disinfection of the equipment was done in C.S.S.D. as well as in patient's wards. The imported pasteurizer was efficacious in disinfection. The pasteurizer made by researchers was convenient for use, not expensive to manufacture and the operating cost for disinfection was 2 to 6 folds less than that done by ethylene oxide gas. CONCLUSION: Pasteurization is effective in disinfection and is applicable to certain heat labile medical equipments. A pasteurizer is not difficult to produce, cheap and the operating cost is low. Pasteurization should be more widely applied in Thailand

Bacterial contamination of vegetables served in hospitals.

OBJECTIVES: To study bacterial contamination of fresh vegetables before cleaning and before serving to patients in 14 hospitals. MATERIAL AND METHOD: Aerobic plate count was performed and emphasized on total viable aerobic bacteria, fecal coliform, fecal Escherichia coli and enteric pathogens in fresh vegetables including romaine lettuce, onion, parsley, celery and tomato before cleaning and before serving. Hospital nutrition officers who were involved in food purchasing and processing were interviewed. RESULTS: One hundred and six of 403 of fresh vegetable samples (26.3%) before cleaning were contaminated with > 10(7) colony forming unit per gram (CFU/gram) of viable aerobic bacteria, 106 of 178 samples (59.6%) contained MPN/fecal coliform >1,100 /gram, 78 samples (43.8%) contained MPN fecal E. coli >10/gram. Enteric bacteria were isolated from 7.2% of the total 304 samples including non typhoid Salmonella (1 sample), Vibrio cholerae non O1/O139 (7 samples) and Aeromonas species (14 samples). Forty of 396 ready to serve vegetable samples (10.1%) contained > 10(7) CFU/gram of viable aerobic bacteria. Seventy five of 183 (40.9%) samples contained >1,100 MPN fecal coliform/gram and 43 (23.5%) contained >10 MPN fecal E. coli/gram. Enteric bacteria were also detected in 7.6% of the samples including V. cholerae non O1/O139 (6 samples) and Aeromonas species (17 samples). There were three different ways in obtaining fresh vegetables to the hospitals: by auction (50%), wholesalers (21.4%) and retailers (14.2%). There were also different standards of transportation, packaging, delivery and food processing, particularly cleaning methods. CONCLUSION: Ready-to-eat fresh vegetables were contaminated in high percentages with microorganisms in the number that exceeded the standard. Better management is required to safeguard patients.

Endemic Serratia marcescens in a neonatal intensive care unit.

OBJECTIVE: To study the endemicity of Serratia marcescens in a neonatal intensive care unit (N.I.C.U). MATERIAL AND METHOD: During the first 4 months of 2001, neonates in the N.I.C.U. in a teaching hospital were screened for S. marcescens by serial throat swabs and collections of other appropriate clinical specimens. Environmental cultures were also done in the same period. Isolated S. marcescens were tested for antimicrobial susceptibility and for genotyping by pulsed field gel electrophoresis. RESULTS: During the period, 104 neonates were studied. S. marcescens were isolated in 34.6% of the cases. Environmental cultures were positive for S. marcescens in 1.4%. There were 10 patterns of antibiogram of the 190 strains isolated. All strains belonged to pulsotype A. CONCLUSION: The study confirmed that S. marcescens was endemic in the N.I.C.U. and belonged to one genotype.

Prevalence and impacts of nosocomial infection in Thailand 2001.

