Hospital In Northeast Thailand Research Articles

Epidemiology and burden of multidrug-resistant bacterial infection in a developing country.

Little is known about the excess mortality caused by multidrug-resistant (MDR) bacterial infection in low- and middle-income countries (LMICs). We retrospectively obtained microbiology laboratory and hospital databases of nine public hospitals in northeast Thailand from 2004 to 2010, and linked these with the national death registry to obtain the 30-day mortality outcome. The 30-day mortality in those with MDR community-acquired bacteraemia, healthcare-associated bacteraemia, and hospital-acquired bacteraemia were 35% (549/1555), 49% (247/500), and 53% (640/1198), respectively. We estimate that 19,122 of 45,209 (43%) deaths in patients with hospital-acquired infection due to MDR bacteria in Thailand in 2010 represented excess mortality caused by MDR. We demonstrate that national statistics on the epidemiology and burden of MDR in LMICs could be improved by integrating information from readily available databases. The prevalence and mortality attributable to MDR in Thailand are high. This is likely to reflect the situation in other LMICs.

Comparison of community-onset Staphylococcus argenteus and Staphylococcus aureus sepsis in Thailand: a prospective multicentre observational study

Staphylococcus argenteus is a globally distributed cause of human infection, but diagnostic laboratories misidentify this as Staphylococcus aureus. We determined whether there is clinical utility in distinguishing between the two. A prospective cohort study of community-onset invasive staphylococcal sepsis was conducted in adults at four hospitals in northeast Thailand between 2010 and 2013. Of 311 patients analysed, 58 (19%) were infected with S. argenteus and 253 (81%) with S. aureus. Most S. argenteus (54/58) were multilocus sequence type 2250. Infection with S. argenteus was more common in males, but rates of bacteraemia and drainage procedures were similar in the two groups. S. argenteus precipitated significantly less respiratory failure than S. aureus (5.2% versus 20.2%, adjusted OR 0.21, 95% CI 0.06–0.74, p 0.015), with a similar but non-significant trend for shock (6.9% versus 12.3%, adjusted OR 0.46, 95% CI 0.15–1.44, p 0.18). This did not translate into a difference in death at 28 days (6.9% versus 8.7%, adjusted OR 0.80, 95% CI 0.24–2.65, p 0.72). S. argenteus was more susceptible to antimicrobial drugs compared with S. aureus, and contained fewer toxin genes although pvl was detected in 16% (9/58). We conclude that clinical differences exist in association with sepsis due to S. argenteus versus S. aureus.

Association between praziquantel treatment and cholangiocarcinoma: a hospital-based matched case-control study.

BackgroundInfection by the liver fluke, Opisthorchis viverrini, remains an important public health problem in Thailand and has resulted in the highest prevalence of infection and incidence of subsequent cholangiocarcinoma (CCA) in the world. Praziquantel (PZQ) is the antihelminthic drug of choice for treatment. Previous studies in hamsters showed that repeated infection and PZQ treatment could increase the risk of CCA. However, the few available epidemiology studies in humans have shown unclear evidence of an increased risk of CCA with frequency of PZQ intake. The present study investigated the relationship between the number of repeated PZQ treatments and CCA.MethodsA hospital-based matched case–control study was conducted. All cases and controls were inpatients of a tertiary hospital in Northeast Thailand. During 2012–2014 a total of 210 incident cases of pathologically diagnosed CCA and 840 control subjects were selected from a hospital inpatient database (four controls per case). The four recruited controls were individually matched with CCA cases by gender, age and date of admission. Data were collected in face-to-face interviews using a standardised pre-tested questionnaire. Multivariable conditional logistic regression was used in the analysis of the data.ResultsThe frequencies of PZQ usage among the 210 cases and 840 controls were 48.6 vs. 66.0 for never, 32.9 vs. 24.4 for once, 8.6 vs. 4.9 for twice, and 10.0 % vs. 4.8 % for more than twice, respectively. There was a statistically significant dose–response relationship (p < 0.001). Compared with subjects who never used PZQ, those who used the medication once, twice, and more than twice were 1.49, 1.82, and 2.30 times more likely to develop CCA (95 % confidence intervals: 1.02 - 2.20, 0.92 - 3.60, and 1.20 - 4.40). These odds ratios (adjusted ORs) had already been adjusted for the effects of eating raw fish, a family history of cancer, and highest educational attainment. Additional PZQ usage increased the odds of developing CCA by 23.0 % (adjusted OR = 1.23; 95 % CI: 1.07 - 1.43).ConclusionsThe findings show that repeated PZQ treatments are associated with an increased risk of CCA. Paradoxically, this contradicts the common belief that repeated PZQ treatments decrease the risk of CCA. The study also showed a strong association between the number of repeated PZQ treatments and the consumption of raw freshwater fish. This suggests that repeated PZQ treatments may be a surrogate marker of habit of eating raw fish.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-015-1788-6) contains supplementary material, which is available to authorized users.

