Cross-Reactivity against Naja sumatrana (Black Spitting Cobra) Envenoming from the Haffkine Antivenom in a Mouse Model.

Naja sumatrana is the dominant cobra species in Malaysia, Singapore, Borneo, and Sumatra, and it does not have specific antivenom. The Haffkine antivenom has been advocated instead. This study aims to determine the efficacy of this antivenom against Naja sumatrana envenoming using a mouse model. Methods. Male Swiss albino mice were used. Intravenous LD50 was first determined separately for Naja naja and Naja sumatrana venom. ED50 was determined by preincubating antivenom with each venom at 2.5 LD50 before administering the mixture into the tail vein. Validation was carried out using a challenge test. Each mouse received 111 µg of Naja sumatrana venom intramuscularly followed by intraperitoneal administration of dilute Haffkine antivenom. Survival was recorded 24 hours after envenoming. Results. The LD50 of Naja naja venom was 78.13 µg, standard error (SE) 13.3 µg. The ED50 of the Haffkine antivenom against Naja naja venom was 45.9 mg, SE 7.5 mg. The LD50 and ED50 of Naja sumatrana venom were 55.5 µg, SE 12.0 µg; and 73.9 mg, SE 12.0 mg, respectively. The intra-peritoneal ED50 against 111 µg intramuscular Naja sumatrana venom was 136.95 mg, SE 36.74 mg. Conclusion. The Haffkine polyvalent antivenom exhibited cross-neutralisation against Naja sumatrana venom when used at a higher dose.

Predicting positive blood cultures in patients presenting with pneumonia at an Emergency Department in Singapore.

INTRODUCTION: Routine blood cultures have been recommended for all patients in treatment guidelines for community-acquired pneumonia (CAP). This practice has become a major area of resource utilisation, despite the lack of evidence in its clinical utility. Calls for abandoning the practice is balanced by the occasions of uncovering an unexpected pathogen or an unusual antimicrobial resistance pattern. The aim of this study is to identify factors that predict positive blood cultures among patients hospitalised for pneumonia upon presentation at the Emergency Department (ED). MATERIALS AND METHODS: A case control study was carried out on patients treated for pneumonia in the ED who had routine blood cultures performed as part of their management. The pneumonia severity index (PSI) was used to categorize patients into low- and high-risk for 30-day mortality. Logistic regression was carried out to determine factors significantly associated with positive blood cultures, from which a predictive probability equation was used to identify patients whose blood cultures were negative at a pre-determined cut-off, with minimum number of culture positive misclassification. A scoring system was devised, with scores predicting which patients would be likely to have a positive or negative blood culture. RESULTS: A total of 1407 patients with pneumonia were treated at ED from May to December 2006, from whom 1800 blood cultures were performed. Of these, 140 cultures (7.8%) grew organisms, comprising 96 (5.3%) true positive cultures and 44 (2.4%) contaminated cultures. Logistic regression analysis identified ill patients with higher PSI classes, smokers and Malay patients to be more likely to have positive blood cultures. Patients who had prior treatment with antibiotics, chronic obstructive pulmonary disease and cough were less likely to have positive blood cultures. An index to predict a negative blood culture resulted in the accurate classification of all but 4 positive patients while still correctly classifying 27.8% of blood culture negative patients. The area under the ROC curve was 0.71 (95% CI, 0.65-0.76). A simplified scoring system was devised based on the predictive model had a sensitivity of 82% and specificity of 38.2% for a positive blood culture. CONCLUSION: Routine blood cultures yielded negative results in 94% of patients presenting with pneumonia. The development of the clinical scoring system is a first step towards selecting patients for whom blood cultures is performed and improve cost-effectiveness.

Effects of topical heparin, antivenom, tetracycline and dexamethasone treatment in corneal injury resulting from the venom of the black spitting cobra (Naja sumatrana), in a rabbit model.

BACKGROUND: The Naja sumatrana cobra can spit venom in defense and may result in permanent blindness. The study sought to determine the efficacy of topical heparin, Haffkine antivenom, tetracycline and dexamethasone. MATERIALS AND METHODS: Male New Zealand White Rabbits were used. Pooled venom was frozen at -30 degrees C. 0.05 mL of 20 times dilute venom was introduced into the conjunctiva, in groups of three rabbits randomly. Heparin at 5000 IU/mL, Haffkine antivenom or saline control was administered repeatedly on each rabbit's eye over 158 minutes, after a specified delay. In other groups, 1% tetracycline, 0.1% dexamethasone or a placebo ointment was applied and repeated at 24 and 48 hours. All the rabbits were assessed after 24, 48, 72 hours, one and two weeks by an ophthalmologist blinded to the treatment arms. OBSERVATIONS: Following ocular envenomation, there was immediate blepharospasm, lacrimal secretions, redness and chemosis; more intense in the normal saline group. The Roper-Hall grades improved, corneas re-epithelialized and inflammation quietened in the heparin and antivenom-treated rabbit eyes compared to controls. Scarring appeared from the first week, but ameliorated in the heparin and antivenom groups. Heparin treatment remained efficacious up to four minutes delay. The tetracycline, dexamethasone and placebo groups had worsening Roper-Hall trends, greater corneal epithelial loss, inflammation and scarring. Combined heparin-tetracycline therapy was as efficacious with heparin alone. CONCLUSION: Topical heparin or antivenom therapy significantly improved overall outcomes in rabbit corneas exposed to Naja sumatrana venom, compared to tetracycline, dexamethasone and controls. Heparin treatment remains efficacious up to 4 minutes delay.