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Factors Predicting and Reducing Mortality in Patients with Invasive Staphylococcus aureus Disease in a Developing Country
Emma K. Nickerson, Vanaporn Wuthiekanun, Gumphol Wongsuvan, Direk Limmathurosakul, Pramot Srisamang, Weera Mahavanakul, Janjira Thaipadungpanit, Krupal R. Shah, Arkhom Arayawichanont, Premjit Amornchai, Aunchalee Thanwisai, Nicholas P. Day, Sharon J. Peacock
PLOS ONE , 2009, DOI: 10.1371/journal.pone.0006512
Abstract: Background Invasive Staphylococcus aureus infection is increasingly recognised as an important cause of serious sepsis across the developing world, with mortality rates higher than those in the developed world. The factors determining mortality in developing countries have not been identified. Methods A prospective, observational study of invasive S. aureus disease was conducted at a provincial hospital in northeast Thailand over a 1-year period. All-cause and S. aureus-attributable mortality rates were determined, and the relationship was assessed between death and patient characteristics, clinical presentations, antibiotic therapy and resistance, drainage of pus and carriage of genes encoding Panton-Valentine Leukocidin (PVL). Principal Findings A total of 270 patients with invasive S. aureus infection were recruited. The range of clinical manifestations was broad and comparable to that described in developed countries. All-cause and S. aureus-attributable mortality rates were 26% and 20%, respectively. Early antibiotic therapy and drainage of pus were associated with a survival advantage (both p<0.001) on univariate analysis. Patients infected by a PVL gene-positive isolate (122/248 tested, 49%) had a strong survival advantage compared with patients infected by a PVL gene-negative isolate (all-cause mortality 11% versus 39% respectively, p<0.001). Multiple logistic regression analysis using all variables significant on univariate analysis revealed that age, underlying cardiac disease and respiratory infection were risk factors for all-cause and S. aureus-attributable mortality, while one or more abscesses as the presenting clinical feature and procedures for infectious source control were associated with survival. Conclusions Drainage of pus and timely antibiotic therapy are key to the successful management of S. aureus infection in the developing world. Defining the presence of genes encoding PVL provides no practical bedside information and draws attention away from identifying verified clinical risk factors and those interventions that save lives.
Strategy for Development of Hospital Budget Planning Based on the Philosophy of Sufficiency Economy: Case of Tha-Wung Hospital
Anuwat Wichaingoen,Direk Rerkrai,Sompong Thongchai
Canadian Social Science , 2011, DOI: 10.3968/j.css.1923669720110706.193
Abstract: The study on strategy for development of hospital budget planning model based on the philosophy of sufficiency economy: case of Tha-Wung Hospital was experimental research as Quasi Experiment: Set Experiment, Set Treatment and Natural Control by comparison between this year used with set treatment and last year with natural control. The mixed method was used both quantitative research and qualitative research. The aim of this study was development of appropriate budget planning model for using as guideline for budget administration for work unit with the following objectives. 1. To construct concept in accordance with philosophy of sufficiency economy for officials and involved official for budget planning implementation, 2. To use the model of Prof. Chalio Buripakdi combined theories and principles involved based on philosophy of sufficiency economy of His Majesty the King for budget planning, 3. To use for budget planning to increase income and decrease expense of work unit. There were 208 peoples who participated in implementation. Descriptive statistics used were percentage, mean, and standard deviation. Inferential statistics was Z-Test and Chi-Square. Qualitative research was used for description according to real situation. Results of three of trimesters