Statin adverse effects: patients' experiences and laboratory monitoring of muscle and liver injuries.

Although statins have great benefit on the prevention of cardiovascular diseases with limited adverse effects (AEs), little is known about patients' contribution of AE reports in clinical practice. To explore patients' experiences of statin AEs and related laboratory monitoring in clinical practice. Outpatient clinics of two University hospitals in northeast Thailand. Generic symptom checklist questionnaires for self-reporting AEs were distributed to patients prescribed simvastatin, atorvastatin, or rosuvastatin at outpatient clinics. Clinical information was obtained from medical records. Reported symptoms were assessed for causality considering previously known statin AEs, concomitant diseases and drugs. Potential statin AEs reported by patients and monitoring of laboratory parameters related to musculoskeletal and liver disorders. Of the total 718 valid responses, 76.0 % of patients reported at least one symptom, most of which (69.0 %) were probable/possible statin AEs. Musculoskeletal and liver-related symptoms were reported by 283 (39.4 %) and 134 patients (18.7 %), respectively. Probable/possible AEs were categorized in 56.7 % of their musculoskeletal and gastrointestinal symptoms. Majority of patients had at least one laboratory test on initiation of (64.8 %) and during statin treatment (61.8 %). Patients taking atorvastatin or rosuvastatin, and patients with history of chronic renal diseases were more likely to have creatine kinase (CK) monitored on initiation of and during statin treatment. Additionally, taking drugs which could potentially increase muscle injury (OR 1.929, P < 0.01) and self-reporting of musculoskeletal symptoms (OR 1.805, P < 0.01) were associated with CK monitoring during statin treatment. Reporters of musculoskeletal symptoms also had significantly higher mean CK level than those not reporting any musculoskeletal symptoms (207.35 ± 155.40 vs. 143.95 ± 83.07 U/L, respectively; P = 0.037). Patient reporting of liver AEs was not related to alanine aminotransferase (ALT) level and monitoring, however, prior history of liver disorders was significantly associated with monitoring of ALT on initiation of and during statin treatment (OR 5.745 and OR 23.063, respectively; P < 0.01). Many patients experienced at least one possible adverse effects on a statin. The findings suggest that laboratory monitoring is relatively selective in relation to risks and patient-reported adverse symptoms.

Increasing incidence of hospital-acquired and healthcare-associated bacteremia in northeast Thailand: a multicenter surveillance study.

