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Koyama H, Chierakul W, Charunwatthana P, Sanguanwongse N, Phonrat B, Silachamroon U, Dondorp AM. Lung Ultrasound Findings of Patients with Dengue Infection: A Prospective Observational Study. Am J Trop Med Hyg 2021; 105:766-770. [PMID: 34280132 DOI: 10.4269/ajtmh.20-1274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 05/27/2021] [Indexed: 11/07/2022] Open
Abstract
Lung ultrasound (LUS) is performed for several conditions and is a more sensitive method of detecting pathological pulmonary changes than chest X-ray. Therefore, LUS for individuals with dengue could be an important tool for the early detection of pleural effusions and pulmonary edema signifying capillary plasma leakage, which is the hallmark of severe dengue pathophysiology. We conducted a prospective observational study of pulmonary changes identifiable with LUS in dengue patients admitted to the Hospital for Tropical Diseases in Mahidol University, Bangkok, and the Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand. The LUS findings were described according to standard criteria, including the presence of A, B1, B2, and C patterns in eight chest regions and the presence of pleural effusions. From November 2017 to April 2018, 50 patients with dengue were included in the study. LUS was performed during the Shonna febrile phase for nine patients (18%) and during the critical-convalescence phase for 41 patients (82%). A total of 33 patients (66%) had at least one abnormality discovered using LUS. Abnormal LUS findings were observed more frequently during the critical-convalescence phase (N = 30/41; 73%) than during the febrile phase (N = 3/9; 33%) (P = 0.047). Abnormal aeration patterns were observed in 31 patients (62%). Only B patterns with only multiple B lines were observed in 21 patients (42%); of these patients, three had already exhibited these during the febrile phase (N = 3). C patterns (N = 10; 24%), pleural effusion (N = 10; 24%), and subpleural abnormalities (N = 11; 27%) were observed only during the critical-convalescence phase. LUS can detect signs of capillary leakage, including interstitial edema and pleural effusions, early during the course of dengue.
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Affiliation(s)
- Hiroshi Koyama
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan.,Department of Critical Care Medicine, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Wirongrong Chierakul
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakaykaew Charunwatthana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Natpatou Sanguanwongse
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand
| | - Benjaluck Phonrat
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Udomsak Silachamroon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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2
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Anunnatsiri S, Chaowagul W, Teparrukkul P, Chetchotisakd P, Tanwisaid K, Khemla S, Narenpitak S, Pattarapongsin M, Kongsawasd W, Pisuttimarn P, Thipmontree W, Mootsikapun P, Chaisuksant S, Chierakul W, Day NPJ, Limmathurotsakul D. A Comparison Between 12 Versus 20 Weeks of Trimethoprim-Sulfamethoxazole as Oral Eradication Treatment for Melioidosis (12vs20): An Open-label, Pragmatic, Multicenter, Non-inferiority, Randomized Controlled Trial. Clin Infect Dis 2020; 73:e3627-e3633. [PMID: 32725199 PMCID: PMC8662794 DOI: 10.1093/cid/ciaa1084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/27/2020] [Indexed: 11/27/2022] Open
Abstract
Background Treatment of melioidosis comprises intravenous drugs for at least 10 days, followed by oral trimethoprim-sulfamethoxazole (TMP-SMX) for 12 to 20 weeks. Oral TMP-SMX is recommended for 12 weeks in Australia and 20 weeks in Thailand. Methods For this open-label, pragmatic, multicenter, noninferiority, randomized controlled trial, we enrolled patients with culture-confirmed melioidosis who had received oral eradication treatment for 12 weeks and had no clinical evidence of active melioidosis. We randomly assigned patients to stop treatment (12-week regimen) or continue treatment for another 8 weeks (20-week regimen). The primary end point was culture-confirmed recurrent melioidosis within 1 year after enrollment. The noninferiority margin was a hazard ratio (HR) of 2.0. The secondary composite end point, combining overall recurrent melioidosis and mortality, was assessed post hoc. Results We enrolled 658 patients: 322 to the 12-week regimen and 336 to the 20-week regimen. There were 5 patients (2%) in the 12-week regimen and 2 patients (1%) in the 20-week regimen who developed culture-confirmed recurrent melioidosis (HR, 2.66; 95% confidence interval [CI], .52–13.69). The criterion for noninferiority of the primary event was not met (1-sided P = .37). However, all-cause mortality was significantly lower in the 12-week regimen group than in the 20-week regimen group (1 [.3%] vs 11 [3%], respectively; HR, 0.10; 95% CI, .01–.74). The criterion for noninferiority of the secondary composite end point, combining overall recurrent melioidosis and mortality, was met (1-sided P = .022). Conclusions Based on the lower total mortality and noninferiority of the secondary composite end point observed, we recommend the 12-week regimen of TMP-SMX for oral eradication treatment of melioidosis. Clinical Trials Registration NCT01420341.
