New Donor Excision Design for Better Hair Alignment in Hair Restoration Surgery.

BACKGROUND: The linear scar and misalignment of hair follicles are disadvantages of the follicular unit transplantation (FUT) or strip technique. The most common misalignment is at the end of the strip. Although most surgeons try to match hair direction to achieve optimal hair alignment, their attempts are often unsuccessful. OBJECTIVES: We aimed to assess strip designs to improve hair alignment during hair transplantation. METHODS: We conducted a retrospective study of 157 patients who underwent hair transplantation with either the commonly used elliptical incision or our novel triangular flag-shaped designed incision on the donor strip tip. Two blind evaluators assessed the outcome of hair alignment using a 5-point visual analog scale. RESULTS: In total, 303 wounds on 157 patients were assessed. Overall, our triangular flag-shaped design (TFD) achieved better hair alignment than the common elliptical design (CED) (p=0.01). Patients with hair direction straight on the upper wound edge and hair direction inward on the lower wound edge showed improved outcomes with TFD, whereas patients with hair direction inward on both upper and lower wound edges showed better outcomes with CED. CONCLUSIONS: The TFD tip of donor strips achieved proper hair alignment for most hair transplant patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Epidemiology, clinical characteristics, and treatment outcomes of patients with COVID-19 at Thailand's university-based referral hospital.

BACKGROUND: The epidemiology and outcomes of COVID-19 patients in Thailand are scarce. METHODS: This retrospective cohort study included adult hospitalized patients who were diagnosed with COVID-19 at Siriraj Hospital during February 2020 to April 2020. RESULTS: The prevalence of COVID-19 was 7.5% (107 COVID-19 patients) among 1409 patients who underwent RT-PCR for SARS-CoV-2 detection at our hospital during the outbreak period. Patients with COVID-19 presented with symptoms in 94.4%. Among the 104 patients who were treated with antiviral medications, 78 (75%) received 2-drug regimen (lopinavir/ritonavir or darunavir/ritonavir plus chloroquine or hydroxychloroquine), and 26 (25%) received a 3-drug regimen with favipiravir added to the 2-drug regimen. Disease progression was observed in 18 patients (16.8%). All patients with COVID-19 were discharged alive. CONCLUSIONS: The prevalence of COVID-19 was 7.5% among patients who underwent RT-PCR testing, and 10% among those having risk factors for COVID-19 acquisition. Combination antiviral therapies for COVID-19 patients were well-tolerated and produced a favorable outcome.

Efficacy and safety of de-escalation therapy to ertapenem for treatment of infections caused by extended-spectrum-ß-lactamase-producing Enterobacteriaceae: an open-label randomized controlled trial.

BACKGROUND: Carbapenem antibiotics are considered the treatment of choice for serious extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria (GNB) infections. The study objectives were to evaluate efficacy and safety of de-escalation therapy to ertapenem for treatment of infections caused by extended-spectrum-ß-lactamase-producing Enterobacteriaceae. METHODS: We conducted a randomized controlled trial of adult patients with documented ESBL-producing Enterobacteriaceae infections who had received any group 2 carbapenem for less than 96 h. In the intervention group, the previously-prescribed group 2 carbapenem was de-escalated to ertapenem. In the control group, the group 2 carbapenem was continued. RESULTS: During June 2011-December 2014, 32 patients were randomized to the de-escalation group and 34 to the control group. Most common sites of infection were urinary tract infection (42%). Characteristics of both groups were comparable. By using a 15% predefined margin, ertapenem was non-inferior to control group regarding the clinical cure rate (%Δ = 14.0 [95% confidence interval: -2.4 to 31.1]), the microbiological eradication rate (%Δ = 4.1 [-5.0 to 13.4]), and the superimposed infection rate (%Δ = -16.5 [-38.4 to 5.3]). Patients in the de-escalation group had a significantly lower 28-day mortality rate (9.4% vs. 29.4%; P = .05), a significantly shorter median length of stay (16.5 days [4.0-73.25] vs. 20.0 days [1.0-112.25]; P = .04), and a significantly lower defined daily dose of carbapenem use (12.9 ± 8.9 vs. 18.4 ± 12.6; P = .05). CONCLUSIONS: Ertapenem could be safely used as de-escalation therapy for ESBL-producing Enterobacteriaceae infections, once the susceptibility profiles are known. Future studies are needed to investigate ertapenem efficacy against ESBL-producing Enterobacteriaceae pneumonia to determine its applicability in life-threatening conditions. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01297842 . Registered on 14 February 2011. First patient enrolled on 27 June 2011.

