Cutaneous phaeohyphomycosis presenting as multiple ecthyma-like skin lesions caused by Curvularia lunata in a previously healthy man: A case report.

Ecthyma grangrenosum is an unusual condition, mostly related to Pseudomonas septicemia. Ecthyma-like skin lesions caused by cutaneous phaeohyphomycosis are extremely rare. Here, we report a case of a 20-year-old Thai man, previously healthy, presenting multiple ecthyma-like skin lesions in both arms and both legs for 2 months. Physical examination revealed ill-defined erythematous plaque with central necrotic crust at both arms and both legs. Tissue biopsy showed a neutrophil collection identified by GMS stain revealing septate hyphae organisms in the vascular lumen. The skin culture was positive for Curvularia lunata, while the final diagnosis was cutaneous phaeohyphomycosis caused by Curvularia lunata. He was empirically treated with amphotericin B and then voriconazole. Itraconazole was administered as a definitive regimen, resulting in complete resolution after 2 months of treatment. Cutaneous phaeohyphomycosis is also an uncommon cause of ecthyma-like lesions and should be considered for investigation when initial results do not demonstrate a bacterial etiology.

In vitro activity, pharmacodynamic profile and dose optimization of biapenem against NDM and OXA-48-like carbapenemase-producing Klebsiella pneumoniae: A multicentre study in Thailand.

BACKGROUND: Biapenem (BIPM) exhibited a less efficient substrate for various metallo-ß-lactamase (MBL) than other carbapenems. OBJECTIVE: We aimed to evaluate in vitro susceptibility data of BIPM and optimal dose based on Monte Carlo simulation to extend treatment options. METHODS: We collected 192 carbapenem-resistant Klebsiella pneumoniae (CRKP) clinical isolates from unique patients among multicentres in Thailand, from June 2019 to March 2023. BIPM disk diffusion and broth-microdilution testing were performed to obtain minimum inhibitory concentration (MIC). Each BIPM regimen was simulated using the Monte Carlo technique to calculate the probability of target attainment (PTA) and the cumulative fraction of response (CFR). RESULTS: The most common genotypes among 192 CRKP isolates were blaOXA-48 (62.3%), blaOXA-48+blaNDM (22.6%) and blaNDM (15.1%). BIPM showed 22.4 and 28.6% susceptible rate when interpreted at clinical breakpoints of 1 and 2 mg/L. The MIC50 and MIC90 of BIPM against CRKP were 8 and 32 mg/L. The BIPM dosing regimens of 300 mg q 6 h infused 6 h and 600 mg q 8 h infused 8 h met the PTA target of %fTime >MIC at 50%, 75% and 100% against isolates MICs of ≤2 mg/L. Based on CFR ≥90%, no BIPM regimens were effective against all the studied CRKP isolates. CONCLUSION: BIPM exhibited a partially susceptible rate among the CRKP isolates in Thailand. The current suggested dose of BIPM with prolonged infusion appears appropriate regimen against CRKP MICs of ≤2 mg/L. However, the empirical use of BIPM for severe CRE infection is not recommended unless the susceptibility has been confirmed.

Effect of montelukast in preventing dengue with warning signs among patients with dengue: A multicenter, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Montelukast has shown potential as a candidate treatment for dengue. This study aimed to evaluate the efficacy and safety of montelukast in preventing dengue with warning signs. METHODS: This multicenter, randomized, double-blind, placebo-controlled trial enrolled adult participants with NS1 antigenemia in Thailand. The participants were randomly assigned to receive either oral montelukast (10 mg) or a placebo for 10 days or until all symptoms resolved. RESULTS: Between January 2021 and June 2023, 358 participants were enrolled and randomly assigned (1:1) to receive either montelukast or placebo. The incidence rate of warning signs in the montelukast group and the placebo group were 9.5% and 7.8% per day, respectively. There was no difference between the two groups (HR 1.36; 95%CI 0.94-1.96, P = 0.105). No statistically significant differences were observed in the incidence rate of severe dengue, hemoconcentration, thrombocytopenia, admission, or recovery from dengue. Neither dengue shock, nor mortality occurred. The montelukast group exhibited a decreased incidence rate of transaminase elevations (0.7% vs 1.4% per day, HR: 0.48, 95%CI 0.25-0.90, P = 0.023). CONCLUSION: Oral montelukast does not reduce the incidence of warning signs among patients with dengue. Nevertheless, the observed decrease in transaminase elevations warrants further investigation to evaluate the potential effect of montelukast. CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov, NCT04673422, registered on 9 December 2020.