OBJECTIVES: To study the prevalence and impacts of nosocomial infection (N.I.) in Thailand. MATERIAL AND METHOD: A point prevalence study on N.I. was carried out in 42 hospitals across Thailand in March 2001. The impacts of N.I. were done in the same hospitals by matched control groups in a period prevalence study March 12-25, 2001. RESULTS: The point prevalence rate of N.I. in 42 hospitals involving 18,456 patients across Thailand in March 2001 was 6.4%. The prevalence was higher in male than female patients (7.8% vs 5.0%). The prevalence rates of over 10% were found in 4 hospitals. The infection rate was highest in surgical followed in rank by medical, pediatric and orthopedic departments (9.1%, 7.6%, 6.1% and 5.8%) respectively. The commonest site of the infection was the lower respiratory tract, followed by urinary tract, surgical site and skin and soft tissue (34.1%, 21.5%, 15.0% and 10.5%). Gram-negative bacteria were isolated in 75.3% and gram-postive 18.4%. Penicillins, cephalosporins, aminoglycosides were the most used antimicrobials (31.2%, 25.2%, 12.3%). A period prevalence study on 53,882 patients during a 2 week period in March 2001 showed an infection rate of 2.5%. By matched control group study, an episode of N.I. was associated with 10.1 to 12.5 extra hospital days. The cost of antimicrobials for treatment of an episode of N.I. was 5919.50 baht (148 U.S. dollars). Thirteen point eight per cent of patients with N.I. died, 6.7% directly due to N.I. CONCLUSION: Nosocomial infection is common in hospitalized patients in Thailand and is associated high mortality rate and economic burden.

Prevalence and antimicrobial susceptibility of Pseudomonas aeruginosa mucoid and non-mucoid type.

Pseudomonas aeruginosa is a leading cause of nosocomial infections. One thousand two hundred and twenty strains of mucoid and non-mucoid types of P. aeruginosa isolated from different patients were examined at Siriraj Hospital from January 2001-October 2003. The prevalences of P. aeruginosa mucoid type and non-mucoid type were 3.6% and 96.4%, respectively. Susceptibility testing was performed by Kirby-Bauer disk diffusion method as recommended by NCCLS. The isolates with mucoid phenotypes were more susceptible than the non-mucoid isolates. The antimicrobial susceptibility pattern of both types should provide guidelines for the selection of appropriate drugs for treatment.

Six-year report of mycobacteria recovered from automated culture system at Siriraj Hospital.

An increased incidence of tuberculosis and other mycobacterial infections among immunocompromised patients has created a serious health crisis, especially in resource-poor countries. In addition, disseminated disease occurs more frequently in these patients. Rapid isolation and accurate identification of causative agents are necessary for selecting an appropriate treatment regimen. Since an isolation of Mycobacterium tuberculosis and slowly growing mycobacteria require 3-4 weeks for conventional culture, the automated system can reduce the detection time to 7-10 days. The present study demonstrated the mycobacteria recovered from hemocultures and other sterile body fluids, using the BACTEC 9000 system. Overall, 5,490 samples during the period 1998-2003 were submitted for hemocuture and the isolated mycobacteria were identified by using molecular techniques, like multiplex PCR and PCR-REA. The results demonstrated that~18-28% of hemocultures were positive for mycobacteria. Of these, M. tuberculosis appeared to be the most common species among mycobacteria isolates whereas the M. avium complex was found to be the second most common. The combined use of an automated culture system and molecular techniques as shown in this study is a useful procedure for rapid isolation and identification of mycobacteria that can reduce the time from 6-8 weeks to 2-3 weeks.

Serological study of Mycoplasma pneumoniae infections.

Mycoplasma pneumoniae antibody was determined in 811 sera of different patients admitted to Siriraj Hospital with respiratory tract infection from July 1, 2000 to August 31, 2003 by agglutination with gelatin particle agglutination test kit (SERODIA-MYCO II, Fujirebio Inc. Japan) in microtiter plates. Three hundred and three sera were positive (37.36%). The five most positive titer were found in patients 5-9 yr (40.26%), followed by patients 1-4 yr (24.75%), 10-14 yr (19.80%), 30-39 yr (5.28%) and 20-29 yr (3.96%). The positive titers ranged from 40 to > 20,480. Female:male ratio in positive patients was approximately the same (1.19:1). High titers (> or = 320) were found in 146 out of 303 patients (48.18%). The infection was mostly found in children aged 5-9 yr. Detection of antibody to M. pneumoniae infection showed that 37.36% of patients who were suspected of having atypical bacterial pneumonia were positive.