High fluoroquinolone MIC is associated with fluoroquinolone treatment failure in urinary tract infections caused by fluoroquinolone susceptible Escherichia coli.

BACKGROUND: Suboptimal clinical response to fluoroquinolone (FQ) therapy has been clearly documented in patients with Salmonella typhi infection with reduced FQ susceptibility. However, the clinical impact of reduced FQ susceptibility on other infections including E. coli urinary tract infections (UTIs) has never been evaluated. METHODS: We conducted a retrospective cohort study of female patients with fluoroquinolone susceptible E. coli (FQSEC) UTIs who received FQ therapy at outpatient services within University of Pennsylvania Health System, Philadelphia. Exposed patients were those with high MIC-FQSEC UTIs (the levofloxacin MIC > 0.12 but ≤ 2 mg/L) while unexposed patients were those with low MIC-FQSEC UTIs (the levofloxacin MIC ≤ 0.12 mg/L). The primary treatment outcome was treatment failure within 10 weeks after initiation of FQ therapy. RESULTS: From May 2008 to April 2011, we enrolled 29 exposed patients and 246 unexposed patients. Two patients in each group experienced treatment failure; exposed vs. unexposed (6.9 vs. 0.8%; p = 0.06). Risk difference and risk ratio (RR) for treatment failure were 0.06 [95% CI -0.03-0.15; exact-p = 0.06] and 8.48 [95% CI 1.24-57.97; exact-p = 0.06], respectively. After adjusting for underlying cerebrovascular disease, the RR was 7.12 (95% CI 1.20-42.10; MH-p = 0.04). CONCLUSION: Our study demonstrated the negative impact of reduced FQ susceptibility on the treatment response to FQ therapy in FQSEC UTIs. This negative impact may be more intensified in other serious infections. Future studies in other clinical situations should be conducted to fill the gap of knowledge.

Effects of a preceding fractional carbon dioxide laser on the outcome of combined local narrowband ultraviolet B and topical steroids in patients with vitiligo in difficult-to-treat areas.

BACKGROUND AND OBJECTIVE: Conventional treatment of vitiligo on hands and feet often produces an unsatisfactory result. Various ablative treatment methods were tried with favorable results in facial, neck, and truncal areas. The aim of this study is to evaluate the efficacy and safety of combined fractional CO2 laser, narrowband UVB (NB-UVB) phototherapy, and topical clobetasol propionate in managing stable vitiligo in difficult-to-treat areas. STUDY DESIGN: A prospective randomized-intraindividual study was conducted on 27 patients with 27 pair-lesions of non-segmental vitiligo on both hands. The lesions were randomized to receive treatment with fractional CO2 laser, NB-UVB phototherapy, and 0.05% clobetasol propionate cream (Group A) or NB-UVB phototherapy and 0.05% clobetasol propionate cream (Group B). Fractional CO2 laser was performed at 1-week interval for 10 sessions. NB-UVB phototherapy was administered twice weekly for 20 sessions. Patients were evaluated 12 weeks after the last treatment. Outcome was evaluated objectively based on standard digital photographs, patient satisfaction, and adverse events. RESULTS: Twenty-six patients completed the study. Six vitiligious lesions (23.1%) in group A achieved good to excellent repigmentation compared with one lesion (3.9%) in group B (P = 0.065). The overall mean improvement score was 1.35 (± 1.38) in group A and 0.50 (± 0.95) in group B (P = 0.0004). Patients' satisfaction score was significantly higher for the lesions in group A than group B. Lesions on the dorsum of the hand showed a higher response rate than those on the fingers. No serious side-effects were noted. CONCLUSION: This study demonstrates that adding fractional CO2 laser treatment to NB-UVB phototherapy and topical steroids improves the repigmentation rate of vitiliginous lesions on hands in some patients. This technique may be offered to vitiligo patients who are unresponsive to other treatments.