were revealed that 1. Building of body of knowledge on philosophy of sufficiency economy was able to enable officials and involved network to gain more knowledge with the post- experiment at moderate level with 3.31 (moderate level between 2.50-3.49) higher than pre-experiment at less level with 2.33 (less level between 1.5-2.49). Income increases in accordance with philosophy of sufficiency economy, total income increased with 12,489,814.21 Baht or 22.62 percents (total income of budget of B.E. 2553 was 55,207,965.21 Baht and total income of budget of B.E. 2554 was 67,697,779.42 Baht). Total expense was decreased with 10,628,149.17 Baht or 15.18 percents (total expense of budget of B.E. 2553 was 70,021,134.06 Baht and total expense of budget of B.E. 2554 was 59,392,984.89 Baht). These caused money liquidity increased as followings. 1. Quick Ratio increased from 1.55 of B.E. 2553 to be 1.96 or 26.45 percents increasing 2. Current Ratio increased from 1.65 of B.E. 2553 to be 2.15 or 30.30 percents increasing. It also found that knowledge level of officials and involved network correlated to level of knowledge of principle of budget planning after knowledge received with μ = 2.02 and σ = 0.254 and knowledge level correlated to income increased and expense decreased with statistically significant a
Removal of a Broken Cannulated Femoral Nail: A Novel Retrograde Impaction Technique
Kongkhet Riansuwan,Direk Tantigate,Banchong Mahaisavariya
Case Reports in Orthopedics , 2013, DOI: 10.1155/2013/601982
Abstract: This report presents a surgical technique to remove a broken cannulated nail from the femur. A Harrington rod was modified for retrograde impaction of the retained fragment. The broken implant was finally removed without complication. This particular procedure was safe, simple, and promising. 1. Introduction Removal of a broken femoral nail especially a retained distal fragment is a challenging procedure in orthopaedic surgery. Generally, pulling of the broken distal fragment is determined as a primary procedure for removal; however, slippage of the extraction device remains a major course of failure. Retrograde impaction is another promising method to overcome such problem. In this particular situation, an appropriate impactor is a key factor of success. Normally, another intramedullary nail or an extraction rod can be applied for such instance [1]. However, the diameter of an impactor should be a major concerning factor regarding knee injury. We, therefore, propose an idea applying a round-end Harrington rod which is smaller than ordinary nail as an impactor for retrograde impaction of the broken cannulated femoral nail. 2. A Case Report and Operative Technique A 35-year-old Thai man underwent closed femoral nailing as a treatment of right femoral shaft fracture. The implant was 11 × 38?mm AO interlocking nail for the femur. Six months later, he sustained another road traffic accident and presented with deformity and pain at the right thigh. The radiographs revealed distal 1/3 femoral shaft fracture with displacement and retained broken femoral nail (Figures 1(a) and 1(b)). Therefore, implant removal and nail exchange by closed technique were determined as a definite treatment. Figure 1: The radiographs show displaced fracture at distal 1/3 of the right femur with a retained broken AO femoral nail in (a) AP and (b) lateral view. The patient was placed supine on a fracture operating table with pulling the affected leg on a skeletal traction at the proximal tibia (Figure 2). The proximal part of the nail was removed routinely by using the specific removal equipment. In order to protect the surrounding soft tissue regarding biology of fracture healing, the distal part of the broken nail was determined to be removed by closed technique. The fracture was reduced using the F-shaped reduction clamp (Figure 3(a)). A nail-driving guide wire was inserted into the medullary canal of the femur and passed across the fracture site into the lumen of the distal portion of the broken nail in order to keep fracture alignment and tract of nail removal (Figure 3(b)).