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Affiliation(s)
- Siriluck Anunnatsiri
- Faculty of Medicine, Khon Kaen University.,Melioidosis Research Centre, Khon Kaen University
| | | | | | - Ploenchan Chetchotisakd
- Faculty of Medicine, Khon Kaen University.,Melioidosis Research Centre, Khon Kaen University
| | | | | | | | | | | | | | | | | | | | | | - Nicholas P J Day
- Centre for Tropical Medicine, and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Direk Limmathurotsakul
- Faculty of Tropical Medicine, Mahidol University, Thailand.,Centre for Tropical Medicine, and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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3
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Beardsley J, Hoang NLT, Kibengo FM, Tung NLN, Binh TQ, Hung LQ, Chierakul W, Thwaites GE, Chau NVV, Nguyen TTT, Geskus RB, Day JN. Do Intracerebral Cytokine Responses Explain the Harmful Effects of Dexamethasone in Human Immunodeficiency Virus-associated Cryptococcal Meningitis? Clin Infect Dis 2020; 68:1494-1501. [PMID: 30169607 PMCID: PMC6481995 DOI: 10.1093/cid/ciy725] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022] Open
Abstract
Background The CryptoDex trial showed that dexamethasone caused poorer clinical outcomes and slowed fungal clearance in human immunodeficiency virus–associated cryptococcal meningitis. We analyzed cerebrospinal fluid (CSF) cytokine concentrations from participants over the first week of treatment to investigate mechanisms of harm and test 2 hypotheses: (1) dexamethasone reduced proinflammatory cytokine concentrations, leading to poorer outcomes and (2) leukotriene A4 hydrolase (LTA4H) genotype influenced the clinical impact of dexamethasone, as observed in tuberculous meningitis. Methods We included participants from Vietnam, Thailand, and Uganda. Using the Luminex system, we measured CSF concentrations of the following: interferon γ, tumor necrosis factor (TNF) α, granulocyte-macrophage colony-stimulating factor, monocyte chemoattractant 1, macrophage inflammatory protein 1α, and interleukin 6, 12p70, 8, 4, 10, and 17. We determined the LTA4H genotype based on the promoter region single-nucleotide polymorphism rs17525495. We assessed the impact of dexamethasone on cytokine concentration dynamics and the association between cytokine concentration dynamics and fungal clearance with mixed effect models. We measured the influence of LTA4H genotype on outcomes with Cox regression models. Results Dexamethasone increased the rate TNF-α concentration’s decline in (−0.13 log2pg/mL/d (95% confidence interval, −.22 to −.06 log2pg/mL/d; P = .03), which was associated with slower fungal clearance (correlation, −0.62; 95% confidence interval, −.83 to −.26). LTA4H genotype had no statistically significant impact on outcome or response to dexamethasone therapy. Better clinical outcomes were associated with higher baseline concentrations of interferon γ. Conclusions Dexamethasone may slow fungal clearance and worsen outcomes by increasing TNF-α concentration’s rate of decline.
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Affiliation(s)
- Justin Beardsley
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom.,Marie Bashir Institute, University of Sydney, New South Wales, Australia
| | - Nhat L T Hoang
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Tran Q Binh
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Le Q Hung
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Wirongrong Chierakul
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | | | - Thuong T T Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
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Phanichkrivalkosil M, Tanganuchitcharnchai A, Jintaworn S, Kantipong P, Laongnualpanich A, Chierakul W, Paris DH, Richards AL, Wangrangsimakul T, Day NPJ, Blacksell SD. Determination of Optimal Diagnostic Cut-Offs for the Naval Medical Research Center Scrub Typhus IgM ELISA in Chiang Rai, Thailand. Am J Trop Med Hyg 2020; 100:1134-1140. [PMID: 30860022 PMCID: PMC6493932 DOI: 10.4269/ajtmh.18-0675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In this diagnostic accuracy study, we evaluated data from 135 febrile patients from Chiang Rai, to determine the optimal optical density (OD) cutoffs for an in-house scrub typhus IgM ELISA. Receiver operating characteristic curves were generated using a panel of reference assays, including an IgM immunofluorescence assay (IFA), PCR, in vitro isolation, presence of an eschar, or a combination of these. Altogether, 33 patients (24.4%) were diagnosed as having scrub typhus. Correlation between positivity by IFA and increasing OD values peaked at a cutoff of 2.0, whereas there was little association between positivity by culture or eschar with increasing ELISA cutoffs—cutoffs of 3.0 and 4.0 were demonstrated to be optimal for the total absorbance of the OD at dilutions 1:100, 1:400, 1:1,600, and 1:6,400, for admission and convalescent samples, respectively. The optimal cutoff at a 1:100 dilution was found to be between 1.85 and 2.22 for admission samples and convalescent-phase samples, respectively. Sensitivities for the cutoffs varied from 57.1% to 90.0% depending on the reference test and sample timing, whereas specificities ranged from 85.2% to 99.0%. We therefore recommend a cutoff of around 2.0, depending on the sensitivity and specificity desired in clinical or epidemiological settings. The results demonstrate the ELISA to be a valuable diagnostic tool, suitable for use in resource-limited endemic regions, especially when used in combination with other diagnostic modalities such as the presence of an eschar.