Accuracy of ICD-10 Coding System for Identifying Comorbidities and Infectious Conditions Using Data from a Thai University Hospital Administrative Database.

OBJECTIVE: To determine the accuracy of International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system in identifying comorbidities and infectious conditions using data from a Thai university hospital administrative database. MATERIAL AND METHOD: A retrospective cross-sectional study was conducted among patients hospitalized in six general medicine wards at Siriraj Hospital. ICD-10 code data was identified and retrieved directly from the hospital administrative database. Patient comorbidities were captured using the ICD-10 coding algorithm for the Charlson comorbidity index. Infectious conditions were captured using the groups of ICD-10 diagnostic codes that were carefully prepared by two independent infectious disease specialists. Accuracy of ICD-10 codes combined with microbiological dataf or diagnosis of urinary tract infection (UTI) and bloodstream infection (BSI) was evaluated. Clinical data gathered from chart review was considered the gold standard in this study. RESULTS: Between February 1 and May 31, 2013, a chart review of 546 hospitalization records was conducted. The mean age of hospitalized patients was 62.8 ± 17.8 years and 65.9% of patients were female. Median length of stay [range] was 10.0 [1.0-353.0] days and hospital mortality was 21.8%. Conditions with ICD-10 codes that had good sensitivity (90% or higher) were diabetes mellitus and HIV infection. Conditions with ICD-10 codes that had good specificity (90% or higher) were cerebrovascular disease, chronic lung disease, diabetes mellitus, cancer HIV infection, and all infectious conditions. By combining ICD-10 codes with microbiological results, sensitivity increased from 49.5 to 66%for UTI and from 78.3 to 92.8%for BS. CONCLUSION: The ICD-10 coding algorithm is reliable only in some selected conditions, including underlying diabetes mellitus and HIV infection. Combining microbiological results with ICD-10 codes increased sensitivity of ICD-10 codes for identifying BSI. Future research is needed to improve the accuracy of hospital administrative coding system in Thailand.

Epidemiology of Antibiotic Use and Antimicrobial Resistance in Selected Communities in Thailand.

OBJECTIVE: To generate epidemiological information regarding antibiotic use and antimicrobial resistance (AMR) in targeted communities for use by the Thailand AMR Containment and Prevention Program. MATERIAL AND METHOD: A survey of antibiotics sold by 215 grocery stores and retail shops located in the target communities was done by the local people who were instructed to purchase specified antibiotics and to present to such stores and shops with symptoms of sore throat, backache, common cold, acute diarrhea, inflamed uterus, and dysuria. The purchased drugs were then identified and recorded. Contamination of extended-spectrum ß-lactamase (ESBL)-producing E. coli was identified in 174 samples of foods and open water sources collected from the target communities. Carriage of ESBL-producing E. coli in gastrointestinal tracts of 534 adults living in the target communities was performed by stool sample culture. One thousand three hundred one patients with upper respiratory infection (URI) and 235 patients with acute diarrhea who attended the tambon health promoting hospitals located in the target communities were monitored for their clinical outcomes of treatments. The patients with URI and acute diarrhea with no indication of antibiotic received symptomatic treatments as appropriate and they were followed via telephone contact every few days until all symptoms related to URI and acute diarrhea disappeared. The data were analyzed by descriptive statistics. RESULTS: Antibiotics were sold to the local people who were presenting with common ailments at many grocery stores and retail shops in their respective communities. In almost all cases, antibiotics were inappropriately given. Overall prevalence of ESBL-producing E. coli contamination in foods and open water sources was 26.4%. ESBL-producing E. coli was isolated from fresh meat and open water sources in many samples. Overall prevalence of ESBL-producing E. coli carriage in gastrointestinal tracts of the adults cultured was 66.5%. All patients with URI and acute diarrhea who had no indication of antibiotics and did not receive antibiotics had either cure or favorable response within seven days of start of symptomatic treatment. CONCLUSION: Antibiotics are widely available and are inappropriately sold and given by grocery stores and retail shops located within local communities in Thailand. Antibiotic-resistant bacteria commonly and freely circulate within the community. Patients with URI and acute diarrhea with no indication for antibiotic therapy can be treated without antibiotics. Findings and observations from this study will be used as part of a social marketing campaign on prevention and containment of AMR to educate people living within communities in Thailand.

