Streptococcus agalactiae in adults at Chiang Mai University Hospital: a retrospective study.

BACKGROUND: Infection caused by Streptococcus agalactiae, a Group B streptococcus, is an emerging disease in non-pregnant adults. This study describes the epidemiological, clinical, and microbiological characteristics of S. agalactiae infection in adult patients in northern Thailand. METHODS: A retrospective study was conducted between January 1, 2006 and December 31, 2009 at Chiang Mai University Hospital among patients aged ≥15 years, whose clinical specimens obtained from normally sterile sites grew S. agalactiae. RESULTS: One-hundred and eighty-six patients and 197 specimens were identified during the 4-year period. Among 186 patients, 82 were documented as having invasive infection; 42 patients were male (51.2%) with the mean age of 48.5 ± 19.4 years (range 17, 83). Fifty-three patients (64.6%) had underlying medical conditions; 17 patients (20.7%), 10 (12.2%), 8 (9.7%) had diabetes, chronic renal diseases, and malignancy, respectively. Among 40 patients (48.8%) with bloodstream infection, no other site of infection was determined in 29 (35.4%) patients. In the remaining 11 patients, 5 patients (6.1%), 5 (6.1%), and 1 (1.2%) had meningitis, arthritis, and meningitis with arthritis, respectively. Forty-two patients (51.2%) presented with localized infection, i.e., subcutaneous abscess (19 patients, 23.2%), chorioamnionitis (10 patients, 12.2%), urinary tract infection (5 patients, 6.1%), arthritis (3 patients, 3.7%), meningitis (2 patients, 2.4%), and spontaneous bacterial peritonitis, uveitis, and tracheobronchitis (1 patient each, 1.2%). The overall mortality was 14.6% (12 patients). CONCLUSIONS: S. agalactiae infection is a growing problem in non-pregnant patients, particularly in those with underlying medical conditions. Physicians should add S. agalactiae infection in the list of differential diagnoses in patients with meningitis and/or septicemia.

Epidemiology of adult candidemia at Chiang Mai University Hospital.

A retrospective study was conducted between July 1, 2004 and June 30, 2009 at Chiang Mai University Hospital among 138 patients with candidemia; 85 patients (61.6%) were male and the mean age was 57.7 +/- 19.4 years. Seventy-eight patients (56.5%) had underlying medical conditions. Candida albicans and non-albicans Candida were identified in 42 (30.4%) and 96 (69.6%) patients, respectively. Not being admitted to the ICU was the only factor associated with non-albicans candidemia (p = 0.018). Sixty patients (43.5%) had favorable outcomes. Factors independently associated with unfavorable outcomes included patients who were in the ICU (p = 0.025), were intubated (p < 0.001) or were on hemodialysis (p = 0.031); prior abdominal surgery was associated with a favorable outcome (p = 0.026). Candidemia is not a rare condition at this hospital. Early recognition and prompt empirical treatment are essential to improve outcomes of patients at risk for developing candidemia. Improvement of surveillance is crucial to recognizing emergence of highly resistant strains of Candida spp.

A novel influenza A H1N1 clinical manifestations in patients at Chiang Mai University Hospital.

OBJECTIVE: To describe the clinical manifestations of patients affected with a novel influenza A (H1N1 2009) during the pandemic. MATERIAL AND METHOD: A retrospective study was conducted in patients with influenza-like illness receiving care at Chiang Mai University Hospital between June 1 and September 30, 2009. The inclusion criteria were as follows 1) patients had influenza-like illness that was defined as fever, with cough and/or sore throat, 2) detection of influenza A H1N1 2009 by real-time polymerase chain reaction (RT-PCR) from nasopharyngeal swabs or throat swabs. RESULTS: Among 278 patients, 150 patients (54.0%) were male and the mean age was 21.4 +/- 13.1 years (range 1-74). Eighty-seven patients (31.3%) were in age group 15-19 years. Fifty-eight patients (20.9%) had underlying diseases and asthma was the most common health problem. The presenting symptoms were cough (dry or productive) (248 patients, 89.2%), fever > or = 38.0 degrees C (229 patients, 82.4%), sore throat (195 patients, 70.1%), rhinorrhea (126 patients, 45.3%) and myalgia (113 patients, 40.6%). Five patients had co-infection at admission, three patients had dengue hemorrhagic fever, one patient had mycoplasma infection, and the other one with Acinetobacter lwoffi bacteremia. One hundred forty four patients (51.8%) received oseltamivir. Two hundred seventy two patients (97.8%) recovered without complications. One pregnant-woman developed severe pre-eclampsia five days after the first symptom, one patient developed Guillain Barre syndrome 10 days after the first symptoms. Four patients died, all had pneumonia. CONCLUSION: Younger people were more likely to be infected with influenza A H1N1 2009. The clinical manifestations were similar to the seasonal influenza. However, the mortality rate was much higher, particularly in patients who developed pneumonia. In this study, all patients who died had existing underlying medical conditions.