BackgroundLittle is known about the epidemiology of nosocomial bloodstream infections in public hospitals in developing countries. We evaluated trends in incidence of hospital-acquired bacteremia (HAB) and healthcare-associated bacteremia (HCAB) and associated mortality in a developing country using routinely available databases.MethodsInformation from the microbiology and hospital databases of 10 provincial hospitals in northeast Thailand was linked with the national death registry for 2004–2010. Bacteremia was considered hospital-acquired if detected after the first two days of hospital admission, and healthcare-associated if detected within two days of hospital admission with a prior inpatient episode in the preceding 30 days.ResultsA total of 3,424 patients out of 1,069,443 at risk developed HAB and 2,184 out of 119,286 at risk had HCAB. Of these 1,559 (45.5%) and 913 (41.8%) died within 30 days, respectively. Between 2004 and 2010, the incidence rate of HAB increased from 0.6 to 0.8 per 1,000 patient-days at risk (p<0.001), and the cumulative incidence of HCAB increased from 1.2 to 2.0 per 100 readmissions (p<0.001). The most common causes of HAB were Acinetobacter spp. (16.2%), Klebsiella pneumoniae (13.9%), and Staphylococcus aureus (13.9%), while those of HCAB were Escherichia coli (26.3%), S. aureus (14.0%), and K. pneumoniae (9.7%). There was an overall increase over time in the proportions of ESBL-producing E. coli causing HAB and HCAB.ConclusionsThis study demonstrates a high and increasing incidence of HAB and HCAB in provincial hospitals in northeast Thailand, increasing proportions of ESBL-producing isolates, and very high associated mortality.

Epidemiology and identification of potential fungal pathogens causing invasive fungal infections in a tertiary care hospital in northeast Thailand.

Invasive fungal infections (IFIs) are life threatening and associated with a high mortality rate. Here, we describe the distribution of pathogens, host risk factors, and significance of fungi isolated from patients with IFIs. The study included 861 fungal isolates recovered between 2006 and 2011 from 802 patients at Srinagarind Hospital, Thailand. Based on the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group 2008 criteria, 28.5% (245/861 isolates) of the fungal isolates were considered to be causative agents of IFIs. The most common fungus was Candida albicans (46%, 396/861 isolates). However, the most common yeast causing IFIs was Cryptococcus neoformans (34.7%, 85/245 isolates), while the most common mould was Penicillium marneffei (10.6%, 26/245 isolates). Cryptococcosis was significantly associated with human immunodeficiency virus infections (P < 0.001). Trend analysis revealed that there was no significant increase in IFI cases (P = 0.34) from 2006 to 2011 or from 2007 to 2011 (P = 0.05), but there was a trend toward significant increases in candidiasis (P = 0.04). The fungal isolates were categorized according to the positive predictive value of their recovery in cultures as being true (>95%), moderate (5%-95%), and rare (<5%) pathogens. This classification system could facilitate the prediction of the likelihood of diseases caused by the isolated fungi.

Unusual clinical manifestations of dengue infection in children in a tertiary care hospital in northeast Thailand

Abstract Background: Dengue virus infection has been a public health concern in Thailand. In the past decades, there has been recent interest concerning unusual clinical manifestations in both dengue fever (DF) and dengue hemorrhagic fever (DHF). Objective: We described the unusual clinical manifestations and outcomes of children with dengue admitted to a tertiary care hospital in northeast Thailand. Materials and Methods: A study was conducted on the 73 patients with serologically confirmed dengue infection admitted to Srinagarind Hospital, a tertiary care facility in northeast Thailand between January 2007 and August 2011. Results: Of the 73 children examined, 42 (57%) were boys and 31 were girls. Their age ranged from 8 months to 14 years (median 11 years). Nine patients developed neurological symptoms, 6 patients had altered consciousness, and 3 patients convulsion. Among 9 patients with neurological symptoms, 1 patient had acute kidney injury, 1 had hepatic failure, and 1 had kidney and liver involvement, mostly associated with fluid resuscitation or prolonged shock. Apart from neurological symptoms, one patient developed infection associated hemophagocytic syndrome and was treated with intravenous immunoglobulin. Two patients died from multiple organ failure, and 1 patient was brought back home in a moribund condition. The other patients recovered completely. Conclusion: Altered consciousness was the most commonly observed unusual neurological manifestation. Patients who did not develop acute kidney injury or liver failure had mild clinical courses and recovered from neurological symptoms without sequelae. Acute kidney injury was associated with fluid overload and/or prolonged shock. Careful fluid management and close monitoring for complications resulted in favorable outcomes.