Antifungal susceptibility and molecular typing of candida albicans isolated from AIDS and non-AIDS Thai patients.

The antifungal susceptibility of Candida albicans isolated from 2 groups of Thai patiens; AIDS patients and non-AIDS patients was investigated. Two hundread and seventeen C. albicans were isolated from the specimens from 54 AIDS patients and 163 non AIDS patients. All isolate were included in the antifungal susceptibility test against amphotericin B, fluconazole, ketoconazole and nystatin. A hundred isolates were randomly selected from both groups for the electrophoretic karyotypes determination. There was not much difference in the value of Mic, MIC50 and MIC90 of all antifungal agent for C. albicans isolates between AIDS and non-AIDS patients. The amphoter B MIC for 61.0% if AIDS isolates and 71.0% of non-AIDS isolates were >0.5 mg/l, while ketoconazole MIC for 94.4% of AIDS and 74.9% of non-AIDS isolates were >0.125 mg/l and fluconazole MIC of 100% of AIDS and non-AIDS isolates were 2.0 mg/l. For nystatin, the MIC for more than 90% of both isolates was <8 mg/l. The MIC50 and MIC90 of all antifungal agents for the two groups of isolates were almost at the same concentration except for fluconazole which showed a two-fold difference of MIC50. The chromosomal DNA karyotypic of C. albicans indicated genetic diversity among all isolates. Twenty-three distinct pulsed-field gel electrophoresis karyotypes and molecular sizes ranging from 3.5 to 0.5 megabases were identified. Most isolates (61%) from both AIDS and non-AIDS isolates belong to type 1 and type 3. Among the AIDS isolates, 38.3% and 29.8% were type 1 and 3, respectivety, and non-AIDS isolates, 20.8% and 33.9% were type 1 and 3, respectively. C. albicans isolates were show to have 8 to 10 chromosomal DNA brands. Most of the isolates (78%) along with C. albicans FC18 control strain had 8 band patterns. The recovery of the common karyotypes in AIDS patients, as well as in non-AIDS patients, suggests that C. albicans infection may develop from a common source by the cross contamination between both groups of patients.

Bacterial isolation with on-site inoculation of ascites fluid into hemoculture bottle in spontaneous bacterial peritonitis.

OBJECTIVE: To compare the on-site bacterial inoculation of ascites fluid into hemoculture bottle with routine method in the patients who were preliminary diagnosed of SBP. MATERIAL AND METHOD: A retrospective analysis of case records during January-December 2001. RESULTS: A total of 673 specimens from 325 patients were retrieved from the data records at the Department of Microbiology, Siriraj Hospital in 2001. The neutrocytic ascites were found in 163 specimens (94 patients). The routine method and on-site inoculation into the hemoculture bottle were employed in 107 and 56 specimens respectively. Culture-positive neutrocytic ascites was found in the routine method 16 (14.9%) specimens and in the on-site inoculation 26 (46.4%) specimens (p < 0.0001). Among these samples, the two methods were simultaneously performed in 42 specimens of which 18 paired specimens were eligible for analysis. Positive culture was found in 2 samples in which the routine method and in an additional 5 samples in which on-site inoculation into hemoculture bottle method. Using Kappa analysis (e score = 0.328, 95% CI = -0.172 to 0.829) that can be interpreted the on-site inoculation method had a higher yield than the routine technique. Moreover, 21 cases also had their blood and ascites samples simultaneously collected and cultured. 4 of ten (19%) and 5 of eleven (23.8%) cases were found in the routine and on-site and direct inoculation groups respectively. These finding suggested that the severity of infection in among two groups were similar and unlikely to be the cause of the difference of the positive isolation rate in both groups. CONCLUSION: The on-site and direct inoculation of ascites into hemoculture bottle method had a significantly higher isolation rate than routine method (i.e. 46.4% versus 14.9% p < 0.0001) either with separated or paired samples of ascites.