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Affiliation(s)
- Meghna Phanichkrivalkosil
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ampai Tanganuchitcharnchai
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Suthatip Jintaworn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Daniel H Paris
- Faculty of Medicine, University of Basel, Basel, Switzerland.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
| | - Allen L Richards
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Viral and Rickettsial Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Tri Wangrangsimakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stuart D Blacksell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Luvira V, Silachamroon U, Piyaphanee W, Lawpoolsri S, Chierakul W, Leaungwutiwong P, Thawornkuno C, Wattanagoon Y. Etiologies of Acute Undifferentiated Febrile Illness in Bangkok, Thailand. Am J Trop Med Hyg 2020; 100:622-629. [PMID: 30628565 DOI: 10.4269/ajtmh.18-0407] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Acute undifferentiated febrile illness (AUFI) has been a diagnostic dilemma in the tropics. Without accurate point-of-care tests, information on local pathogens and clinical parameters is essential for presumptive diagnosis. A prospective hospital-based study was conducted at the Bangkok Hospital for Tropical Diseases from 2013 to 2015 to determine common etiologies of AUFI. A total of 397 adult AUFI cases, excluding malaria by blood smear, were enrolled. Rapid diagnostic tests for tropical infections were performed on admission, and acute and convalescent samples were tested to confirm the diagnosis. Etiologies could be identified in 271 (68.3%) cases. Dengue was the most common cause, with 157 cases (39.6%), followed by murine typhus (20 cases; 5.0%), leptospirosis (16 cases; 4.0%), influenza (14 cases; 3.5%), and bacteremia (six cases; 1.5%). Concurrent infection by at least two pathogens was reported in 37 cases (9.3%). Furthermore, characteristics of dengue and bacterial infections (including leptospirosis and rickettsioses) were compared to facilitate dengue triage, initiate early antibiotic treatment, and minimize unnecessary use of antibiotics. In conclusion, dengue was the most common pathogen for AUFI in urban Thailand. However, murine typhus and leptospirosis were not uncommon. Empirical antibiotic treatment using doxycycline or azithromycin might be more appropriate, but cost-benefit studies are required. Physicians should recognize common causes of AUFI in their localities and use clinical and laboratory clues for provisional diagnosis to provide appropriate treatment while awaiting laboratory confirmation.
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Affiliation(s)
- Viravarn Luvira
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Udomsak Silachamroon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Watcharapong Piyaphanee
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Saranath Lawpoolsri
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Pornsawan Leaungwutiwong
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charin Thawornkuno
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Yupaporn Wattanagoon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Wright SW, Emond MJ, Lovelace-Macon L, Ducken D, Kashima J, Hantrakun V, Chierakul W, Teparrukkul P, Chantratita N, Limmathurotsakul D, West TE. Exonic sequencing identifies TLR1 genetic variation associated with mortality in Thais with melioidosis. Emerg Microbes Infect 2019; 8:282-290. [PMID: 30866782 PMCID: PMC6455179 DOI: 10.1080/22221751.2019.1575172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Melioidosis, an infectious disease caused by the bacterium Burkholderia pseudomallei, is a common cause of sepsis in Southeast Asia. We investigated whether novel TLR1 coding variants are associated with outcome in Thai patients with melioidosis. We performed exonic sequencing on a discovery set of patients with extreme phenotypes (mild vs. severe) of bacteremic melioidosis. We analysed the association of missense variants in TLR1 with severe melioidosis in a by-gene analysis. We then genotyped key variants and tested the association with death in two additional sets of melioidosis patients. Using a by-gene analysis, TLR1 was associated with severe bacteremic melioidosis (P = 0.016). One of the eight TLR1 variants identified, rs76600635, a common variant in East Asians, was associated with in-hospital mortality in a replication set of melioidosis patients (adjusted odds ratio 1.71, 95% CI 1.01–2.88, P = 0.04.) In a validation set of patients, the point estimate of effect of the association of rs76600635 with 28-day mortality was similar but not statistically significant (adjusted odds ratio 1.81, 95% CI 0.96–3.44, P = 0.07). Restricting the validation set analysis to patients recruited in a comparable fashion to the discovery and replication sets, rs76600635 was significantly associated with 28-day mortality (adjusted odds ratio 3.88, 95% CI 1.43–10.56, P = 0.01). Exonic sequencing identifies TLR1 as a gene associated with a severe phenotype of bacteremic melioidosis. The TLR1 variant rs76600635, common in East Asian populations, may be associated with poor outcomes from melioidosis. This variant has not been previously associated with outcomes in sepsis and requires further study.
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Affiliation(s)
- Shelton W Wright
- a Division of Pediatric Critical Care Medicine, Department of Pediatrics , University of Washington , Seattle , WA , USA
| | - Mary J Emond
- b Department of Biostatistics , University of Washington , Seattle , WA , USA
| | - Lara Lovelace-Macon
- c Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Washington , Seattle , WA , USA
| | - Deirdre Ducken
- c Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Washington , Seattle , WA , USA
| | - James Kashima
- c Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Washington , Seattle , WA , USA
| | - Viriya Hantrakun
- d Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Wirongrong Chierakul
- d Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,e Department of Clinical Tropical Medicine, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Prapit Teparrukkul
- f Department of Internal Medicine , Sunpasitthiprasong Hospital , