Thana Khawcharoenporn

Colistin-based treatment for extensively drug-resistant Acinetobacter baumannii pneumonia☆

Data for treatment and outcomes of extensively drug-resistant Acinetobacter baumannii (XDR-AB) pneumonia are limited. A retrospective cohort study of 236 adult patients with XDR-AB pneumonia was conducted between January 2009 and December 2012. The median age of subjects was 70 years (range 17-95 years), 53% were male, 55% had ventilator-associated pneumonia and 42% had been admitted to the intensive care unit. All XDR-AB isolates were susceptible only to tigecycline and colistin; 52 (22%) of the 236 subjects did not receive an agent active against XDR-AB, with an associated 28-day survival of 0%. Colistin-based two-drug combination treatment was prescribed to 166 subjects (70%); regimens included (i) colistin and high-dose sulbactam (n=93); (ii) colistin and tigecycline (n=43); and (iii) colistin and high-dose prolonged infusion of a carbapenem (n=30). The 28-day survival rate and mean length of hospital stay were not statistically different between these three regimens (65%, 53% and 60% and 39, 39 and 38 days, respectively). Predictors of mortality included Acute Physiology and Chronic Health Evaluation (APACHE) II score [adjusted odds ratio (aOR)=1.11; P<0.001 for each point increase], duration from infection onset to receipt of active regimen (aOR=1.01; P=0.002 for each hour delay), underlying malignancy (aOR=3.46; P=0.01) and chronic kidney disease (aOR=2.85; P=0.03). These findings suggest that the three colistin-based two-drug combination regimens may be treatment options for XDR-AB pneumonia.

Effectiveness of infection prevention measures featuring advanced source control and environmental cleaning to limit transmission of extremely-drug resistant Acinetobacter baumannii in a Thai intensive care unit: An analysis before and after extensive flooding

BACKGROUND Advanced source control (once-daily bathing and 4-times daily oral care with chlorhexidine aqueous solution) and thorough environmental cleaning were implemented in response to an increased incidence of colonization and infection with extremely drug-resistant (XDR) Acinetobacter baumannii in a Thai medical intensive care unit (MICU). METHODS During the 12-month baseline period (P1), contact isolation, active surveillance for XDR A baumannii, cohorting of XDR A baumannii patients, twice-daily environmental cleaning with detergent-disinfectant, and antibiotic stewardship were implemented. In the 5.5-month intervention period (P2), additional measures were introduced. Sodium hypochlorite was substituted for detergent-disinfectant, and advanced source control was implemented. All interventions except cleaning with sodium hypochlorite were continued during the 12.5-month follow-up period (P3). Extensive flooding necessitating closure of the hospital for 2 months occurred between P2 and P3. RESULTS A total of 1,365 patients were studied. Compared with P1 (11.1 cases/1,000 patient-days), the rate of XDR A baumannii clinical isolates declined in P2 (1.74 cases/1,000 patient-days; P < .001) and further in P3 (0.69 cases/1,000 patient-days; P < .001). Compared with P1 (12.15 cases/1,000 patient-days), the rate of XDR A baumannii surveillance isolates also declined in P2 (2.11 cases/1,000 patient-days; P < .001) and P3 (0.98 cases/1,000 patient-days; P < .001). Incidence of nosocomial infections remained stable. Six patients developed chlorhexidine-induced rash (1.4/1,000 patient-days); 31 patients developed mucositis (17.1/1,000 patient-days). CONCLUSIONS These results support advanced source control and thorough environmental cleaning to limit colonization and infection with XDR A baumannii in MICUs in resource-limited settings.

Tuberculin skin test and QuantiFERON-TB Gold In-tube Test for latent tuberculosis in Thai HIV-infected adults

Limited data exist for the performance of QuantiFERON‐TB Gold In‐tube Test (QFT‐IT) in comparison to tuberculin skin test (TST) for detecting latent tuberculosis (LTB) in patients with human immunodeficiency virus (HIV) infection from tuberculosis (TB)‐endemic Asia‐Pacific countries.

HIV knowledge risk perception and pre-exposure prophylaxis interest among Thai university students.

To assess HIV risk perception and pre-exposure prophylaxis (PrEP) interest among university students, an anonymous survey was conducted among students from a large public university in Thailand. There were 641 participants; 118 (18%) were categorised into moderate or high-risk group. Of these 118 participants, 111 (94%) perceived themselves as no or low risk. Despite high levels of knowledge about HIV transmission risks, rates of consistent condom use with vaginal, oral and anal sex were all low (43%, 18% and 33%, respectively). The low rates of consistent condom use were significantly associated with false perception of low HIV risk (P < 0.05). Independent factors associated with the false perception were male gender (P < 0.001), living with a domestic partner (P = 0.004), being homosexual or bisexual (P = 0.02) and being students from a non-medicine faculty (P = 0.04). Of the 641 participants, 211 (33%) were not interested in PrEP. Consistent condom use with oral sex (P = 0.004), consistent condom use with vaginal sex (P = 0.04) and being heterosexual (P = 0.02) were independently associated with no PrEP interest. Our study suggests the need for enhanced interventions to improve HIV risk perception and safe sex practices among the university students.