Detection of Clostridium difficile toxin A and B genes from stool samples of Thai diarrheal patients by polymerase chain reaction technique.

The prevalence of Clostridium difficile isolated from stools of Thai adult patients with suspected antibiotic-associated diarrhea (AAD) was 18.64 per cent. The recovery rate of toxin genes (tcdA and tcdB) by polymerase chain reaction (PCR) from stool samples yielded almost the same compared to the recovery rate of the toxin detection by enzyme immunoassay (EIA), which were 44.9 per cent and 46.7 per cent, respectively. Correlation of toxin gene detection by PCR and toxin detection by EIA was 90.6 per cent. All but one stool sample, the tcdA gene was detected together with the tcdB gene. Both genes were always detected together from tox gene-positive strains. Although, there were some discrepancy results for certain samples, the direct PCR-based-detection of C. difficile tox genes in stool samples seems to be the appropriate method for the diagnosis of C. difficile diarrhea. The PCR assay should be a recommended technique to be used routinely in laboratories. Further optimization of the technique to increase the sensitivity of the PCR assays is still needed. However, a quantitative isolation of the organism from stools of suspected antibiotic-associated diarrhea (AAD) or antibiotic-associated colitis (AAC) patients may give some evidence for clinicians in hospitals who cannot perform PCR-based or EIA-based techniques, since 48.6 per cent of the isolates were demonstrated as toxigenic strains.

An open-label, non-comparative phase IIIb study of oral gatifloxacin in the treatment of acute, uncomplicated bacterial sinusitis in Thai patients.

This was an open-label, non-comparative phase IIIb study of oral gatifloxacin in the treatment of acute, uncomplicated bacterial sinusitis in Thai patients. The study was conducted at three otolaryngologic centers in Thailand, i.e. Siriraj Hospital, Srinakarind Hospital, and Bhumipol Hospital, during the period of November 1999 through October 2000. Thirty patients with symptoms and signs of acute maxillary sinusitis, which were confirmed by abnormal radiological findings, were included. Documentation of infection was made by pre- and post-therapy culture and susceptibility testing. All patients received gatifloxacin 400 mg tablet orally once daily for 10 days. Symptoms and signs were evaluated on four occasions, i.e. before treatment started (day 0, V1), day 3-5 (V2), the third (V3) on day 11-14 (V3), and day 21-28 (V4). Primary outcome measures were the changes in the percentage of patients who had general clinical symptoms (i.e. fever, malaise, chill, sore throat, headache, cough, and halitosis), and also the clinical symptoms and signs of sinusitis (i.e. sinus pain, sinus tenderness, purulent nasal discharge, facial pressure, nasal congestion, postnasal drip, and anosmia). The clinical responses were classified as cure, improvement, relapse or failure at the end of treatment (V3) and at follow up (V4). Treatment success was defined as cure or improvement. The safety of gatifloxacin was assessed from vital signs, general physical examination, hemato-biochemical parameters, and adverse events reported. There were 13 males and 17 females, with a mean age of 34.7 + 12.2 years (range 21-70). The mean duration of symptoms was 2.4 + 8.8 weeks. At V1,23 patients (76.7%) had headache, 19 patients (63.3%) had cough, and 14 patients (46.7%) had halitosis. At V3 and V4 all these symptoms had resolved, except in 1 patients who still had cough. The percentages of patients who had symptoms and sign of sinusitis at V1 were as follows : purulent nasal discharge 90%, nasal congestion 86.7%, postnasal drip 86.7%, sinus pain 80%, facial pain 66.7%, and sinus tenderness 63.6%. After 3-5 days of treatment (V2), the percentages of patients who had symptoms and signs of sinusitis decreased significantly for every symptom and sign. The same was true at V3 and V4. The total percent improvement in radiological findings was 83.4% (41.7% resolution, 41.7% improvement). Pretreatment cultures were positive in 23 out of 30 patients (76.7%). The most common pathogens were Hemophilus influenzae (18.4%), Streptococcus pneumoniae (9.4%), other Streptococcus species (9.4%), Klebsiella pneumoniae (6.3%) and coagulase negative Staphylococcus (6.3%). The anaerobes found were Peptostreptococcus prevotii (9.4%), Fusobacterium nucleatum (9.4%), Bacteroides species (6.1%) and Prevotella species (3.1%). Bacteriological responses at V3 were 30.4% eradication, 65.2% presumed eradication, and 4.4% persistence. Clinical responses at V4 were 88.9% cured, 7.4% relapsed, and 3.7% failed. Adverse events were found in 4 patients (13.3%) which were transient and resolved spontaneously. Adverse events found were nausea, vomiting, dry mouth, constipation, agitation and tremor. This study showed the efficacy and safety of a 10-day course of oral gatifloxacin 400 mg once daily in the treatment of acute uncomplicated bacterial sinusitis. 88.9% of patients experienced a cure, and bacteriological eradication was achieved in 95.6%. The excellent profile of gatifloxacin makes it suitable for the treatment of community acquired acute bacterial sinusitis. The once daily regimen enhances patient compliance.