Risk Factors for Hospitalization Due to Hypoglycemia in Diabetic Patients in Northeast Thailand

Background: Hypoglycemia among diabetic patients is a major complication, which results in high morbidity and mortality. Hospitalization provides the inadequate patient care and management. Objective: The aim of this study was to determine the potential risk factors for hospitalization due to hypoglycemia among diabetic patients. Method: In a case-control study, the cases were diabetic patients admitted due to hypoglycemia. Controls were diabetic patients admitted for other reasons. The cases and control subjects were recruited from the inpatient department of the middle level hospital in Northeast Thailand. The total sample size was 360 patients who met the criteria and had been hospitalized. The number of case was 90, and the number of controls was 270. The data were analyzed by determining the adjusted odds ratio, and 95% confidence interval of the ORs using multiple logistic regression models. Results: Using a multivariate logistic regression model, five variables were significantly associated with hospitalization due to hypoglycemia among diabetic patients: 1) patients who received insulin injections (AOR = 20.75; 95% CI: 4.7 - 91.41; p = 0.001); 2) patients who did not carry sugar candy or a dessert with them at all times (AOR = 13.89; 95% CI: 1.92 - 100.31; p = 0.01); 3) patients with an occurrence of hypoglycemia at least once a week at home(AOR = 8.83; 95% CI: 2.58 - 30.20; p = 0.001); 4) patients who were adjusted for doses of medication on their own (AOR = 6.62; 95% CI: 1.30 - 33.70; p = 0.02); and 5) patients who lacked knowledge did not understand the causes and symptoms of low blood sugar (AOR = 7.97; 95% CI: 1.97 - 32.22; p = 0.001). Conclusion: Receiving insulin injection and poor knowledge and self-care of hypoglycemia prevention were the best predictors of hospitalization due to hypoglycemia among diabetic patients. These factors need to be adequately addressed in order to provide better care and management to prevent hospitalization among diabetic patients.

PHP110 - Long-Term Survival After Intensive Care Unit Discharge in Thailand: A Retrospective Study

Economic evaluations of interventions in the hospital setting often rely on the estimated long-term impact on patient survival. Estimates of mortality rates and long-term outcomes among patients discharged alive from the intensive care unit (ICU) are lacking from lower- and middle-income countries. This study aimed to assess the long-term survival and life expectancy (LE) amongst post-ICU patients in Thailand, a middle-income country. In this retrospective cohort study, data from a regional tertiary hospital in northeast Thailand and the regional death registry were linked and used to assess patient survival time after ICU discharge. Adult ICU patients aged at least 15 years who had been discharged alive from an ICU between 1 January 2004 and 31 December 2005 were included in the study, and the death registry was used to determine deaths occurring in this cohort up to 31st December 2010. These data were used in conjunction with standard mortality life tables to estimate annual mortality and life expectancy. This analysis included 10,321 ICU patients. During ICU admission, 3,251 patients (31.5%) died. Of 7,070 patients discharged alive, 2,527 (35.7%) were known to have died within the five-year follow-up period, a mortality rate 2.5 times higher than that in the Thai general population (age and sex matched). The mean LE was estimated as 18.3 years compared with 25.2 years in the general population. Post-ICU patients experienced much higher rates of mortality than members of the general population over the five-year follow-up period, particularly in the first year after discharge. Further work assessing Health Related Quality of Life (HRQOL) in both post-ICU patients and in the general population in developing countries is needed.