Disseminated coinfection with Mycobacterium Avium complex and Mycobacterium Kansasii in a patient with idiopathic CD4+ lymphocytopenia: A case report.

Simultaneously disseminated coinfection with two species of nontuberculous mycobacteria (NTM) is extremely rare and had been reported only in immunocompromised individuals. Here, we report a 59-year-old Thai man, previously healthy. He presented with a 2-month history of prolonged fever, constitutional symptoms, and hepatosplenomegaly. His chest and abdomen computed tomography illustrated multiple enlarged mediastinal lymph nodes accompanied with multifocal crazy-paving appearance in both lungs and hepatosplenomegaly. Endobronchial ultrasound-guided transbronchial needle aspiration was performed on the mediastinal nodes. The pathologic findings were necrotizing granulomatous lymphadenitis with numerous AFB-positive bacilli. Blood culture subsequently isolated M. intracellulare, while BAL and lymph node culture isolated M. intracellulare and M. kansasii, which confirmed species by multiplex PCR and 16s rRNA sequencing. Idiopathic CD4+ lymphocytopenia (ICL) was diagnosed as the cause of secondary immune deficiency. Intravenous imipenem, amikacin, and azithromycin were administered as an empirical antibiotic regimen for 4 weeks, then substituted to oral rifampicin, clarithromycin, moxifloxacin, and ethambutol as definitive regimen. Unfortunately, it was found that he had died unexpectedly at home after 4 months of treatment, possibly related to this illness. In our view, patients with severe disseminated NTM disease should be evaluated to explore a secondary immune deficiency disorder. An ICL is a rare heterogenous syndrome but should be considered.

The Activities of Antimicrobials Against Stenotrophomonas maltophilia Isolates and Evaluation of Clinical Outcomes Among Treatment Regimens in Patients with Stenotrophomonas maltophilia Infections: A Retrospective Multicenter Cohort Study.

Purpose: Stenotrophomonas maltophilia, a multidrug-resistant pathogen can cause hospital-acquired infections such as pneumonia, or bloodstream infection. S. maltophilia infection is associated with high mortality rates. This retrospective study examined the antimicrobial susceptibility profile of clinical S. maltophilia isolates and evaluated clinical outcomes, treatment regimens, and risk factors associated with 30-day mortality or treatment failure of S. maltophilia infections at three tertiary care hospitals in Central Thailand. Patients and Methods: The characteristics, microbiological data, and clinical treatment outcomes were derived from medical records obtained from three tertiary care hospitals in Central Thailand from January 2017 to October 2022. The primary outcomes were treatment failure and 30-day mortality. The antimicrobial susceptibility rates of trimethoprim-sulfamethoxazole (TMP-SMX), levofloxacin, and ceftazidime were determined by minimum inhibitory concentration (MIC), which were based on broth microdilution and clear zone diameters using the disk diffusion method. However, we also report the susceptibility of minocycline and tigecycline in some clinical S. maltophilia strains (n = 149) and determined by MIC with E-test method. Results: The antimicrobial susceptibility rates to TMP-SMX, levofloxacin, and ceftazidime were 97.1%, 93%, and 55.3%, respectively. The treatment failure rate and 30-day mortality were 66.3% and 49%, respectively. Significant factors associated with treatment failure included APACHE II score ≥15 (OR 3.37, 95% confidence interval (CI) 1.46-7.76), polymicrobial infections (OR 3.20, 95% CI 1.35-7.55). The significant factors associated with reduced treatment failure was treatment with TMP-SMX-based regimen (OR 0.29, 95% CI 0.11-0.76). The 30-day mortality rate was associated with APACHE II score ≥15 (OR 3.27, 95% CI 1.45-7.39) and septic shock (OR 2.53, 95% CI 1.36-4.69). Conclusion: The results indicate a high mortality rate for S. maltophilia infection. The predictive factors for an unfavourable outcome were severity of illness, septic shock, and non-use of TMP-SMX. Therefore, a TMP-SMX-based regimen is recommended for the treatment of S. maltophilia infections.