The outbreak of Serratia marcescens bacteremia in a pediatric ward, Siriraj Hospital 1997.

Between October 20 and November 11, 1997, Serratia marcescens bacteremia was identified in 8 patients in a pediatric ward at Siriraj Hospital. The organism was isolated from 17 blood and 3 bone marrow specimens. The only common associated factor in these patients was that they all had received an intravenous fluid infusion. In the attempt to investigate the source of S. marcescens implicated in the outbreak, 108 specimens of intravenous fluid, 3 intravenous fluid bottle caps, 4 specimens from intravenous fluid tubing sets, 21 specimens of antiseptics used on the ward, 28 specimens of rectal swabs from patients on the ward, 1 sample of blood culture media prepared by the hospital for routine use, and 62 environmental specimens including hand swabs of the medical personnel, refrigerator, air conditioning, milk samples, room air, water sink, wooden splint and adhesive tape used to immobilize the intravenous access. Of 227 specimens sent for culture, S. marcescens was isolated from only one specimen collected from the in-use intravenous fluid given to a patient with Serratia bacteremia. S. marcescens was not found in any other surveillance culture. The 8 patients were placed under quarantine in the same room with an exclusive nursing team. With the investigation and intervention including monitoring for meticulous hand washing of the ward staff, the outbreak was stopped within 7 days. Although the investigation failed to discover the environmental reservoir of S. marcescens in this outbreak, the data suggested that intravenous fluid was probably the route of transmission and the medical personnel played an important role in spreading the infection.

Antiseptics for preventing omphalitis.

BACKGROUND: Omphalitis may cause serious complications and contribute to neonatal morbidity and mortality. From January 1997 to August 1998, the incidence of omphalitis in the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital had been increased from 0.9 to 17.4 per 1,000 live births. A prospective randomized trial using antiseptic applied directly to the umbilical stump was conducted aiming to reduce an epidemic outbreak of omphalitis in the newborn nursery. OBJECTIVE: To determine which antiseptic is appropriate for preventing omphalitis in the newborn infants. PATIENTS AND METHOD: Newborn infants delivered in the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital were randomized into group A (Triple dye) or group B (70% Alcohol). The infant with omphalitis was assessed by a pediatrician or a neonatology fellow. At home, the same antiseptic will be continually applied to the umbilical stump daily until a few days after cord detachment. Relative risk was calculated and statistical significance was tested by Chi-square test. RESULTS: Four hundred and twenty-seven infants were enrolled. Birth weight, gestational age and gender of the infants in both groups were not different. There were no known maternal risk factors for omphalitis. Omphalitis was observed in 9/213 (4.2%) infants in group A and 23/214 (10.7%) infants in group B. The relative incidence rate between each group was statistically significant (p<0.01). Triple dye group was 60 per cent less likely to develop omphalitis compared to 70 per cent Alcohol group (RR 0.39, 95% CI: 0.19-0.83). The mean duration for cord detachment were 13.6 and 11.5 days in group A and group B, respectively. CONCLUSION: During an epidemic outbreak of omphalitis, Triple dye was the most appropriate and effective antiseptic to prevent omphalitis but could delay cord separation.

