Short-Course Versus Long-Course Colistin for Treatment of Carbapenem-Resistant A.baumannii in Cancer Patient.

Carbapenem-resistant Acinetobacter baumannii (CRAB) is one of the most commonly reported nosocomial infections in cancer patients and could be fatal because of suboptimal immune defenses in these patients. We aimed to compare clinical response, microbiological response, nephrotoxicity, and 30-day mortality between cancer patients who received short (<14 days) and long (≥14 days) courses of colistin for treatment of CRAB infection. A retrospective cohort study was conducted in cancer patients with CRAB infection who received short or long courses of colistin between 2015 to 2017 at Chiang Mai University Hospital (CMUH). A total of 128 patients met the inclusion criteria. The results of this study show that patients who received long course of colistin therapy had a higher rate of clinical response; adjusted odds ratio (OR) was 3.16 times in patients receiving long-course colistin therapy (95%CI, 1.37-7.28; p value = 0.007). Microbiological response in patients with long course was 4.65 times (adjusted OR) higher than short course therapy (95%CI, 1.72-12.54; p value = 0.002). Moreover, there was no significant difference in nephrotoxicity (adjusted OR, 0.91, 95%CI, 0.39-2.11; p value = 0.826) between the two durations of therapy. Thirty-day mortality in the long-course therapy group was 0.11 times (adjusted OR) compared to the short-course therapy group (95%CI, 0.03-0.38; p value = 0.001). Propensity score analyses also demonstrated similar results. In conclusion, cancer patients who received a long course of colistin therapy presented greater clinical and microbiological responses and lower 30-day mortality but similar nephrotoxicity as compared with those who a received short course. Therefore, a long course of colistin therapy should be considered for management of CRAB infection in cancer patients.

A Comparison of Colistin versus Colistin Plus Meropenem for the Treatment of Carbapenem-Resistant Acinetobacter baumannii in Critically Ill Patients: A Propensity Score-Matched Analysis.

Carbapenem-resistant Acinetobacter baumannii (CRAB), an important nosocomial pathogen, occurs particularly in the intensive care unit (ICU). Thus, the aim of this study was to compare the efficacy and safety of documented treatment with colistin monotherapy versus colistin plus meropenem in critically ill patients with CRAB infections at Chiang Mai University Hospital (CMUH). We conducted a retrospective cohort study of critically ill patients with CRAB infections in an ICU from 2015 to 2017, who received colistin monotherapy versus colistin plus meropenem. After propensity score matching, an adjusted odds ratio (aOR) of a 30-day mortality rate in patients who received colistin plus meropenem was 0.43 compared to those who received colistin monotherapy (95% CI, 0.23-0.82, p = 0.01). aORs of clinical response and microbiological response were also higher in patients who received colistin plus meropenem (1.81, 95% CI 1.01-3.26, p = 0.048 and 2.08, 95% CI 1.11-3.91, p = 0.023, respectively). There was no significant difference in nephrotoxicity (aOR, 0.76, 95% CI, 0.43-1.36, p = 0.363) between colistin monotherapy and colistin plus meropenem. In conclusion, the addition of meropenem to colistin caused a reduction in 30-day mortality, higher clinical and microbiological responses, and did not increase nephrotoxicity compared to colistin monotherapy. Furthermore, 30-day mortality was significantly related with age, receiving vasopressor, having malignancy, and the APACHE II score.

Clinical outcomes and nephrotoxicity of colistin loading dose for treatment of extensively drug-resistant Acinetobacter baumannii in cancer patients.