Epidemiology, Microbiology and Mortality Associated with Community-Acquired Bacteremia in Northeast Thailand: A Multicenter Surveillance Study
Manas Kanoksil, Anchalee Jatapai, Sharon J. Peacock, Direk Limmathurotsakul
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0054714
Abstract: Background National statistics in developing countries are likely to underestimate deaths due to bacterial infections. Here, we calculated mortality associated with community-acquired bacteremia (CAB) in a developing country using routinely available databases. Methods/Principal Findings Information was obtained from the microbiology and hospital database of 10 provincial hospitals in northeast Thailand, and compared with the national death registry from the Ministry of Interior, Thailand for the period between 2004 and 2010. CAB was defined in patients who had pathogenic organisms isolated from blood taken within 2 days of hospital admission without a prior inpatient episode in the preceding 30 days. A total of 15,251 CAB patients identified, of which 5,722 (37.5%) died within 30 days of admission. The incidence rate of CAB between 2004 and 2010 increased from 16.7 to 38.1 per 100,000 people per year, and the mortality rate associated with CAB increased from 6.9 to 13.7 per 100,000 people per year. In 2010, the mortality rate associated with CAB was lower than that from respiratory tract infection, but higher than HIV disease or tuberculosis. The most common causes of CAB were Escherichia coli (23.1%), Burkholderia pseudomallei (19.3%), and Staphylococcus aureus (8.2%). There was an increase in the proportion of Extended-Spectrum Beta-Lactamases (ESBL) producing E. coli and Klebsiella pneumoniae over time. Conclusions This study has demonstrated that national statistics on causes of death in developing countries could be improved by integrating information from readily available databases. CAB is neglected as an important cause of death, and specific prevention and intervention is urgently required to reduce its incidence and mortality.
Burkholderia pseudomallei Is Genetically Diverse in Agricultural Land in Northeast Thailand
Vanaporn Wuthiekanun,Direk Limmathurotsakul,Narisara Chantratita,Edward J. Feil,Nicholas P. J. Day,Sharon J. Peacock
PLOS Neglected Tropical Diseases , 2009, DOI: 10.1371/journal.pntd.0000496
Abstract: Background The soil-dwelling Gram-negative bacterium Burkholderia pseudomallei is the cause of melioidosis. Extreme structuring of genotype and genotypic frequency has been demonstrated for B. pseudomallei in uncultivated land, but its distribution and genetic diversity in agricultural land where most human infections are probably acquired is not well defined. Methods Fixed-interval soil sampling was performed in a rice paddy in northeast Thailand in which 100 grams of soil was sampled at a depth of 30 cm from 10×10 sampling points each measuring 2.5 m by 2.5 m. Soil was cultured for the presence of B. pseudomallei and genotyping of colonies present on primary culture plates was performed using a combination of pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Principal Findings B. pseudomallei was cultured from 28/100 samples. Genotyping of 630 primary colonies drawn from 11 sampling points demonstrated 10 PFGE banding pattern types, which on MLST were resolved into 7 sequence types (ST). Overlap of genotypes was observed more often between sampling points that were closely positioned. Two sampling points contained mixed B. pseudomallei genotypes, each with a numerically dominant genotype and one or more additional genotypes present as minority populations. Conclusions Genetic diversity and structuring of B. pseudomallei exists despite the effects of flooding and the physical and chemical processes associated with farming. These findings form an important baseline for future studies of environmental B. pseudomallei.