Risk factors for ambulatory urinary tract infections caused by high-MIC fluoroquinolone-susceptible Escherichia coli in women: results from a large case-control study.

OBJECTIVES: The prevalence of high-MIC fluoroquinolone-susceptible Escherichia coli (FQSEC) has been increasing. These isolates are one step closer to full fluoroquinolone (FQ) resistance and may lead to delayed response to FQ therapy. Our study aimed to investigate the epidemiology of high-MIC FQSEC in ambulatory urinary tract infections (UTIs). PATIENTS AND METHODS: A case-control study was conducted at outpatient services within the University of Pennsylvania Health System, Philadelphia. All female subjects with non-recurrent UTI caused by FQSEC (levofloxacin MIC < 4 mg/L) were enrolled. Cases were subjects with high-MIC FQSEC UTI (levofloxacin MIC >0.12 but < 4 mg/L) and controls were subjects with low-MIC FQSEC UTI (levofloxacin MIC ≤0.12 mg/L). Data on microbiology results and baseline characteristics were extracted from electronic medical records. RESULTS: During the 3 year study period (May 2008-April 2011), 11 287 episodes of E. coli bacteriuria were identified. The prevalence of FQSEC, FQ-intermediate susceptible E. coli and FQ-resistant E. coli was 75.0%, 0.4% and 24.6%, respectively. A total of 2001 female subjects with FQSEC UTI were enrolled into our study (165 cases and 1836 controls). Independent risk factors for high-MIC FQ susceptibility included Asian race (OR = 2.92; 95% CI = 1.29-6.58; P = 0.02), underlying renal disease (OR = 2.18; 95% CI = 1.15-4.14; P = 0.02) and previous nitrofurantoin exposure (OR = 8.86; 95% CI = 1.95-40.29; P = 0.005). CONCLUSIONS: Asian race, underlying renal disease and previous exposure to nitrofurantoin were identified as independent risk factors for high-MIC FQSEC. There may be some factors that are more common in Asians, which may result in the selection of high-MIC FQSEC. Further studies are necessary to explore these findings.

Early postoperative single treatment ablative fractional lasing of Mohs micrographic surgery facial scars: a split-scar, evaluator-blinded study.