Low prevalence of contraceptive counseling at Srinagarind hospital, Thailand among women of reproductive age with systemic lupus erythematosus

ObjectiveUnplanned pregnancy in women with SLE can have grave complications both for the child and the woman. We studied the prevalence of contraceptive counseling among women of reproductive age with SLE at a university hospital in Northeast Thailand.MethodsRecruited: 125 women with SLE, between 15 and 50 years, followed up at the Rheumatology Clinic. A questionnaire was administered and the results analyzed to identify the prevalence of contraceptive counseling.ResultsThe majority of women with SLE had had their reproductive goals evaluated (76.00%, 95% CI 66–83) and received contraceptive counseling (72%). Among the SLE patients at risk for pregnancy, only one-third used effective contraception and one-fifth of those did not have any background knowledge about SLE and pregnancy. Contraceptive counseling was more frequently given to women who had had a previous pregnancy or who were already concerned about SLE as related to pregnancy.ConclusionThe majority of SLE patients had at one time or other received contraceptive counseling, but some reported not grasping the gravity. The survey results presented herein suggest that a multidisciplinary team is needed to improve patient knowledge regarding SLE as it affects on pregnancy and relatedly contraceptive counseling.

Epidemiology, microbiology and mortality associated with community-acquired bacteremia in northeast Thailand: a multicenter surveillance study.

BackgroundNational statistics in developing countries are likely to underestimate deaths due to bacterial infections. Here, we calculated mortality associated with community-acquired bacteremia (CAB) in a developing country using routinely available databases.Methods/Principal FindingsInformation was obtained from the microbiology and hospital database of 10 provincial hospitals in northeast Thailand, and compared with the national death registry from the Ministry of Interior, Thailand for the period between 2004 and 2010. CAB was defined in patients who had pathogenic organisms isolated from blood taken within 2 days of hospital admission without a prior inpatient episode in the preceding 30 days. A total of 15,251 CAB patients identified, of which 5,722 (37.5%) died within 30 days of admission. The incidence rate of CAB between 2004 and 2010 increased from 16.7 to 38.1 per 100,000 people per year, and the mortality rate associated with CAB increased from 6.9 to 13.7 per 100,000 people per year. In 2010, the mortality rate associated with CAB was lower than that from respiratory tract infection, but higher than HIV disease or tuberculosis. The most common causes of CAB were Escherichia coli (23.1%), Burkholderia pseudomallei (19.3%), and Staphylococcus aureus (8.2%). There was an increase in the proportion of Extended-Spectrum Beta-Lactamases (ESBL) producing E. coli and Klebsiella pneumoniae over time.ConclusionsThis study has demonstrated that national statistics on causes of death in developing countries could be improved by integrating information from readily available databases. CAB is neglected as an important cause of death, and specific prevention and intervention is urgently required to reduce its incidence and mortality.

Long-term survival after intensive care unit discharge in Thailand: a retrospective study

IntroductionEconomic evaluations of interventions in the hospital setting often rely on the estimated long-term impact on patient survival. Estimates of mortality rates and long-term outcomes among patients discharged alive from the intensive care unit (ICU) are lacking from lower- and middle-income countries. This study aimed to assess the long-term survival and life expectancy (LE) amongst post-ICU patients in Thailand, a middle-income country.MethodsIn this retrospective cohort study, data from a regional tertiary hospital in northeast Thailand and the regional death registry were linked and used to assess patient survival time after ICU discharge. Adult ICU patients aged at least 15 years who had been discharged alive from an ICU between 1 January 2004 and 31 December 2005 were included in the study, and the death registry was used to determine deaths occurring in this cohort up to 31st December 2010. These data were used in conjunction with standard mortality life tables to estimate annual mortality and life expectancy.ResultsThis analysis included 10,321 ICU patients. During ICU admission, 3,251 patients (31.5%) died. Of 7,070 patients discharged alive, 2,527 (35.7%) were known to have died within the five-year follow-up period, a mortality rate 2.5 times higher than that in the Thai general population (age and sex matched). The mean LE was estimated as 18.3 years compared with 25.2 years in the general population.ConclusionsPost-ICU patients experienced much higher rates of mortality than members of the general population over the five-year follow-up period, particularly in the first year after discharge. Further work assessing Health Related Quality of Life (HRQOL) in both post-ICU patients and in the general population in developing countries is needed.