BACKGROUND: Colistin is a last-line defense therapy against extensively drug-resistant Acinetobacter baumannii (XDR-AB). Despite a loading dose of colistin being applied in many clinical practices, studies evaluating the effect of the loading dose of colistin in cancer patients remain limited. PATIENTS AND METHODS: A retrospective cohort study of cancer patients who received either a loading or non-loading dose of colistin for treatment of XDR-AB was conducted. For each group, the clinical response, bacteriological eradication and serum creatinine were recorded. Logistic regression was applied to evaluate the effects of therapy on each of the three aforementioned outcomes. RESULTS: One hundred and two patients diagnosed with XDR-AB infections between January 2012 and December 2015 were recruited. Only 75 patients were given a loading dose of colistin. There was no significant clinical and microbiological response in patients in the loading dose group or patients in the non-loading dose group. However, 38 (50.67%) patients in the loading dose group and 6 (22.22%) patients in the non-loading dose group developed nephrotoxicity according to the RIFLE criteria (p = 0.013). Multivariate logistic regression analysis showed that independent predictors of clinical response were Charlson score ≥4 and duration of colistin treatment ≥10 days. Septic shock correlated with both poor clinical and microbiological response. Independent predictors for nephrotoxicity were loading dose colistin and patient's age ≥60 years. CONCLUSION: Administration of colistin loading dose did not significantly increase clinical response, microbiological response or mortality rate compared to non-loading dose in cancer patients with XDR-AB-related infections. However, nephrotoxicity was significantly higher when patients received loading dose colistin.

The 10-year effectiveness of combination antiretroviral treatment in perinatally HIV-infected children participating in Thailand's National Access Program.

BACKGROUND: The National Access to Antiretroviral Program for People Living with HIV/AIDS was launched in Thailand in 2002. HIV-infected, antiretroviral-naive, severely immunosuppressed children were initiated on highly active combination antiretroviral treatment (cART). This study aimed to determine the long-term effectiveness of cART. METHODS: Data were extracted from medical records. Primary end points were mortality rate, proportion of children who remained on first-line cART regimen and children with plasma HIV RNA level (pVL) <50 copies/ml at week 520. RESULTS: From August 2002 to July 2003, 107 children were enrolled. The baseline median age was 7.6 years (IQR 5.7-10.0), the median CD4(+) T-cell count was 60 cells/mm(3) (IQR 21-272) and the median pVL was 5.37 log10 copies/ml (IQR 5.01-5.76). The mortality rate during and after the first year was 3.7 and 0.006 deaths/100 person-years, respectively. At week 520, 90 (84%) continued to be actively followed. Their median age was 17.8 years (IQR 15.8-19.8). 73 (81% as-treated) remained on the first-line regimen, while 18 (20%) had switched to a second-line cART regimen, at the median time of 272 weeks (IQR 256-363) after the first-line cART initiation. 69 (77%) had pVL<50 copies/ml and the median CD4(+) T-cell count was 636 cells/mm(3) (IQR 466-804). 83 (92%) and 64 (71%) had CD4(+) T-cell counts ≥200 and >500 cells/mm(3), respectively. CONCLUSIONS: Long-term virological control, favourable immunological outcomes and healthy survival was achieved in severely immunosuppressed, perinatally HIV-infected children who started first-line NNRTI-based cART. Continuing surveillance for long-term complications is warranted.

Preventive antiretroviral therapy in non-thalassemia carrier infants exposed to mother-to-child transmission of HIV decreases cord and after delivery red blood production without altering the development of hemoglobin.

Antiretroviral (ARV) prophylaxis for prevention of mother to child transmission (MTCT) of HIV could affect hemoglobin (Hb) development of infants. A cross-sectional descriptive study was conducted in 24 HIV-infected and 21 HIV-uninfected pregnancies. ARV drugs were administered to HIV-infected pregnancies at 21 weeks of gestational age and at labor. Their infants received zidovudine (ZDV) until 4 weeks of age. Blood samples of ARV-exposed and - unexposed infants were collected at delivery, 1, 2 and 4 months of age. Molecular analyses for α-thalassemia-1 Southeast Asian (SEA) type deletion, ß-thalassemia mutations and Hb E were performed for excluding the thalassemia carrier infants. Hemoglobinopathy and Hb A, Hb F and Hb A2 were analyzed by using capillary electrophoresis (CE) while hematological parameters were measured using an automated blood counter. At delivery, 1 and 2 months of age, ARVexposed infants had significantly lower levels of RBC counts than ARV-unexposed infants (3.56 vs 4.90, 2.66 vs 4.62 and 3.01 vs 4.05 x10(12)/L; P <0.001, <0.001 and 0.001, respectively). At delivery, there was a trend for low hemoglobin level in the group of ARV-exposed infants as compared to the group of ARV-unexposed infants (149 vs 154 g/L; P = 0.09) and the significantly different levels were observed among the two groups at 1 and 2 months of age (89 vs 136 and 87 vs 110 g/L; P < 0.001 and 0.001, respectively). The development of Hb A, Hb F and Hb A2 levels from delivery to 4 months of age among the two groups was not significantly different. Therefore, ARV treatments for prevention of MTCT of HIV decreased RBC counts and hemoglobin but did not alter the development of Hb A, Hb F and Hb A2 of non-thalassemia carrier infants.