Towards optimizing carbapenem selection in stewardship strategies: a prospective propensity score-matched study of ertapenem versus class 2 carbapenems for empirical treatment of third-generation cephalosporin-resistant Enterobacterales bacteraemia.

BACKGROUND: Third-generation cephalosporin-resistant Enterobacterales (3GCRE) are increasing in prevalence, leading to greater carbapenem consumption. Selecting ertapenem has been proposed as a strategy to reduce carbapenem resistance development. However, there are limited data for the efficacy of empirical ertapenem for 3GCRE bacteraemia. OBJECTIVES: To compare the efficacy of empirical ertapenem and class 2 carbapenems for the treatment of 3GCRE bacteraemia. METHODS: A prospective non-inferiority observational cohort study was performed from May 2019 to December 2021. Adult patients with monomicrobial 3GCRE bacteraemia receiving carbapenems within 24 h were included at two hospitals in Thailand. Propensity scores were used to control for confounding, and sensitivity analyses were performed in several subgroups. The primary outcome was 30 day mortality. This study is registered with clinicaltrials.gov (NCT03925402). RESULTS: Empirical carbapenems were prescribed in 427/1032 (41%) patients with 3GCRE bacteraemia, of whom 221 received ertapenem and 206 received class 2 carbapenems. One-to-one propensity score matching resulted in 94 pairs. Escherichia coli was identified in 151 (80%) of cases. All patients had underlying comorbidities. Septic shock and respiratory failure were the presenting syndromes in 46 (24%) and 33 (18%) patients, respectively. The overall 30 day mortality rate was 26/188 (13.8%). Ertapenem was non-inferior to class 2 carbapenems in 30 day mortality (12.8% versus 14.9%; mean difference -0.02; 95% CI: -0.12 to 0.08). Sensitivity analyses were consistent regardless of aetiological pathogens, septic shock, source of infection, nosocomial acquisition, lactate levels or albumin levels. CONCLUSIONS: Ertapenem may be of comparable efficacy to class 2 carbapenems in the empirical treatment of 3GCRE bacteraemia.

Isolated Tuberculous Transverse Myelitis Without Meningitis Among Patients With AIDS: A Case Report.

Acute transverse myelitis is an inflammatory disorder of the spinal cord, characterized by acute or subacute onset of paraparesis, bilateral sensory deficit, and impaired urinary bladder and sphincter tone function. Mycobacterium tuberculosis, a very rare cause of transverse myelitis, especially tuberculous myelitis without meningitis, is extremely rare. The main etiologic mechanism consists of an abnormal activation of the immune system against the spinal cord as well as the direct invasion by the bacillus. We present a 30-year-old Thai woman with AIDS, presenting with paraplegia for two days. Her MRI of the whole spine showed nodular enhancing intramedullary lesions involving the spinal cord at the T11-T12 level, and intramedullary enhancing lesion along the T12 spinal cord to the conus medullaris. Cerebrospinal fluid (CSF) examination revealed only a few white blood cells without hypoglycorrhachia or elevated CSF protein. CSF polymerase chain reaction (PCR) and culture for M. tuberculosis produced negative results. Other investigations did not demonstrate other organ involvement. Spinal cord biopsy at T12 was performed and exhibited diffuse epithelioid histiocytic proliferation admixed with small lymphocytes and plasma cells with numerous acid-fast bacilli (AFB)-positive bacilli organisms. PCR for M. tuberculosis was also detected in spinal cord tissue. Thus, acute transverse myelitis caused by isolated tuberculous myelitis without meningeal involvement was diagnosed. She had marked clinical improvement and neurologic recovery after treatment with anti-tuberculosis and intravenous steroid pulses. Isolated M. tuberculosis spinal tuberculous myelitis without meningitis is exceptionally uncommon and should be carefully considered, particularly in severely immunocompromised individuals residing in regions with a high tuberculosis burden.