BACKGROUND/OBJECTIVES: Despite precise surgical technique, some postoperative facial scars will depress and widen over time, likely due to weakened or inadequately replaced collagen fibers in the underlying dermis. The purpose of this study is to evaluate whether a 10,600 nm ablative carbon dioxide (CO2 ) fractional laser used early in the post-surgical setting results in improved postoperative facial scars after a single treatment session. STUDY DESIGN: A prospective randomized, comparative split-scar study was conducted on 20 subjects between the ages of 20-90. Subjects underwent Mohs surgery for nonmelanoma skin cancer of the face. Subsequent to tumor removal, subjects with a linear scar of 4 cm or greater were enrolled. On the day of suture removal, all subjects had one-half of their scar randomly selected and treated with a 10,600 nm CO2 fractional laser (energy = 10 mJ; density = 10%; spot size = 7 mm; pulse = 1). The untreated scar half served as a control. Scars were re-evaluated 12 weeks later. An independent blinded observer graded the scar halves with the Vancouver scar scale (VSS) immediately prior to treatment and 12 weeks after treatment. Subjects completed a visual analog scale (VAS) at the same time points. RESULTS: Three months after laser treatment, a significant decrease in VSS and 3 of the 4 of its individual parameters were detected in both control and treated halves of the scar. When comparing the laser group versus the control group, a statistically significant difference was not noted in VSS (P = 0.31) but a statistically significant difference in patient VAS was detected (P = 0.002). No side effects of the laser treatment were noted. CONCLUSION: Facial wounds sutured in a layered manner heal well. Patients prefer early fractional CO2 lasing of surgical scars, though use of the VSS failed to detect an objective difference between laser and control halves of scars. Conservative laser settings, a single session treatment, and VSS insensitivity for surgical scars may influence these findings.

A New Tool to Maximize Donor Harvesting With Safer Closure.

BACKGROUND: Scalp laxity is a major factor in achieving the maximum number of grafts in donor harvesting during hair restoration surgery. Proper assessment is important for each individual but especially so in patients presenting tight scalp. OBJECTIVE: To validate cross beam laser (CBL) for scalp laxity assessment in comparison with Mayer elasticity scale (MES). MATERIALS AND METHODS: In a retrospective study of 165 patients, both CBL and MES were used to evaluate scalp laxity in vertical plane at the center and lateral area before surgery. The real width (RW) of donor strip during surgery was considered the gold standard. RESULTS: Spearman correlation coefficient revealed that the CBL width was significantly correlated with the MES width in the following subgroups: (1) subjects undergoing their first session, (2) subsequent session patients, and (3) patients who required maximum number of grafts. Although the CBL width was statistically significant when compared with the RW in certain areas, whereas the MES width was statistically significant in all areas, the differences between the CBL width and the RW were minimal and clinically insignificant. CONCLUSION: The accuracy of scalp laxity measurements using the CBL procedure establishes CBL as a reliable tool for hair restoration surgery.

Rare manifestations of Streptococcus pneumoniae infection; the first case report in Thailand and literature review of pneumococcal endophthalmitis and endocarditis.

We report a case of endogenous endophthalmitis and endocarditis caused by a rare causative organism: Streptococcus pneumoniae. A 69-year-old woman with diabetes mellitus and pre-existing mitral regurgitation presented with acute fever and severe left eye pain. Ophthalmologic examination revealed bilateral endophthalmitis. Blood and vitreous fluid culture grew penicillin-susceptible S. pneumoniae. Transesophageal echocardiogram documented a 5-mm oscillating mass at right coronary cusp of aortic valve. After 4 weeks of combined ceftriaxone and levofloxacin therapy, the patient improved and was later discharged with blindness in her left eye.

Epidemiology of ventilator-associated tracheobronchitis and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria at a tertiary care hospital in Thailand.