Therapeutic effectiveness of a generic versus original meropenem in serious infections.

BACKGROUND: Meropenem plays a significant role in the current antimicrobial treatment of serious infections. Recently, generic meropenems have become widely available in Thailand. OBJECTIVE: Compare the effectiveness and safety ofa generic meropenem (Mapenem) with the original meropenem (Meronem) in clinical practice. MATERIAL AND METHOD: A retrospective cohort study was conducted in hospitalized patients with serious infections that had been treated with either the generic or the original meropenem in nine secondary- and tertiary-care hospitals nationwide. The treatment outcomes at days 3, 7, and 14 after the use ofmeropenem between the two groups were compared. RESULTS: Three hundred ninety seven patients with a mean (SD) age of 66.4 +/- 16.9 years were included. There were 228 (57.4%) males and 169 (42.6%) females. Two hundred and seven (52.1%) and 190 (47.9%) cases fell into the generic and original groups respectively. There were no significant differences regarding age, gender history of underlying disease, body weight, and ward of admission between the two groups. The majority ofpatients had presented with the respiratory tract (48.6%) and bloodstream infections (29.5%). The three most common causative bacteria were Pseudomonas aeruginosa, Acinetobacter baumannii, and extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The distribution ofthe sites of infection, causative microorganisms, the dosage ofmeropenem, and duration oftreatment were similar between the two groups. The distribution of patients with complete resolution, improvement, stable, worse, diedfrom infection, and died from other causes were similar between the two groups at day 3, 7, and 14 ofmeropenem use (p > 0.05). The drugs were well-tolerated, and less than 2% of patients in both groups discontinued meropenem due to the adverse drug effects. CONCLUSION: The generic meropenem has a similar effectiveness in the treatment of serious bacterial infections when compared with original meropenem. Both formulations are well tolerated among patients with substantial comorbidities. Adverse drug effects that lead to drug discontinuation are uncommon.

Discontinuation of primary and secondary prophylaxis for opportunistic infections in HIV-infected patients who had CD4+ cell count <200 cells/mm(3) but undetectable plasma HIV-1 RNA: an open-label randomized controlled trial.

Abstract The CDC recommends discontinuing opportunistic infections (OIs) prophylaxis in HIV-infected patients who have CD4+ cell count >200 cells/mm(3) after receiving combination antiretroviral therapy (cART). A prospective randomized controlled trial was conducted at Chiang Mai University Hospital from June 1, 2009 to January 31, 2012 in 74 adult HIV-infected patients who had received cART and had CD4+ cell count <200 cells/mm(3) but plasma HIV-1 RNA<50 copies/ml. Forty-three patients (58.1%) were male and the mean age was 41.8±8.1 years; 68 (91.9%) and 59 (79.7%) patients were receiving co-trimoxazole and antifungal prophylaxis, respectively. The median CD4+ cell counts at enrollment were 142 (IQR 108, 161) and 158 (IQR 141, 176) cells/mm(3) among patients who discontinued and continued OIs prophylaxis, respectively (p value=0.041). One of 37 patients (2.7%) in the discontinuation group developed Pneumocystis jiroveci pneumonia, giving the incidence rate of 1.57/1000 person-months. None of the 37 patients in the continuation group developed OIs. The difference in the prevention rates of OIs between groups was -2.7% (95% CI -7.9, 2.5). In conclusion, in the setting where plasma HIV-RNA measurement is available, e.g., Asia-Pacific region, discontinuation of prophylaxis is considerably safe in HIV-infected patients receiving cART with undetectable plasma HIV-RNA but incomplete immune recovery.

Resistance-associated mutations after initial antiretroviral treatment failure in a large cohort of patients infected with HIV-1 subtype CRF01_AE.