Unusual manifestations of Epstein-Barr virus infection in an 8-month-old male infant.

Severe acute hepatitis is a rare complication of Epstein-Barr virus (EBV) infection. The authors report a case of an 8-month-old male infant who presented with subacute fever and jaundice. The physical examination showed hepatosplenomegaly and ecchymoses on his abdomen, chest wall and extremities. He received vitamin K therapy and prednisolone, and he recovered well without further complications or sequelae. Although severe acute hepatitis is a rare complication of EBV infection, clinicians should recognise this condition in order to provide a prompt treatment.

Disseminated cryptococcosis in an HIV-positive boy.

Cryptococcosis is rare among children, only occurring in about 1% of children with HIV. We report the case of a 12-year-old boy with disseminated cryptococcosis. He had a history of recurrent pneumonia. He then developed meningeal symptoms and was found to have disseminated Cryptococcus neoformans by cerebrospinal fluid and bone marrow aspirate culture. He was treated with amphotericin B for 2 weeks (1 mg/kg/day), and then with fluconazole orally for 8 weeks (12 mg/kg/day). He also received a new diagnosis of HIV and was started on antiretroviral therapy 2 weeks after starting antifungal treatment. At follow-up 8 weeks later, he was doing well.

A 3-year-old boy with kyphosis, back mass and weakness.

Spinal tuberculosis (TB) in children is uncommon. The authors report a case of a 3-year-old boy who was diagnosed with TB spondylitis. He presented to the hospital with a back mass, back pain and inability to walk. He failed to receive TB prophylaxis after having been in close contact to his mother who had pulmonary TB. He received incision and drainage and continued on anti-TB regimens without complications. At 4-month follow-up, he was able to stand and walk without assistance. It is important to carry out contact investigations and provide TB prophylaxis to children who have had a history of contacting TB index cases to prevent TB disease and serious complications of TB infection.

Nosocomial Infections among Pediatric Patients with Neoplastic Diseases.

Background. Pediatric patients with neoplastic diseases are more likely to develop nosocomial infections (NIs). NIs may prolong their hospital stay, and increase morbidity and mortality. Objectives. The objectives of this study were to determine: (1) the incidence of NIs, (2) sites of NIs, (3) causal organisms, and (4) outcomes of NIs among pediatric patients with neoplastic diseases. Methods. This study was a prospective cohort study of pediatric patients with neoplastic diseases who were admitted to the Chiang Mai University Hospital, Thailand. Results. A total of 707 pediatric patients with neoplastic diseases were admitted. Forty-six episodes of NIs in 30 patients were reported (6.5 NIs/100 admission episodes and 7 NIs/1000 days of hospitalization). Patients with acute lymphoblastic leukemia had the highest number of NIs (41.3%). The most common causal organisms were gram-negative bacteria (47.1%). Patients who had undergone invasive procedures were more likely to develop NIs than those who had not (P < .05). The mortality rate of patients with NIs was 19.6%. Conclusion. Pediatric patients with neoplastic diseases are more likely to develop NIs after having undergone invasive procedures. Pediatricians should be aware of this and strictly follow infection control guidelines in order to reduce morbidity and mortality rates related to NIs.