Multidrug resistant mycobacterium tuberculosis infections in patients with acquired immunodeficiency syndrome at Siriraj Hospital.

Bachground : The increase in the prevalence of multidrug-resistant tuberculosis (MDR-TB) has been alarming globally. HIV and Mycobacterium tuberculosis co-infection is not uncommon. The mortality rate of MDR-TB it self is generally high. We describe 21 patients with multidrug-resistant Mycobacterium tuberculosis infection (MDR-TB), who had acquired immunodeficiency syndrome (AIDS). Methods: Information concerning all patients with AIDS and M. tuberculosis co-infection treated at Siriraj Hospital was collected from January 1, 1998, through June 30, 2001 which included clinical presentation, laboratory data, chest x-ray findings, treatment and outcome. Results: Six hundred and forty nine isolates of M. tuberculosis were tested for antimycobacterial susceptibility. 58 isolates (8.9%) were multidrug-resistant. Twenty one patients (36%) had AIDS. Of these, seven patients (33.3%) had primary drug resistant tuberculosis and 15 (66.7%) had secondary drug resistant tuberculosis. The mortality rate of MDR-TB with AIDS was 71.4%. The most common clinical presentations were fever (61.9%), cough (47.6%), and peripheral lymphadenopathy (33.3%). Twenty four percent had pulmonary disease only, 52% had both pulmonary and extrapulmonary diseases. The mean CD4 lymphocyte count was 38.8+45.77 cells/?L. Thirty three percent of the isolates were resistant to isoniazid and rifampicin only, 43% were resistant to 3 drugs and 24% to 4 drugs. Conclusion: The prevalence of MDR-TB was 8.9% ( 58 of 649 cases) in Siriraj Hospital from January 1, 1998 through June 30, 2001. Twenty-one of these patients (36%) had AIDS. Patients with MDR-TB were more likely to have disseminated disease and low CD4 lymphocyte counts. The mortality rate was high. All isolates of M. tuberculosis should be tested for antimycobacterial susceptibility to guide treatment and improve the outcome.

Sterility and storage period of placental blood from neonates delivered by caesarian section.

A prospective study was conducted to evaluate the storage period and sterility of placental blood from neonates delivered by caesarian section. Following caesarian section of the infant and placenta, the placenta was immediately placed in a sterile tray and the umbilical cord near the clamps was rinsed with sterile saline and cut 2 cm below the clamps with sterile scissors. An Fr 8 feeding tube was inserted into an umbilical vein and 43 ml of placental blood was drawn into a 50 ml disposable syringe which contained 7 mls of CPDA-1 solution. Five-ml aliquots of blood retrieved from the placenta were inoculated into aerobic and anaerobic blood culture bottles. Sixty-four specimens of CODA-1 anticoagulant blood were retrieved from the placenta and evaluated for biochemical changes to determine the recommended storage period. The mean plasma potassium concentrations were 4.9 + 1.1, 9.1 + 2.6, 13.1 + 2.0 mM/l at 0, 48 and 72 hours after collection, respectively. The 72-hour potassium concentration was higher than the value in adult whole blood stored for 7 days, which is considered fresh blood and recommended for transfusing newborn infants. The 107 paired aerobic/anaerobic culture specimens showed an overall contamination rate of 13%. These findungs suggest that placental blood in CPDA-1 can be stored for 48 hours for autologous transfusion and that rinsing the umbilical cord in sterile saline cannot prevent bacterial contamination in the retrieved placental blood.