A retrospective study to define the incidence and associated mortality of hospital-acquired bacteraemia at a regional hospital in northeast Thailand

A retrospective study to define the incidence and associated mortality of hospital-acquired bacteraemia at a regional hospital in northeast Thailand

Neurodevelopmental outcomes of children with gastroschisis at university hospital in northeast Thailand

Background: Gastroschisis is common among congenital abdominal wall defects. The cause is unknown but it was found to be associated with young maternal age. The association between gastroschisis and delayed development is undetermined. Objective: We described neurodevelopmental outcomes in patients with gastroschisis at 24±6 months corrected age (CA) and identify factors associated with delayed neurodevelopmental outcomes. Method: This is a cross sectional descriptive study, in patients with gastroschisis born between July 2007 and December 2008, who were admitted to the neonatal unit at Srinagarind hospital, a university hospital in northeast Thailand. The patients underwent developmental assessment at 24±6 months CA by Bayley Scales of Infant Development III (BSID III) which assesses three domains: cognitive, language and motor development. Result: Fifteen of 21 patients with gastroschisis were included in the study. The mean age at follow up was 21.8±3.9 months. Four patients (26.7%) had delayed development. One was mildly delayed in all aspects including cognitive, language, and motor development. Three patients (20%) had mild delay in language development only. No significant risk factor associated with delayed neurodevelopmental outcomes was identified. Transient hypothyroidism from iodine excess was found in three out of four patients (75%) who had undergone the silooperation (p=0.01). Conclusion: Developmental evaluation should be performed in patients with gastroschisis because we found that 26.7% of patients with gastroschisis had delayed development. However, significant risk factors could not be identified due to limited number of subjects. If the patient underwent the silo-operation, thyroid function should be tested and closely followed-up.

Molecular detection and speciation of pathogenic Leptospiraspp. in blood from patients with culture-negative leptospirosis

BackgroundPathogenic Leptospira spp. present in the blood of patients with leptospirosis during the first week of symptoms can be detected using culture or PCR. A proportion of patients who are positive by PCR are negative by culture. Leptospira spp. are fastidious bacteria, and we hypothesized that a false-negative culture result may represent infection with a distinct bacterial subset that fail to grow in standard culture medium.MethodsWe evaluated our hypothesis during a prospective study of 418 consecutive patients presenting to a hospital in northeast Thailand with an acute febrile illness. Admission blood samples were taken for Leptospira culture and PCR. A single tube nested PCR that amplified a region of the rrs gene was developed and applied, amplicons sequenced and a phylogenetic tree reconstructed.Results39/418 (9%) patients were culture-positive for Leptospira spp., and 81/418 (19%) patients were culture-negative but rrs PCR-positive. The species associated with culture-positive leptospirosis (37 L. interrogans and 2 L. borgpetersenii) were comparable to those associated with culture-negative, PCR-positive leptospirosis (76 L. interrogans, 4 L. borgpetersenii, 1 unidentified, possibly new species).ConclusionMolecular speciation failed to identify a unique bacterial subset in patients with culture-negative, PCR-positive leptospirosis. The rate of false-negative culture was high, and we speculate that antibiotic pre-treatment is the most likely explanation for this.