Objectives: To investigate the epidemiology of MDR Gram-negative bacilli ventilator-associated tracheobronchitis (MDR GNB-VAT) and MDR GNB ventilator-associated pneumonia (MDR GNB-VAP) among mechanically ventilated patients. Methods: We conducted a retrospective observational study among hospitalized patients who underwent continuous mechanical ventilation for ≥48 h at Siriraj Hospital, Thailand. Results: During the 18 month study period, 1824 unique patients underwent continuous mechanical ventilation (12 216 ventilator-days). The cumulative incidences of MDR GNB-VAT and -VAP were 8.4% and 8.3%, respectively. The incidence rates of MDR GNB-VAT and -VAP were 12.52 and 12.44 episodes/1000 ventilator-days, respectively. Among those with VAT, the cumulative incidence and incidence rate of subsequent VAP development within 7 days were 11.76% and 2.81 episodes/1000 ventilator-days, respectively. The median durations of mechanical ventilation before having VAP and VAT were 9 and 12 days, respectively. Multivariate analysis identified three independently associated factors for patients having VAP compared with having VAT: underlying cerebrovascular disease [adjusted OR (aOR): 0.46; 95% CI: 0.27-0.78; P = 0.04], previous surgery (aOR: 0.68; 95% CI: 0.57-0.8; P < 0.001) and acute renal failure (aOR: 1.75; 95% CI: 1.27-2.40; P = 0.001). Conclusions: The study revealed high incidences of MDR GNB-VAT and -VAP among mechanically ventilated patients. The independent risk factors for having VAP can help identify patients at risk for developing VAP and who need early weaning from mechanical ventilation.

Epidemiology of bacteremia caused by uncommon non-fermentative gram-negative bacteria.

BACKGROUND: Prevalence of bacteremia caused by non-fermentative gram-negative bacteria (NFGNB) has been increasing over the past decade. Although many studies have already investigated epidemiology of NFGNB bacteremia, most focused only on common NFGNB including Pseudomonas aeruginosa (PA) and Acinetobacter baumannii (AB). Knowledge of uncommon NFGNB bacteremia is very limited. Our study aimed to investigate epidemiology and identify factors associated with uncommon NFGNB bacteremia. METHODS: This observational study was conducted at a university hospital in Thailand during July 1, 2007-Dec 31, 2008. All patients who had at least one blood culture positive for NFGNB and met the criteria for systemic inflammatory response syndrome within 24 hours before/after obtaining the blood culture were enrolled. The NFGNB isolates that could not be satisfactorily identified by the standard biochemical assays were further characterized by molecular sequencing methods. To identify factors associated with uncommon NFGNB bacteremia, characteristics of patients in the uncommon NFGNB group were subsequently compared to patients in the common NFGNB group (AB and PA bacteremia). RESULTS: Our study detected 223 clinical isolates of NFGNB in 221 unique patients. The major causative pathogens were AB (32.7%), followed by PA (27.8%), Stenotrophomonas maltophilia (5.4%), Acinetobacter lwoffii (4.9%) and Burkholderia pseudomallei (2.7%). Infection-related mortality was 63.0% in the AB group, 40.3% in the PA group and 17.4% in the uncommon NFGNB group. Factors associated with uncommon NFGNB bacteremia (OR [95% CI]; p-value) were male sex (0.28 [0.14-0.53]; p < 0.001), hospital-acquired infection (0.23 [0.11-0.51]; p < 0.001), recent aminoglycosides exposure 0.23 [0.06-0.8]; p = 0.01), primary bacteremia (6.43 [2.89-14.2]; p < 0.001]), catheter related infection (4.48 [1.54-13.06]; p < 0.001) and recent vancomycin exposure (3.88 [1.35-11.1]; p = 0.02). CONCLUSIONS: Our distribution of causative pathogens was slightly different from other studies. The common NFGNB group had a remarkably higher ID-mortality than the uncommon NFGNB group. Knowledge of factors associated with uncommon NFGNB bacteremia would help physicians to distinguish between low vs. high risk patients.

Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial.

BACKGROUND: Many patients undergoing Mohs micrographic surgery (MMS) experience anxiety and stress. Although music has been proven to reduce anxiety and promote relaxation in other fields of medicine, scant research investigates the effect of music on anxiety during MMS. OBJECTIVES: To determine whether music can reduce anxiety in patients undergoing MMS. METHODS AND MATERIALS: An open-labeled randomized controlled trial was conducted to assess anxiety before and after listening to music. Subjects undergoing MMS were randomly allocated to listen to self-selected music (n = 50) or to have surgery without music (n = 50). Anxiety was measured using the State-Trait Anxiety Inventory (STAI) and on a visual analog scale (VAS). RESULTS: Subjects in the music group experienced statistically significantly lower STAI and VAS scores than those in the control group. STAI and VAS scores were significantly lower in subjects who underwent MMS for the first time. Anxiety measures did not correlate with sex or type of skin cancer. CONCLUSION: Listening to self-selected music reduces anxiety in patients undergoing MMS, especially those who undergo MMS for the first time. Presenting patients the opportunity to listen to music is a simple strategy to minimize anxiety during MMS.