National survey of practices to prevent health care-associated infections in Thailand: The role of prevention bundles

HIGHLIGHTSSeveral recommended practices to prevent health care‐associated infections are used infrequently in hospitals across Thailand.Infrastructure and organizational factors, such as involvement in health care‐associated infection prevention collaboratives and leadership support for infection control, are associated with greater use of infection prevention practices.Bundling prevention practices and ensuring a high compliance level to bundled approaches may be effective strategies for targeting common health care‐associated infections in Thailand. Background: We evaluated the practices used in Thai hospitals to prevent catheter‐associated urinary tract infection (CAUTI), central line‐associated bloodstream infection (CLABSI), and ventilator‐associated pneumonia (VAP). Methods: From January 1, 2014‐November 30, 2014, we surveyed all Thai hospitals with an intensive care unit and at least 250 beds. The use of prevention practices for CAUTI, CLABSI, and VAP was assessed. High compliance (≥75%) with all components of the CLABSI and VAP prevention bundles were determined. CAUTI, CLABSI, and VAP infection rates before and after implementing infection control practices are reported. Multivariable regression was used to examine associations between infection prevention bundle compliance and infection rate changes. Results: Out of 245 eligible hospitals, 212 (86.5%) responded. A total of 120 (56.6%) and 115 hospitals (54.2%) reported ≥75% compliance for all components of the CLABSI and VAP prevention bundles, respectively, and 91 hospitals (42.9%) reported using ≥ 4 recommended CAUTI‐prevention practices. High compliance with all of the CLABSI and VAP bundle components was associated with significant infection rate reductions (CLABSI, 38.3%; P < .001; VAP, 32.0%; P < .001). Hospitals regularly using ≥ 4 CAUTI‐prevention practices did not have greater reductions in CAUTI (0.02%; P = .99). Conclusions: Compliance with practices to prevent hospital infections was suboptimal. Policies and interventions promoting bundled approaches may help reduce hospital infections for Thai hospitals.

Hepatitis B revaccination in HIV-infected vaccine non-responders: is double dosing always necessary?

Limited data exist on hepatitis B revaccination strategies for HIV-infected individuals who do not develop immunity after the first vaccination series. A retrospective cohort study was conducted to assess the immunogenicity of the second series of hepatitis B vaccine given in standard dosing (SD) and double dosing (DD) strategies among Thai HIV-infected adults during the period from January 2006 to December 2014. Of the 120 eligible patients, 68 (57%) were men, median age was 38 years old, 87 (73%) received SD and 33 (27%) received DD revaccination. The demographic and clinical characteristics of SD and DD groups were comparable. The overall vaccine response rate was significantly higher in DD group than SD group (97% vs. 70%; p = 0.001). Independent factors associated with no response to hepatitis B revaccination were receipt of SD vaccine (adjusted odds ratio [aOR] 16.04; p = 0.009), age ≥ 40 years (aOR 3.66; p = 0.009) and CD4 cell count at the time of revaccination less than 450 cells/µL (aOR 2.96; p = 0.04). These findings suggest that DD hepatitis B revaccination series should be given in HIV-infected patients who were at least 40 years old or had CD4 counts less than 450 cells/µL after no response to the first vaccination series.

Central nervous system infection due to Mycobacterium haemophilum in a patient with acquired immunodeficiency syndrome.

Summary Mycobacterium haemophilum is an environmental organism that rarely causes infections in humans. We report a patient with acquired immunodeficiency syndrome who had central nervous system infection due to M. haemophilum. The diagnosis required brain tissue procurement and molecular identification method while the treatment outcome was unfavourable.

Impact of Cohorting for Multidrug-Resistant Organisms with and without Real-Time Feedback

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Assessment of risk for pulmonary tuberculosis after non-reactive tuberculin skin testing among patients with HIV infection in a resource-limited setting.

A cross-sectional study of 350 patients with HIV-1 infection was conducted to identify risks for pulmonary Mycobacterium tuberculosis (TB) after non-reactive two-step tuberculin skin tests (TST). Among 219 patients (62.6%) with non-reactive TST, independent risks for active pulmonary TB were prior known TB exposure (adjusted odds ratio [aOR] = 16.00, 95% confidence interval [CI] = 2.00–26.36, P = 0.008), CD4 <100 cells/μL (aOR = 2.50, 95% CI = 1.30–6.50, P = 0.04) and less than secondary-school education (aOR = 2.60, 95% CI = 1.50–6.90, P = 0.02). Our findings suggest that further diagnostic work-up for pulmonary TB is warranted among patients with HIV infection, non-reactive TSTs and either prior known TB exposure, CD4 counts <100 cells/μL or limited formal education.

Cost and cost-effectiveness analysis of pre-exposure prophylaxis among men who have sex with men in two hospitals in Thailand

Abstract Introduction In 2014, the Government of Thailand recommended pre‐exposure prophylaxis (PrEP) as an additional HIV prevention programme within Thailands National Guidelines on HIV/AIDS Treatment Prevention. However, to date implementation and uptake of PrEP programmes have been limited, and evidence on the costs and the epidemiological and economic impact is not available. Methods We estimated the costs associated with PrEP provision among men having sex with men (MSM) participating in a facility‐based, prospective observational cohort study: the Test, Treat and Prevent HIV Programme in Thailand. We created a suite of scenarios to estimate the cost‐effectiveness of PrEP and sensitivity of the results to the model input parameters, including PrEP programme effectiveness, PrEP uptake among high‐risk and low‐risk MSM, baseline and future antiretroviral therapy (ART) coverage, condom use, unit cost of delivering PrEP, and the discount rate. Results Drug costs accounted for 82.5% of the total cost of providing PrEP, followed by lab testing (8.2%) and personnel costs (7.8%). The estimated costs of providing the PrEP package in accordance with the national recommendation ranges from US