Strategies to Reduce Mortality from Bacterial Sepsis in Adults in Developing Countries
Allen C Cheng,T. Eoin West,Direk Limmathurotsakul,Sharon J Peacock
PLOS Medicine , 2008, DOI: 10.1371/journal.pmed.0050175
Effect of colony morphology variation of Burkholderia pseudomallei on intracellular survival and resistance to antimicrobial environments in human macrophages in vitro
Sarunporn Tandhavanant, Aunchalee Thanwisai, Direk Limmathurotsakul, Sunee Korbsrisate, Nicholas PJ Day, Sharon J Peacock, Narisara Chantratita
BMC Microbiology , 2010, DOI: 10.1186/1471-2180-10-303
Abstract: Morphotype was associated with survival in the presence of H2O2 and antimicrobial peptide LL-37, but not with susceptibility to acid, acidified sodium nitrite, or resistance to lysozyme, lactoferrin, human neutrophil peptide-1 or human beta defensin-2. Incubation under anaerobic conditions was a strong driver for switching of type III to an alternative morphotype. Differences were noted in the survival and replication of the three types following uptake by human macrophages, but marked strain-to strain-variability was observed. Uptake of type III alone was associated with colony morphology switching.Morphotype is associated with phenotypes that alter the ability of B. pseudomallei to survive in adverse environmental conditions.Burkholderia pseudomallei is an environmental Gram-negative bacterium that causes a severe and often fatal disease called melioidosis. This is an important cause of sepsis in south-east Asia and northern Australia, a geographic distribution that mirrors the presence of B. pseudomallei in the environment [1]. Melioidosis may develop following bacterial inoculation or inhalation and occurs most often in people with regular contact with contaminated soil and water [1]. Clinical manifestations of melioidosis are highly variable and range from fulminant septicemia to mild localized infection. The overall mortality rate is 40% in northeast Thailand (rising to 90% in patients with severe sepsis) and 20% in northern Australia [1,2].A major feature of melioidosis is that bacterial eradication is difficult to achieve. Fever clearance time is often prolonged (median 8 days), antimicrobial therapy is required for 12-20 weeks, and relapse occurs in around 10% of patients despite an appropriate course of antimicrobial therapy [3,4]. The basis for persistence in the infected human host is unknown, although several observations made to date may be relevant to the clinical behaviour of this organism [2,5]. B. pseudomallei can resist the action of bactericidal
Burkholderia pseudomallei Is Spatially Distributed in Soil in Northeast Thailand
Direk Limmathurotsakul ,Vanaporn Wuthiekanun,Narisara Chantratita,Gumphol Wongsuvan,Premjit Amornchai,Nicholas P. J. Day,Sharon J. Peacock
PLOS Neglected Tropical Diseases , 2010, DOI: 10.1371/journal.pntd.0000694
Abstract: Background Melioidosis is a frequently fatal infectious disease caused by the soil dwelling Gram-negative bacterium Burkholderia pseudomallei. Environmental sampling is important to identify geographical distribution of the organism and related risk of infection to humans and livestock. The aim of this study was to evaluate spatial distribution of B. pseudomallei in soil and consider the implications of this for soil sampling strategies. Methods and Findings A fixed-interval sampling strategy was used as the basis for detection and quantitation by culture of B. pseudomallei in soil in two environmental sites (disused land covered with low-lying scrub and rice field) in northeast Thailand. Semivariogram and indicator semivariogram were used to evaluate the distribution of B. pseudomallei and its relationship with range between sampling points. B. pseudomallei was present on culture of 80/100 sampling points taken from the disused land and 28/100 sampling points from the rice field. The median B. pseudomallei cfu/gram from positive sampling points was 378 and 700 for the disused land and the rice field, respectively (p = 0.17). Spatial autocorrelation of B. pseudomallei was present, in that samples taken from areas adjacent to sampling points that were culture positive (negative) for B. pseudomallei were also likely to be culture positive (negative), and samples taken from areas adjacent to sampling points with a high (low) B. pseudomallei count were also likely to yield a high (low) count. Ranges of spatial autocorrelation in quantitative B. pseudomallei count were 11.4 meters in the disused land and 7.6 meters in the rice field. Conclusions We discuss the implications of the uneven distribution of B. pseudomallei in soil for future environmental studies, and describe a range of established geostatistical sampling approaches that would be suitable for the study of B. pseudomallei that take account of our findings.