Staphylococcus aureus nasal carriage and bloodstream infection among conventional hemodialysis patients in Thailand: a prospective multicenter cohort study.

OBJECTIVE: Staphylococcus aureus nasal carriage screening among hemodialysis patients is not standard practice in Thailand, because of data lacking regarding prevalence and correlation with subsequent infection. We aimed to investigate the prevalence of S. aureus nasal carriage and its association with bloodstream infection among hemodialysis patients. In this prospective multicenter cohort study, participants were screened for S. aureus nasal carriage over 2 consecutive weeks. Incidence of S. aureus bloodstream infection over the next 12 months was observed. RESULTS: The prevalence of S. aureus nasal carriage was 11.67%. Incidence of S. aureus bacteremia among participants with and without S. aureus nasal carriage were 7.1% and 3.8%, respectively. The odds ratio for nasal carriage and subsequent bacteremia was 1.96 (95% CI 0.04-21.79; p = 0.553). Survival analysis showed that time to bacteremia among participants in the two groups did not significantly differ (p = 0.531). Prevalence of S. aureus nasal carriage among hemodialysis patients in Thailand was low. Patients presenting with S. aureus nasal carriage did not have increased risk of S. aureus bacteremia after 12-month follow-up. Nasal S. aureus screening and decolonization should not be encouraged in this setting.

Correction: Nulsopapon et al. The Synergistic Activity and Optimizing Doses of Tigecycline in Combination with Aminoglycosides against Clinical Carbapenem-Resistant Klebsiella pneumoniae Isolates. Antibiotics 2021, 10, 736.

There were errors made in the original article [...].

Bacterial etiology and mortality rate in community-acquired pneumonia, healthcare-associated pneumonia and hospital-acquired pneumonia in Thai university hospital.

Pneumonia is caused by infection at the pulmonary parenchyma which constitutes a crucial risk factor for morbidity and mortality. We aimed to determine the mortality rate and its risk factors as well as etiology among inpatients with community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and healthcare-associated pneumonia (HCAP). A hospital-based retrospective cohort study was conducted in a university hospital located in Bangkok, Thailand. A total of 250 inpatients with pneumonia was included in the present study. The inhospital mortality rate was 1.25 (95% CI 0.99-1.56) per 100 person-days. The present study reported that overall pneumonia caused by gram-negative pathogens accounted for 60.5%. P. aeruginosa was a frequent gram-negative pathogen among these participants, especially among patients with HCAP and HAP. Adjusted hazard ratio (AHR) of inhospital mortality among patients with HAP was 1.75 (95% CI 1.01-3.03) times that of those among patients with CAP, while AHR for 28-day mortality among patients with HAP compared with those with CAP was 2.81 (95% CI 1.38-5.75). Individual risks factors including cardiomyopathy, active-smoker and insulin use were potential risk factors for mortality. Initial qSOFA and acid-based disturbance should be assessed to improve proper management and outcomes.

Optimizing Doses of Ceftolozane/Tazobactam as Monotherapy or in Combination with Amikacin to Treat Carbapenem-Resistant Pseudomonas aeruginosa.

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a hospital-acquired pathogen with a high mortality rate and limited treatment options. We investigated the activity of ceftolozane/tazobactam (C/T) and its synergistic effects with amikacin to extend the range of optimal therapeutic choices with appropriate doses. The E-test method is used to determine in vitro activity. The optimal dosing regimens to achieve a probability of target attainment (PTA) and a cumulative fraction of response (CFR) of ≥90% were simulated using the Monte Carlo method. Of the 66 CRPA isolates, the rate of susceptibility to C/T was 86.36%, with an MIC50 and an MIC90 of 0.75 and 24 µg/mL, respectively. Synergistic and additive effects between C/T and amikacin were observed in 24 (40%) and 18 (30%) of 60 CRPA isolates, respectively. The extended infusion of C/T regimens achieved a ≥90% PTA of 75% and a 100% fT > MIC at C/T MICs of 4 and 2 µg/mL, respectively. Only the combination of either a short or prolonged C/T infusion with a loading dose of amikacin of 20−25 mg/kg, followed by 15−20 mg/kg/day amikacin dosage, achieved ≥90% CFR. The C/T infusion, combined with currently recommended amikacin dose regimens, should be considered to manage CRPA infections.

Antimicrobial Activity Profiles and Potential Antimicrobial Regimens against Carbapenem-Resistant Enterobacterales Isolated from Multi-Centers in Western Thailand.

The spread of carbapenem-resistant Enterobacterales (CRE) constitutes a global health burden. Antimicrobial susceptibility and types of carbapenemase differ by geographic region. This study aimed to (1) examine the minimum inhibitory concentrations (MICs) and antibiotic resistance genes and (2) investigate antibiotic dosing regimens against CRE using Monte Carlo simulation. Clinical carbapenem-resistant Klebsiella pneumoniae (CRKP), Escherichia coli (CREC), and Enterobacter cloacae (CREclo) isolates were collected from various hospitals in western Thailand. Broth microdilution was performed, and the types of carbapenemase and mcr-1 genes were detected using polymerase chain reaction (PCR). Monte Carlo simulation was used to establish optimal antimicrobial dosing regimens meeting the criterion of a cumulative fraction of response (CFR) >90%. A total of 150 CRE isolates from 12 hospitals were included. The proportion of CRKP (76%) was greater than that of CREC (22%) and CREclo (2%). Regional hospitals reported higher rates of resistance than general hospitals. Most isolates were resistant to aztreonam and ceftazidime/avibactam, whereas they were highly susceptible to aminoglycosides. Most carbapenemases were NDM (47.33%), OXA-48 (43.33%) and NDM plus OXA-48 (6.67%); five OXA-48 positive isolates carried mcr-1 genes. Currently, high-dose tigecycline is the only optimal regimen against CRE isolates. Further extensive research on antibiotic synergism or new antibiotics should be conducted.

Impact of Inappropriate Empirical Antibiotic on Outcomes in Community-acquired Third Generation Cephalosporin Resistant Enterobacterales Bacteremia.

BACKGROUND: Currently, third generation cephalosporin resistant Enterobacterales (3GCRE) are becoming more common in community-acquired infection, leading to increasing consumption of carbapenems. Because community-acquired 3GCRE infections are generally less severe and of lower pathogenicity, the impact of inappropriate empirical antibiotics among patients with community-acquired 3GCRE bacteremia remains unknown. MATERIALS AND METHODS: This prospective cohort study included adult patients with 3GCRE bacteremia from April 2018 to December 2021. Participants were followed for 30 days to measure the primary outcome of mortality. Propensity score analysis was performed to adjust for treatment selection bias. RESULTS: A total of 155 patients met the eligible criteria (42 participants in the appropriate antibiotics group, and 113 participants in the inappropriate antibiotics group). Eight participants in the inappropriate antibiotics group never received appropriate antibiotics, three of whom died before microbiological results were made available. The most common clinical syndromes were urinary tract infection (56.8%) and biliary tract infection (22.6%). The overall 30-day mortality rate was 12.9%, 14.3% in the appropriate empirical antibiotics group and 12.4% in the inappropriate empirical antibiotics group. After propensity score weighted adjustment, the 30-day mortality rate in the inappropriate group was non-inferior to the appropriate group (mean difference 1.9%; 95% confidence interval: -10.1 - 14.0). From the multivariate analysis, acute respiratory failure and primary bacteremia were associated with 30-day mortality. CONCLUSION: Among patients with community-acquired 3GCRE bacteremia, inappropriate empirical treatment given within 24 hours after the onset of bacteremia was non-inferior to appropriate antibiotics. In the setting of a high prevalence of 3GCRE carriage in community, adjustment to carbapenem might be tolerable among patients with community-acquired infections. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03765749.

The Synergistic Activity and Optimizing Doses of Tigecycline in Combination with Aminoglycosides against Clinical Carbapenem-Resistant Klebsiella pneumoniae Isolates.

Carbapenem-resistant Enterobacteriaceae (CRE), especially carbapenem-resistant Klebsiella pneumoniae (CRKP), are among the largest pathogenic threats to humans. The available antibiotic treatment options for combating CRKP are limited. Colistin-resistant Enterobacteriaceae (CoRE) have also been reported worldwide, including in Thailand. Therefore, this study aimed (1) to determine minimum inhibitory concentrations (MICs) and synergistic activities of antibiotics of CRKP, and (2) to determine the probability target of attainment (PTA) and cumulative fraction of response (CFR) using pharmacokinetic/pharmacodynamic (PK/PD) data. Clinical CRKP isolates were obtained from Phramongkutklao Hospital (June to November 2020). Broth microdilution and checkerboard techniques were used to determine the mono- and synergistic activities of antibiotics. Carbapenemase and mcr-1 genes were also identified by polymerase chain reaction (PCR). The optimal antibiotic regimens were evaluated using Monte Carlo simulations. Forty-nine CRKP isolates were collected, 40 of which were CoRKP strains. The MIC50 and MIC90 of tigecycline, amikacin, and gentamicin were 1 and 2 µg/mL, 4 and 16 µg/mL, and 0.25 and 4 µg/mL, respectively. None of any isolates expressed the mcr-1 gene, whereas blaOXA-48 (53.1%) and blaOXA-48 plus blaNDM (42.9%) were detected. Synergistic activity was observed in 8.2% of isolates for tigecycline combined with amikacin or gentamicin. Additive activity was observed in 75.5% of isolates for tigecycline-amikacin and 69.4% for tigecycline-gentamicin, and no antagonism was observed. High-dose antibiotic regimens achieved the PTA target. The general recommended dose of combination regimens began with 200 mg tigecycline and 25 mg/kg amikacin, or 7 mg/kg gentamicin, followed by 100 mg tigecycline every 12 h and 15 mg/kg amikacin or 5 mg/kg gentamicin every 24 h. In conclusion, tigecycline plus aminoglycosides might be a potential regimen against CRKP and CoRKP. The appropriate combination regimen based on MIC-based dose adjustment can improve optimal antibiotic dosing. Further research via clinical studies will be necessary to confirm these results.

The Potential Use of Ceftazidime-Avibactam Against Carbapenem Resistant Klebsiella pneumoniae Clinical Isolates Harboring Different Carbapenemase Types in a Thai University Hospital.

PURPOSE: MBL and OXA-48 genes in carbapenem-resistant Enterobacterales (CRE) have emerged as a major public health problem worldwide, including Thailand. Due to the lack of susceptibility data and dosing regimens of ceftazidime-avibactam (CZA) against CRE in Thailand, especially in colistin-resistant era, we aimed to demonstrate in vitro susceptibility data of CZA and optimal dose based on Monte Carlo simulation of CZA to expand the treatment options. PATIENTS AND METHODS: We collected 49 carbapenem-resistant Klebsiella pneumoniae (CRKP) clinical isolates from unique patients at Phramongkutklao Hospital (June-October 2020). CZA disk diffusion and E-test testing were performed to obtain minimum inhibitory concentration (MIC). Each drug regimen was simulated using the Monte Carlo technique to calculate the probability of target attainment (PTA) and the cumulative fraction of response (CFR). RESULTS: The most common genotypes of CRKP were blaOXA-48 (53.1%) and blaOXA-48 +blaNDM (42.8%). CZA showed 47.7% and 90.5% susceptible rate against all genotypes of carbapenemases and OXA-48 type CRKP isolates. The MIC50 and MIC90 of CZA against CRKP were 2 and >256 µg/mL. The categorical agreement (CA) between disk diffusion and E-test testing of CZA against CRKP was 95.4%. The CZA dosing regimens of 2.5 g infused 2-3 h every 8 h achieved ≥90% of the target of free ceftazidime plasma concentration over MIC (%fTime >MIC) ≥50% and 100% against isolates MICs of ≤8 and ≤8 µg/mL, respectively. The avibactam regimens also provided 100%fTime at 0.5 µg/mL. Based on CFR ≥90%, no CZA regimens were effective against all of the studied CRKP isolates except CRKP carrying OXA-48. CONCLUSION: CZA exhibited a fairly susceptible rate among the OXA-48-positive isolates in Thailand. The current suggested dose of CZA with prolonged infusion appears appropriate to achieve the pharmacokinetic/pharmacodynamic targets of ceftazidime and avibactam against CRKP carrying blaOXA-48 .

