Epidemiology of bloodstream infections and predictive factors of mortality among HIV-infected adult patients in Thailand in the era of highly active antiretroviral therapy

Few studies have described the pattern of bloodstream infections (BSI) among HIV-infected patients in the highly active antiretroviral therapy (HAART) era, particularly in resource-limited settings. A retrospective cohort study was conducted among 140 HIV-infected patients who had a positive blood culture from 2004-2008. Of the 140 patients, 91 (65%) were male with a mean (SD) age of 38 (9.1) years and a median (IQR) CD4 cell count of 32 (9-112) cells/mm(3). Community-acquired infection was detected in 89% of patients. The blood cultures contained Gram-negative bacteria, 40%; fungi, 24%; Mycobacterium spp., 20%; and Gram-positive bacteria, 16%. Common causative pathogens were Cryptococcus neoformans, 21%; Salmonella spp., 15%; and Mycobacterium tuberculosis, 12%. Common focal sites of infection were the central nervous system, 24%; respiratory tract, 20%; and gastrointestinal tract, 18%. CD4 cell count (OR, 0.61 per 50 cells/mm(3) increment; 95% CI, 0.39-0.96; P = 0.031) was the only factor associated with mycobacterial or fungal BSI. The crude mortality was 21%. HAART (OR, 0.23; 95% CI, 0.01-0.77; P = 0.017), focal infection (OR, 0.31; 95% CI, 0.10-0.97; P = 0.044), and complication (e.g., shock) (OR, 9.26; 95% CI, 3.25-26.42; P < 0.001) were the predictive factors of mortality. In conclusion, opportunistic infections are still the leading causes of BSI among HIV-infected patients in the HAART era.     

The effect of quicklime (calcium oxide) as an inhibitor of Burkholderia pseudomallei

Measurement of in vitro activity of quicklime against Burkholderia pseudomallei revealed that quicklime at concentrations of 10% or more was bactericidal for up to 35 d. The effect of quicklime as an inhibitor of B. pseudomallei in soil from a rice field was studied in a laboratory setting. The soil, collected from a rice field in north-eastern Thailand, was mixed with B. pseudomallei. In experiment 1, quicklime was mixed with the soil in different amounts. In experiment 2, quicklime was spread over the soil surface. In experiment 3, quicklime solution was poured onto the soil. It was found that the pH of the soil in experiment 1 was much higher than that in experiments 2 and 3. Only quicklime mixed with soil at a concentration of 40% or more (weight/weight) was effective in inhibiting the growth of B. pseudomallei for up to six weeks.     

Evaluation of Thailand national external quality assessment on HIV testing

PURPOSE: The Thailand National Institute of Health (NIH) established an external quality assessment (EQA) scheme on HIV serology testing since 1994 for many public health laboratories. For the past six years, the NIH has evaluated the activities of 226 laboratories. DESIGN/METHODOLOGY/APPROACH: Approximately 40,000 tests using 16 trial samples of external quality assessment panel performed at 226 laboratories during 2000-2006. The methods performed were classified into five assays; machine-based enzyme immunoassay (MBA), microplate-based enzyme immunoassay (EIA), simple/rapid test and antigen assay only performed at blood screening laboratory centers. A few laboratories performed confirmation method by western blot (WB). Most participating laboratories performed at least two methods. FINDINGS: The evaluation showed that, during the six-year period, the program had an increasing response rate among all groups of laboratories: government hospital laboratories, private hospital and clinic laboratories and blood screening laboratory centers. Moreover, there were no significantly different errors found between these groups. The highest median percent of overall errors found was in antigen assay. Very minimal errors appeared on other methods. ORIGINALITY/VALUE: National HIV EQA program has played an important role in improving the quality of participating laboratory performance. The participating laboratories gained a better understanding and were able to use good quality anti-HIV approved kits. Furthermore, HIV serology testing selection was varied over the past six years as microplate-based EIA was mostly used in the past but currently MBA and simple/rapid test are more commonly used. The test methods were determined by test volumes and budget. In addition, sensitivity was one critical reason labs chose to use EIA. The most popular method used was simple/rapid testing. Overall errors occurred with all assays but not with WB. Errors could occur with any test techniques if good quality management is not employed.     

Development of an Anti-Elicitin Antibody-Based Immunohistochemical Assay for Diagnosis of Pythiosis

Pythiosis is an emerging and life-threatening infectious disease of humans and animals living in tropical and subtropical countries and is caused by the fungus-like organism Pythium insidiosum. Antifungals are ineffective against this pathogen. Most patients undergo surgical removal of the infected organ, and many die from advanced infections. Early and accurate diagnosis leads to prompt management and promotes better prognosis for affected patients. Immunohistochemical assays (IHCs) have been developed using rabbit antibodies raised against P. insidiosum crude extract, i.e., culture filtrate antigen (CFA), for the histodiagnosis of pythiosis, but cross-reactivity with pathogenic fungi compromises the diagnostic performance of the IHC. Therefore, there is a need to improve detection specificity. Recently, the elicitin protein, ELI025, was identified in P. insidiosum, but it was not identified in other human pathogens, including true fungi. The ELI025-encoding gene was successfully cloned and expressed as a recombinant protein in Escherichia coli. This study aims to develop a new IHC using the rabbit anti-ELI025 antibody (anti-ELI) and to compare its performance with the previously reported anti-CFA-based IHC. Thirty-eight P. insidiosum histological sections stained positive by anti-ELI-based and anti-CFA-based IHCs indicating 100% detection sensitivity for the two assays. The anti-ELI antibody stained negative for all 49 negative-control sections indicating 100% detection specificity. In contrast, the anti-CFA antibody stained positive for one of the 49 negative controls (a slide prepared from Fusarium-infected tissue) indicating 98% detection specificity. In conclusion, the anti-ELI based IHC is sensitive and specific for the histodiagnosis of pythiosis and is an improvement over the anti-CFA-based assay.     