The Influence of Symptoms, Social Support, Uncertainty, and Coping on Health-Related Quality of Life Among Cholangiocarcinoma Patients in Northeast Thailand

Health-related quality of life (HRQOL) is an important outcome for evaluating the effectiveness of cancer care. Cholangiocarcinoma (CCA) is a major public health problem in northeast Thailand. There is little information regarding factors influencing HRQOL in CCA patients. Understanding the factors affecting HRQOL in CCA patients is necessary to develop nursing interventions to improve the HRQOL. The purpose of this study was to develop and test a model that explained the influence of symptoms, social support, uncertainty, and coping on the HRQOL in CCA patients. Using a cross-sectional descriptive design, a convenience sample of 260 CCA patients were consecutively recruited from a regional hospital and a university hospital in northeast Thailand. All participants responded to a set of 6 questionnaires in structured interview format. A linear structural relationship was used to test the hypothesized model. Findings revealed the hypothesized model fit the empirical data and explained 69.4% of the variance of HRQOL. Symptoms were the most influential factor affecting HRQOL directly and indirectly through uncertainty. Social support had a direct effect on HRQOL and an indirect effect on HRQOL through uncertainty. Uncertainty had a direct effect on coping and HRQOL. Coping had a nonsignificant direct effect on HRQOL. Symptoms, social support, and uncertainty were important factors influencing HRQOL in CCA patients. Cholangiocarcinoma is a unique yet understudied condition. Further work in developing CCA-specific HRQOL interventions is warranted.

Increasing Incidence of Human Melioidosis in Northeast Thailand

Melioidosis is a serious community-acquired infectious disease caused by the Gram-negative environmental bacterium Burkholderia pseudomallei. A prospective cohort study identified 2,243 patients admitted to Sappasithiprasong Hospital in northeast Thailand with culture-confirmed melioidosis between 1997 and 2006. These data were used to calculate an average incidence rate for the province of 12.7 cases of melioidosis per 100,000 people per year. Incidence increased incrementally from 8.0 (95% confidence interval [CI] = 7.2–10.0) in 2000 to 21.3 (95% CI = 19.2–23.6) in 2006 (P < 0.001; χ2 test for trend). Male sex, age ≥ 45 years, and either known or undiagnosed diabetes were independent risk factors for melioidosis. The average mortality rate from melioidosis over the study period was 42.6%. The minimum estimated population mortality rate from melioidosis in 2006 was 8.63 per 100,000 people (95% CI = 7.33–10.11), the third most common cause of death from infectious diseases in northeast Thailand after human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and tuberculosis.

Factors Predicting and Reducing Mortality in Patients with Invasive Staphylococcus aureus Disease in a Developing Country

BackgroundInvasive Staphylococcus aureus infection is increasingly recognised as an important cause of serious sepsis across the developing world, with mortality rates higher than those in the developed world. The factors determining mortality in developing countries have not been identified.MethodsA prospective, observational study of invasive S. aureus disease was conducted at a provincial hospital in northeast Thailand over a 1-year period. All-cause and S. aureus-attributable mortality rates were determined, and the relationship was assessed between death and patient characteristics, clinical presentations, antibiotic therapy and resistance, drainage of pus and carriage of genes encoding Panton-Valentine Leukocidin (PVL).Principal FindingsA total of 270 patients with invasive S. aureus infection were recruited. The range of clinical manifestations was broad and comparable to that described in developed countries. All-cause and S. aureus-attributable mortality rates were 26% and 20%, respectively. Early antibiotic therapy and drainage of pus were associated with a survival advantage (both p<0.001) on univariate analysis. Patients infected by a PVL gene-positive isolate (122/248 tested, 49%) had a strong survival advantage compared with patients infected by a PVL gene-negative isolate (all-cause mortality 11% versus 39% respectively, p<0.001). Multiple logistic regression analysis using all variables significant on univariate analysis revealed that age, underlying cardiac disease and respiratory infection were risk factors for all-cause and S. aureus-attributable mortality, while one or more abscesses as the presenting clinical feature and procedures for infectious source control were associated with survival.ConclusionsDrainage of pus and timely antibiotic therapy are key to the successful management of S. aureus infection in the developing world. Defining the presence of genes encoding PVL provides no practical bedside information and draws attention away from identifying verified clinical risk factors and those interventions that save lives.