First-Line Antiretroviral Regimen Failure and Determinants in an Urban HIV Clinic at Phramongkutklao Hospital, Bangkok, Thailand: 20 Years Experience.

PURPOSE: HIV treatment involves antiretroviral therapy (ART) endeavoring to suppress viral load to an undetectable level. Virologic failure occurs when ART fails to suppress and sustain an individual's viral load to less than 200 copies/mL after 6 months of therapy. In Thailand, the data among first-line antiretroviral regimen failure and determinants remains limited, especially in urban HIV clinics. We aimed to demonstrate factors of first-line antiretroviral regimen failures in an urban HIV/AIDS clinic at Phramongkutklao Hospital. PATIENTS AND METHODS: A nested case control 1:4 study was conducted. Data were collected from the electronic patient database among naïve people living with HIV/AIDS (PLWHA), aged ≥18 years and receiving ART continuously for at least 2 years at Phramongkutklao Hospital from 1 January 2000 to 31 December 2019. Multiple logistic regression was used to identify the determinants of virologic failure. Adjusted HRs (AHRs) with 95% CIs were used to declare statistical significance. RESULTS: Of 200 PLWHA included in the study, 40 participants experienced HIV virologic failure. The median time after starting ART to virologic failure was 24 months (IQR 7-96.0). Univariate and multivariate analysis showed significant factors affecting first-line antiretroviral regimen failure included being female (37.5 vs 26.88%, adjusted odds ratio 5.08 [1.05-24.6, p-value 0.043], age ≤40 yr. (62.5 vs 49.6%, adjusted odds ratio 4.59 [1.47-14.37], p-value 0.009), CD4+count ≤200 cell/µL (77.5 vs 52.5%, adjusted odds ratio 4.83 [1.28-18.9], p value 0.02), tuberculosis (42.5 vs 7.5%, adjusted odds ratio 8.66 [2.37-31.56], p value <0.001) and initiation of ART at CD4+ count <350 cell/µL (72.5 vs 48.13%, adjusted odds ratio 31.36 [6.51-151.22], p value <0.001). Estimated prevalence of virologic failure in Phramongkutklao Hospital was 5.34%. CONCLUSION: Our study revealed factors favoring virologic failure included being female, younger age, CD4+ count <200 cells/µL, tuberculosis and initiation of ART at CD4+ count <350 cell/µL. Multidisciplinary HIV comprehensive care teams should encourage patient adherence and support patients along HIV continuum of care to prevent virologic failure and drug resistance, especially among patients initiating ART at low CD4+ count and tuberculosis co-infection.

Fatal Cervical Spinal Epidural Abscess and Spondylodiscitis Complicated With Rhombencephalitis Caused by Klebsiella pneumoniae: A Case Report and Literature Review.

Spinal epidural abscess (SEA) is a rare but sometimes life-threatening condition. The principal organisms in SEA and spondylodiscitis are gram-positive bacteria, e.g., Staphylococcus aureus and Streptococci. Spontaneous gram-negative SEA and spondylodiscitis especially Klebsiella pneumoniae are very rare. We report a 71-year-old Thai male with diabetes, presenting fever, enlarged neck mass, and progressive painful swallowing a week before admission. MRI of the whole spine demonstrated epidural abscess along the anterior thecal sac from C2 to C7 levels with spinal meningitis; multiple rim-enhancing lesions at the left sternocleidomastoid/levator scapulae, splenius capitis, semispinalis capitis, and bilateral scalene muscles; and rhombencephalitis with brain abscess. Klebsiella pneumoniae was isolated from blood culture. CT of the whole abdomen showed unremarkable intra-abdominal lesion. Intravenous ceftriaxone was administered, but the patient was unable to undergo surgical drainage due to unstable condition and died after two weeks of admission. Spontaneous SEA and spondylodiscitis caused by K. pneumoniae are very rare but sometimes fatal. In the case of SEA and spondylodiscitis, even when K. pneumoniae is uncommon, it should be also considered as a pathogen, especially when the patient had important risk factors.