Comparison of the mathematical equation and trapezoidal approach for 24 h area under the plasma concentration-time curve calculation in patients who received intravenous vancomycin in an acute care setting.

The current recommendation for therapeutic monitoring of vancomycin has recently suggested AUC-guided dosing in patients with serious methicillin-resistant Staphylococcus aureus infections. The study objective was to evaluate mathematical equations and trapezoidal methods for calculating the 24 h area under the plasma vancomycin concentration-time curve (AUC24). The analysis of plasma vancomycin concentrations was performed in 20 adult patients treated with intravenous vancomycin. For each patient, AUC24 was estimated using two methods including, equation and trapezoidal calculation. The AUC24 from two methods was analyzed for correlation. The correlation between the equation and trapezoidal methods was strong. The coefficient of determination (R2 ) values was greater than .99. The two plasma vancomycin concentrations to achieve the highest correlation were concentration at 2.5 to 3 h after starting the infusion and concentration at 1 h before the next dose. Moreover, the AUC24 calculation from trapezoidal and equation methods showed that 19 out of 20 patients (95%) had AUC24 of more than 400 mg·h/L, and more than 50% in this group had AUC24/MIC greater than 600. Of those patients with AUC-trapezoidal >600, 15.38% of patients had trough under 15 mg/L, 15.38% of patients had trough in the range 15 to 20 mg/L and 69.23% of patients had trough more than 20 mg/L. The results of AUC-equation were similar to those of the AUC-trapezoidal method. Our study confirmed that the AUC monitoring is more appropriate than the trough vancomycin concentration. Given these considerations, the AUC-equation method is better and more practical to use in part of a point-of-care treatment, especially in the part of the Bayesian program is not available. The best sampling time point of the peak concentration was 0.5-1 h after 2-h infusion.

Rat bite fever caused by Streptobacillus notomytis mimicking pyogenic polyarthritis: A case report.

We report the world's sixth case of rat bite fever caused by Streptobacillus notomytis that mimicked pyogenic polyarthritis and required surgical debridement in combination with prolonged antibiotic therapy. This case report highlights the higher severity of rat bite fever caused by S. notomytis compared to S. moniliformis.

Development and Implementation of a Mobile Application for Choosing Empirical Antimicrobial Therapy for Bacteremia, Pneumonia, Urinary Tract Infection, and Skin and Soft Tissue Infection among Hospitalized Patients.

Clinical practice guidelines (CPGs) and computerized clinical decision support programs are effective antimicrobial stewardship strategies. The DigitalAMS™, a mobile-based application for choosing empirical antimicrobial therapy under the hospital's CPGs, was implemented at Siriraj Hospital and evaluated. From January to June 2018, a cross-sectional study was conducted among 401 hospitalized adults who received ≥1 dose of antimicrobials and had ≥1 documented site-specific infection. The antimicrobial regimen prescribed by the ward physician (WARD regimen), recommended by the DigitalAMS™ (APP regimen), and recommended by two independent infectious disease (ID) physicians before (Emp-ID regimen) and after (Def-ID regimen) the final microbiological results became available were compared in a pairwise fashion. The percent agreement of antimicrobial prescribing between the APP and Emp-ID regimens was 85.7% in the bacteremia group, 59.1% in the pneumonia group, 78.6% in the UTI group, and 85.2% in the SSTI group. The percent agreement between the APP and Emp-ID regimens was significantly higher than that between the WARD and Emp-ID regimens in three site-specific infection groups: the bacteremia group (85.7% vs. 47.9%, p < 0.001), the UTI group (78.6% vs. 37.8%, p < 0.001), and the SSTI group (85.2% vs. 40.2%, p < 0.001). Furthermore, the percent agreement between the APP and Def-ID regimens was similar to that between the Emp-ID and Def-ID regimens in all sites of infection. In conclusions, the implementation of DigitalAMS™ seems useful but needs some revisions. The dissemination of this ready-to-use application with customized clinical practice guidelines to other hospital settings may be beneficial.