The nucleoside reverse transcriptase inhibitors (NRTIs), zidovudine (AZT) and stavudine (d4T) are thymidine analog drugs recommended as first-line antiretroviral therapy in HIV-1-naive patients. Two thymidine analog mutation (TAM) pathways, TAM-1 and TAM-2, confer high levels of resistance with mutations in the viral RT. The relative prevalence of TAM pathways and their associations with other NRTI resistance mutations acquired under the pressure of drug treatment in a large cohort of 1,876 patients infected with HIV-1 CRF01_AE attending the Infectious Disease Clinic, Chiang Mai University Hospital, Chiang Mai, Thailand, were studied. From 117 patients infected with HIV-1 CRF01_AE who had plasma HIV-1 RNA of ≥500 copies/mL, 69 patients had at least one TAM. The most common mutation associated with NRTI resistance was M184V/I (89.9%). The TAM-2 (89.9%) pathway occurred approximately two times more frequently than the TAM-1 (43.5%) pathway. The presence of TAM and the TAM-1 pathway was significantly more frequent in the AZT- than the d4T-receiving group ((OR, 2.89; 95% CI, 1.12-7.46; P< 0.05) and (OR, 3.33; 95% CI, 1.19-9.37; P< 0.05), respectively). In conclusion, the TAM-2 pathway was selected more frequently than the TAM-1 pathway by thymidine analog drugs in HIV-1 CRF01_AE-infected patients, while the TAM-1 pathway occurred more frequently than the TAM-2 pathway in such patients with AZT-based treatment. Routine monitoring of plasma HIV-1 RNA may result in less exposure to failing regimens and reduce the opportunity for TAMs to accumulate. However, the low frequency of the TAM-1 pathway in our cohort data suggests that these patients should respond well to second-line regimens containing a ritonavir-boosted protease inhibitor.

Impact of the frequency of plasma HIV-1 RNA monitoring on the outcome of antiretroviral therapy.

BACKGROUND: Current guidelines for HIV management recommend monitoring plasma HIV-1 RNA level every 3-6 months in patients on a stable antiretroviral regimen. However, cost is the major obstacle to follow the guidelines in resource-limited settings. OBJECTIVE: This study aimed to compare the outcome of antiretroviral therapy among HIV-infected patients on a stable regimen who had plasma HIV-1 RNA monitoring once vs. twice yearly. METHODS: A retrospective cohort study was conducted among HIV-infected patients receiving antiretroviral therapy since 2002 at Chiang Mai University Hospital, Thailand. We evaluated the incidence of virological failure and number of reverse transcriptase (RT) mutations between groups. RESULTS: Of 551 patients on a stable antiretroviral regimen, 405 (73.5%) and 146 (26.5%) patients had plasma HIV-1 RNA measurement once and twice yearly, respectively. Forty-seven of 405 patients (11.6%) in once-yearly group and 15 of 146 patients (10.3%) in twice-yearly group developed virological failure, giving the incidence rate of 2.03/100 and 1.95/100 person-years, respectively. The probability of virological failure did not differ between groups (p=0.897, log-rank test). The number of RT mutations was not statistically different between groups (all p-values>0.05). The predicting factors for virological failure from a multivariate analysis were adherence rate <95% and baseline CD4 cell count <50 cells/mm3 but not the frequency of HIV-1 RNA monitoring. CONCLUSIONS: The incidence of virological failure and the number of RT mutations were not different between groups. Therefore, in resource-limited settings, the recommendation to perform plasma HIV-1 RNA measurement once yearly in patients on a stable antiretroviral regimen is justified.

Current molecular epidemiology and recombination of HIV type 1 subtypes in northern Thailand.

HIV subtype characterization is an important tool to monitor the genetic variation of the HIV epidemic. This study investigated the current HIV subtype distribution and recombination among the northern Thai population. An in-house genotypic assay of HIV protease and reverse transcriptase genes was performed on 420 plasma specimens from HIV-infected patients residing in several northern Thai provinces. HIV subtyping was determined by phylogenetic analysis. Three hundred and ninety-eight sequences (94.8%) were identified as CRF01_AE with the genetic distance of 1.848 ± 0.957% and 12 (2.9%) as subtype B with the genetic distance of 4.186 ± 0.849%. In addition, two sequences (0.5%) of HIV subtype C were found, suggesting that these patients were either immigrants from another country or were infected through heterosexual contact with HIV-infected subjects from another country. Bootscan analysis showed that there were eight (1.9%) unique recombinant forms (URFs) consisting of a recombinant of CRF01_AE with subtype B or subtype C. The information from this study is useful for prevention programs to halt the onward transmission of a particular HIV outbreak. However, characterization of the full genome of these CRF01_AE/B and CRF01_AE/C intersubtype recombinants, and also subtype C, is required for confirmation and elucidation.