Low serum potassium among patients with COVID-19 in Bangkok, Thailand: Coincidence or clinically relevant?

Our cross-sectional study estimated the prevalence and clinical relevance of hypokalaemia among confirmed COVID-19 cases admitted in three hospitals in Bangkok during the early outbreak in Thailand. Of 36 patients, nine were in the hypokalaemia group (25%) and 27 in the normokalaemia group (75%). All cases were asymptomatic, and 94.4% had mild hypokalaemia. Hypokalaemia was found significantly earlier in the course of COVID-19 without evidence of significant extrarenal potassium loss. Body temperature and mean serum sodium in the hypokalaemia group tended to be higher than the normokalaemia group. Hypokalaemia and potentially higher serum sodium among COVID-19 patients were the remarkable findings. This issue warrants for further investigation.

Case Report: Dengue and COVID-19 Coinfection in Thailand.

We report a 50-year-old Thai woman with recent travel to Denmark who presented with acute high-grade fever, vomiting, and myalgia for 1 day. Initial laboratory results revealed leukopenia, elevated aspartate transaminase, and elevated alanine transaminase. Chest radiograph showed no pulmonary infiltration. Reverse transcriptase-PCR (RT-PCR) of the nasopharyngeal swab detected SARS-CoV-2, and RT-PCR of the blood detected dengue virus serotype 2. COVID-19 with dengue fever co-infection was diagnosed. Her symptoms were improved with supportive treatment. Integration of clinical manifestations, history of exposure, laboratory profiles, and dynamic of disease progression assisted the physicians in precise diagnosis. Co-circulating and nonspecific presentations of dengue infection and COVID-19 challenge the healthcare system in tropical countries. To solve this threat, multi-sector strategies are required, including public health policy, development of accurate point-of-care testing, and proper prevention for both diseases.

Is Echocardiography Mandatory for All Streptococcus gallolyticus Subsp. pasteurianus Bacteremia?

BACKGROUND: Streptococcus gallolyticus, formerly known as one of the Streptococcus bovis group, is frequently associated with endocarditis. Current guidelines recommended diagnostic work-up for endocarditis among patients with S. gallolyticus bacteremia. However, S. gallolyticus subsp. pasteurianus, was found to be associated with neonatal sepsis and liver diseases and is less commonly associated with endocarditis compared with S. gallolyticus subsp. gallolyticus. Our study aimed to identify the risk factors for S. gallolyticus subsp. pasteurianus endocarditis to help select the patients for echocardiography. METHODS: In this retrospective cohort study, medical records from all adult patients with S. gallolyticus subsp. pasteurianus isolated from blood cultures at Phramongkutklao Hospital from 2009 to 2015 were reviewed. Patients who had mixed bacteremia or missing records were excluded from the study. RESULTS: During the study period, S. gallolyticus subsp. pasteurianus was isolated among 106 individuals. Mean age was 66.9±15.6 years. Most patients (61.3%) were male, with cirrhosis as the most common underlying diseases (46.2%), followed by malignancy and chronic kidney disease. Most common manifestations included primary bacteremia (44.3%), followed by spontaneous bacterial peritonitis (23.6%). Infective endocarditis was found among 9 patients. No patients with cirrhosis or single blood specimen of bacteremia had endocarditis (RR 0; p-value 0.003, and RR 1.35; p-value 0.079). The common complications associated with endocarditis were acute respiratory failure (RR 4.32; p-value 0.05), whereas acute kidney injury was a protective factor (RR 0; p-value 0.01). Among 76 patients who had records of 2-year follow-up, no new diagnosis of endocarditis or malignancy was observed. CONCLUSION: Among patients with S. gallolyticus subsp. pasteurianus bacteremia, echocardiography might not be needed among patients with cirrhosis and without sustained bacteremia.