Efficacy of mefenamic acid and hyoscine for pain relief during saline infusion sonohysterography in infertile women: a double blind randomized controlled trial

Objectives

To evaluate the efficacy and level of satisfaction from mefenamic acid and hyoscine when used for pain relief during saline infusion sonohysterography.

Study design

In this double blind randomized controlled trial, 141 nulliparous women were allocated to receive 500 mg of mefenamic acid, 10 mg of hyoscine or a placebo, which was packed in the same outer capsule. Saline infusion sonohysterography (SIS) was performed 30 min later by one operator. Pain and satisfaction scores were evaluated using a 10 cm visual analog scale. Baseline characteristics, pain and satisfaction scores were compared among the three groups. Pain scores were recorded before, after catheter insertion, during, immediately after, and 30 min after the procedure.

Results

No statistically significant differences were found in baseline characteristics, pain and satisfaction scores among the three groups. Maximum pain during SIS was 4.40 ± 3.34, 4.67 ± 3.14 and 4.85 ± 3.19 in the mefenamic acid, hyoscine and placebo groups respectively. There was a 31.1% prevalence of intrauterine abnormality and the most frequent finding was endometrial polyp.

Conclusion

There is no benefit in using mefenamic acid and hyoscine in the prevention of pain occurring from SIS.     

Treatment With Intrastromal and Intracameral Voriconazole in 2 Eyes With Lasiodiplodia theobromae Keratitis: Case Reports

To report the clinical presentation and the role of intrastromal and intracameral voriconazole injection in the management of rare cases of fungal keratitis caused by Lasiodiplodia theobromae.Two eyes of 2 patients with Lasiodiplodia keratitis unresponsive to topical and oral antifungal medications were included in this study. Diagnosis of Lasiodiplodia keratitis was confirmed by microbiological analysis, including culture-based (case 1 and 2) and DNA sequencing techniques (case 2 only).The first patient presented with multiple satellite lesions and one of these infiltrates spread deeply into the cornea, forming a stromal abscess. Another patient had a large full-thickness corneal infiltrates with several fungal balls in the anterior chamber, requiring a limbus-to-limbus therapeutic penetrating keratoplasty. Despite aggressive topical therapy, the stromal abscess continued to worsen in the first case and recurrent keratitis was observed postoperatively in the second case. Voriconazole 50 μg/0.1 mL was administered intracamerally and intrastromally around the fungal abscess as adjuncts to topical antimycotics in the first case. The second patient who needed therapeutic keratoplasty was treated with an intracameral injection of 50 μg/0.1 mL voriconazole at the end of surgery. Postoperatively, 100 μg/0.1 mL voriconazole was also injected intracamerally after the recurrence of infection was noted in the graft. Reinjections were given 48 hours apart in both cases. After the injections, all corneal and anterior chamber lesions were reduced in size and density and completely resolved within 4 weeks.Intrastromal and intracameral voriconazole injections may offer safe and effective treatment options for L theobromae keratitis.     

Obligatory Role of Gamma Interferon for Host Survival in a Murine Model of Infection with Burkholderia pseudomallei

Burkholderia pseudomallei, the causative agent of melioidosis, is a gram-negative bacterium capable of causing either acute lethal sepsis or chronic but eventually fatal disease in infected individuals. However, despite the clinical importance of this infection in areas where it is endemic, there is essentially no information on the mechanisms of protective immunity to the bacterium. We describe here a murine model of either acute or chronic infection with B. pseudomallei in Taylor Outbred (TO) mice which mimics many features of the human pathology. Intraperitoneal infection of TO mice at doses of >10(6) CFU resulted in acute septic shock and death within 2 days. In contrast, at lower doses mice were able to clear the inoculum from the liver and spleen over a 3- to 4-week period, but persistence of the organism at other sites resulted in a chronic infection of between 2 and 16 months duration which was eventually lethal in all of the animals tested. Resistance to acute infection with B. pseudomallei was absolutely dependent upon the production of gamma interferon (IFN-gamma) in vivo. Administration of neutralizing monoclonal antibody against IFN-gamma lowered the 50% lethal dose from >5 x 10(5) to ca. 2 CFU and was associated with 8,500- and 4,400-fold increases in the bacterial burdens in the liver and spleen, respectively, together with extensive destruction of lymphoid architecture in the latter organ within 48 h. Neutralization of either tumor necrosis factor alpha or interleukin-12 but not granulocyte-macrophage colony-stimulating factor, also increased susceptibility to infection in vivo. Together, these results provide the first evidence of a host protective mechanism against B. pseudomallei. The rapid production of IFN-gamma within the first day of infection determines whether the infection proceeds to an acute lethal outcome or becomes chronic.