Patient self-reporting of potential adverse drug reactions to non-steroidal anti-inflammatory drugs in Thailand

To validate and pilot in Thailand a questionnaire to enable patients to identify and report symptoms perceived as potential ADRs from NSAIDs. To determine the questionnaire's usefulness in enabling Thai out-patients to report potential ADRs. To determine the frequency with which symptoms patients reported were recorded by health professionals and the frequency of ADRs to these drugs reported to the APRM Centre. To assess whether patients reported symptoms from non COX-selective inhibitors and COX-2 selective NSAIDs with different frequencies. Out-patient departments (OPD) of a University teaching hospital in North-East Thailand. A questionnaire which incorporated an extensive symptoms checklist, developed and validated in English, was translated, piloted and validated in Thai. This was distributed to patients receiving one of five NSAIDs. Causality assessment of the symptoms reported was undertaken by a pharmacist, using data on concomitant medicines and disease states from OPD records. Frequency and type of symptoms reported by patients, recording of these in OPD records, reports sent to APRM Centre. Piloting found that patients were able to understand the questionnaire, but were unaware of drug names. A response rate of 42% was obtained: 694 usable questionnaires were returned out of 1,654 distributed. Overall 73% of respondents reported at least one symptom perceived to be an ADR. Sixty percent of symptoms reported were classed as probably or possibly an ADR. Fewer symptoms per patient were reported by those taking COX-2 selective inhibitors (3.5) than those taking non-selective NSAIDs (5.5), although there were no differences in the frequency of GI symptoms reported between these two sub-classes, which may relate to other factors, such as age, previous GI problems and prescription of protective ulcer-healing therapy. Only 5% of symptoms were recorded in OPD records and reporting of ADRs to these drugs to the APRM Centre of the Thai FDA during the study was very limited. Thai out-patients were willing and able to complete questionnaires regarding potential ADRs. The questionnaire could form part of routine out-patient monitoring, aiding identification of ADRs, and may help to increase ADR reporting in Thailand.

Staphylococcus aureus Bacteraemia in a Tropical Setting: Patient Outcome and Impact of Antibiotic Resistance

BackgroundMost information on invasive Staphylococcus aureus infections comes from temperate countries. There are considerable knowledge gaps in epidemiology, treatment, drug resistance and outcome of invasive S. aureus infection in the tropics.MethodsA prospective, observational study of S. aureus bacteraemia was conducted in a 1000-bed regional hospital in northeast Thailand over 1 year. Detailed clinical data were collected and final outcomes determined at 12 weeks, and correlated with antimicrobial susceptibility profiles of infecting isolates.Principal FindingsNinety-eight patients with S. aureus bacteraemia were recruited. The range of clinical manifestations was similar to that reported from temperate countries. The prevalence of endocarditis was 14%. The disease burden was highest at both extremes of age, whilst mortality increased with age. The all-cause mortality rate was 52%, with a mortality attributable to S. aureus of 44%. Methicillin-resistant S. aureus (MRSA) was responsible for 28% of infections, all of which were healthcare-associated. Mortality rates for MRSA and methicillin-susceptible S. aureus (MSSA) were 67% (18/27) and 46% (33/71), respectively (p = 0.11). MRSA isolates were multidrug resistant. Only vancomycin or fusidic acid would be suitable as empirical treatment options for suspected MRSA infection.Conclusions S. aureus is a significant pathogen in northeast Thailand, with comparable clinical manifestations and a similar endocarditis prevalence but higher mortality than industrialised countries. S. aureus bacteraemia is frequently associated with exposure to healthcare settings with MRSA causing a considerable burden of disease. Further studies are required to define setting-specific strategies to reduce mortality from S. aureus bacteraemia, prevent MRSA transmission, and to define the burden of S. aureus disease and emergence of drug resistance throughout the developing world.