A prospective study of ceftriaxone treatment in acute pyelonephritis caused by extended-spectrum beta-lactamase-producing bacteria.

BACKGROUND: Much controversy exists as to whether cephalosporin treatment is appropriate for infections caused by ESBL-producing organisms because no randomized controlled studies have been performed. OBJECTIVE: Evaluate the therapeutic outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis. MATERIAL AND METHOD: The authors performed a prospective study in female patients hospitalized with acute pyelonephritis caused by ESBL-producing or ESBL-nonproducing E. coli, K. pneumoniae, or P. mirabilis in four hospitals in Thailand from 2004 to 2006. The clinical and microbiological outcomes were evaluated at 72 hours after empirical ceftriaxone treatment. RESULTS: One hundred eleven patients with the mean age of 65.29 years participated in this study. There were no differences in demographic and clinical characteristics and laboratory data between the ESBL-producing and ESBL-nonproducing groups except the higher rates of previous antibiotic use and urinary tract infection; and the lower frequency of costovertebral angle tenderness in the ESBL-producing group. Both clinical (65% and 93%) and microbiological (67.5% and 100%) responses at 72 hours after ceftriaxone treatment were poorer in the ESBL-producing group than in the ESBL-nonproducing group (p < 0.0002). CONCLUSION: To the authors' knowledge, this is the first prospective study to evaluate the outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Enterobacteriaceae. The present study confirms that acute pyelonephritis in the female patients caused by ESBL-producing strains could not be treated with ceftriaxone.

A study of Clostridium difficile-associated disease at King Chulalongkorn Memorial Hospital, Thailand.

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.

Uropathogens and empiric antibiotics for the treatment of urinary tract infections in spinal cord injured patients at rehabilitation center, Thai Red Cross Society during 2001 to 2005.

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.

Salmonella gas-forming femoral osteomyelitis and pyomyositis: the first case and review of the literature.

The authors describe the first case of Salmonella serogroup D gas-forming femoral osteomyelitis and pyomyositis in a 51-year-old man with non-Hodgkin lymphoma. The patient was successfully treated with surgical debridement as well as clindamycin plus ceftriaxone, and then switched to ciprofloxacin. However, he eventually died due to multidrug-resistant Acinetobacter baumannii pneumonia. In addition, five cases of Salmonella gas-forming pyomyositis in the literature were reviewed.

Prevalence of adrenal insufficiency in critically ill patients with AIDS.

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.

Nontuberculous mycobacterial infections in King Chulalongkorn Memorial Hospital.

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.

Galactomannan antigenemia for the diagnosis of invasive aspergillosis in neutropenic patients with hematological disorders.

OBJECTIVES: Invasive aspergillosis (IA) is among the most common invasive fungal infections in neutropenic patients with hematological disorders in the authors' institution, King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand Previous studies have reported the Aspergillus galactomannan enzyme immunosorbent assay (GMEIA) may be a useful diagnostic tool for IA. The authors evaluated the performance of the GM EIA for the diagnosis and monitoring of the course of IA in KCMH. MATERIAL AND METHOD: The authors prospectively performed the study from June 2002 to January 2004 in a consecutive series of adult neutropenic patients with hematological disorders who were at risk for developing IA. During hospitalization, serum galactomannan levels were measured once or twice weekly using the Platellia Aspergillus EIA test kit. The sensitivity and specificity of the GM EIA were calculated according to the proportion of patients with true and false positive and negative tests. RESULTS: There were 50 treatment episodes in 44 patients with 5 proven, 12 probable, and 33 possible or no IA. The cutoff GM index of > 0.75 was determined with a sensitivity of 94.1% and a specificity of 78.8%. There was a close relationship between clinical outcome and the kinetics of GM indices. CONCLUSION: The GM EIA is a useful diagnostic toolfor the diagnosis and monitoring of the course oflA in the presented institute.

Brucellosis: the first case of King Chulalongkorn Memorial Hospital and review of the literature.

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 in King Chulalongkorn Memorial Hospital and review of the literature in Thailand.

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.

Streptococcus suis meningitis in Thailand.

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.

MR imaging of CNS leiomyosarcoma in AIDS patients.

Leiomyosarcomas of the central nervous system are extremely rare; however they are becoming more prevalent in immunocompromised patients. The authors present MRI (Magnetic Resonance Imaging) of six cases of pathological proved leiomyosarcomas of the central nervous system in patients infected with human immunodeficiency virus. MR images of 4 cases of intraspinal leiomyosarcoma showed lobulated masses expanding multilevel of neural foramina with extradural and intradural extension, giving dumbbell appearance which mimic neurofibroma. Two cases of intracranial leiomyosarcoma revealed a mass at the left cavernous sinus involving prepontine cistern in one case and two lesions in the other case showing masses with dural based appearance at the region of the planum sphenoidale and the posterior aspect of the falx cerebri which mimiced a meningioma. The leiomyosarcoma should be included in the differential diagnosis of extra-axial CNS lesions in HIV-infected patients.

Adenovirus hemorrhagic cystitis in a stem cell transplant patient: the first reported case in Southeast Asia.

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.

Hydatid disease of the liver: the first indigenous case in Thailand and review of the literature.

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.