A cost-effectiveness analysis of the 13-valent pneumococcal conjugated vaccine and the 23-valent pneumococcal polysaccharide vaccine among Thai older adult.

Introduction: This study aims to assess the economic impact of introducing the 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) to Thai older adult aged ≥ 65 years who are healthy or with chronic health conditions and immunocompromised conditions from a societal perspective in order to introduce the vaccine to Thailand's National Immunization Program for the older adult. Methods: A Markov model was adopted to simulate the natural history and economic outcomes of invasive pneumococcal diseases using updated published sources and Thai databases. We reported analyses as incremental cost-effectiveness ratios (ICER) in USD per quality-adjusted life year (QALY) gained. In addition, sensitivity analyses and budget impact analyses were conducted. Results: The base-case analysis of all interventions (no vaccinations [current standard of care in Thailand], PPSV23, and PCV13) showed that PPSV23 was extendedly dominated by PCV13. Among healthy individuals or those with chronic health conditions, ICER for PCV13 was 233.63 USD/QALY; meanwhile, among individuals with immunocompromised conditions, ICER for PCV13 was 627.24 USD/QALY. PCV13 are economical vaccine for all older adult Thai individuals when compared to all interventions. Conclusions: In the context of Thailand, PCV13 is recommended as the best buy and should be primarily prioritized when both costs and benefits are considered. Also, this model will be beneficial to the two-next generation pneumococcal vaccines implementation in Thailand.

Pneumococcal carriage among high-risk adults in a country with nonmandatory pneumococcal vaccination during the coronavirus disease 2019 pandemic.

BACKGROUND: Streptococcus pneumoniae carriage is a prerequisite for clinical infections and is used to make public health decisions on vaccine licensure. Pneumococcal carriage data among high-risk Thai adults are needed before national vaccine program introduction. The association between coronavirus disease 2019 (COVID-19) and pneumococcal carriage were also investigated. METHODS: During the COVID-19 pandemic, a multi-center cross-sectional study was conducted among high-risk Thai adults from September 2021 to November 2022. Pneumococcal carriage and serotypes were investigated using both conventional and molecular methods. Demographics and co-morbidities were determined for carriage while accounting for case clustering from various study sites. RESULTS: A total of 370 individuals were enrolled. The prevalence of pneumococcal carriage, as determined by the molecular method, was 30.8 % (95 % confidence interval (CI): 26.1-35.8), while after excluding non-typeable pneumococci from the oropharyngeal sample, the carriage prevalence was 20.8 % (95 % CI: 16.79-25.31). The serotype coverage rates by pneumococcal vaccine were 12.3 %, 13.1 %, and 16.4 % for PCV13, PCV15 or PCV20, and PPSV23, respectively, while the non-vaccine type was the majority (45.1 %). The most common serotype was 19B/C (35.5 %), followed by 6 A/B/C/D (10.7 %). The age group under 65 years was associated with a higher pneumococcal carriage rate than the age group 85 and older (odds ratio (OR): 5.01, 95 % CI: 1.75-14.36). There was no significant difference between SARS-CoV-2 and carriage status. CONCLUSIONS: The prevalence of pneumococcal carriage in Thais was high. The majority of serotypes were not covered by the vaccine. Further studies on the link between carriage serotypes and disease are required. The magnitude and serotype distribution of carriage were comparable in the SARS-CoV-2 positive and negative groups.