Molecular detection and speciation of pathogenic Leptospira spp. in blood from patients with culture-negative leptospirosis
Siriphan Boonsilp, Janjira Thaipadungpanit, Premjit Amornchai, Vanaporn Wuthiekanun, Wirongrong Chierakul, Direk Limmathurotsakul, Nicholas P Day, Sharon J Peacock
BMC Infectious Diseases , 2011, DOI: 10.1186/1471-2334-11-338
Abstract: We evaluated our hypothesis during a prospective study of 418 consecutive patients presenting to a hospital in northeast Thailand with an acute febrile illness. Admission blood samples were taken for Leptospira culture and PCR. A single tube nested PCR that amplified a region of the rrs gene was developed and applied, amplicons sequenced and a phylogenetic tree reconstructed.39/418 (9%) patients were culture-positive for Leptospira spp., and 81/418 (19%) patients were culture-negative but rrs PCR-positive. The species associated with culture-positive leptospirosis (37 L. interrogans and 2 L. borgpetersenii) were comparable to those associated with culture-negative, PCR-positive leptospirosis (76 L. interrogans, 4 L. borgpetersenii, 1 unidentified, possibly new species).Molecular speciation failed to identify a unique bacterial subset in patients with culture-negative, PCR-positive leptospirosis. The rate of false-negative culture was high, and we speculate that antibiotic pre-treatment is the most likely explanation for this.Leptospirosis is an acute febrile illness caused by pathogenic species belonging to the genus Leptospira [1,2]. This zoonotic disease has a worldwide distribution but is most common in tropical and subtropical regions and has the greatest impact on public health in developing countries [1-4]. Disease is maintained by chronic carrier hosts that excrete the organism into the environment, and infection in man results from direct contact with infected animals or indirect contact with a contaminated environment [1-3].Leptospira are present in the blood during the first week of infective symptoms [1,2]. Culture is rarely performed in routine clinical practice since this may take several months and requires considerable expertise, which places it within the domain of specialist reference centres. Culture continues to have an important role, however, in defining the global epidemiology of infection [4]. Identification of the serovar of infecting isolate
Activities of Daily Living Associated with Acquisition of Melioidosis in Northeast Thailand: A Matched Case-Control Study
Direk Limmathurotsakul ,Manas Kanoksil,Vanaporn Wuthiekanun,Rungrueng Kitphati,Bianca deStavola,Nicholas P. J. Day,Sharon J. Peacock
PLOS Neglected Tropical Diseases , 2013, DOI: 10.1371/journal.pntd.0002072
Abstract: Background Melioidosis is a serious infectious disease caused by the Category B select agent and environmental saprophyte, Burkholderia pseudomallei. Most cases of naturally acquired infection are assumed to result from skin inoculation after exposure to soil or water. The aim of this study was to provide evidence for inoculation, inhalation and ingestion as routes of infection, and develop preventive guidelines based on this evidence. Methods/Principal Findings A prospective hospital-based 1:2 matched case-control study was conducted in Northeast Thailand. Cases were patients with culture-confirmed melioidosis, and controls were patients admitted with non-infectious conditions during the same period, matched for gender, age, and diabetes mellitus. Activities of daily living were recorded for the 30-day period before onset of symptoms, and home visits were performed to obtain drinking water and culture this for B. pseudomallei. Multivariable conditional logistic regression analysis based on 286 cases and 512 controls showed that activities associated with a risk of melioidosis included working in a rice field (conditional odds ratio [cOR] = 2.1; 95% confidence interval [CI] 1.4–3.3), other activities associated with exposure to soil or water (cOR = 1.4; 95%CI 0.8–2.6), an open wound (cOR = 2.0; 95%CI 1.2–3.3), eating food contaminated with soil or dust (cOR = 1.5; 95%CI 1.0–2.2), drinking untreated water (cOR = 1.7; 95%CI 1.1–2.6), outdoor exposure to rain (cOR = 2.1; 95%CI 1.4–3.2), water inhalation (cOR = 2.4; 95%CI 1.5–3.9), current smoking (cOR = 1.5; 95%CI 1.0–2.3) and steroid intake (cOR = 3.1; 95%CI 1.4–6.9). B. pseudomallei was detected in water source(s) consumed by 7% of cases and 3% of controls (cOR = 2.2; 95%CI 0.8–5.8). Conclusions/Significance We used these findings to develop the first evidence-based guidelines for the prevention of melioidosis. These are suitable for people in melioidosis-endemic areas, travelers and military personnel. Public health campaigns based on our recommendations are under development in Thailand.
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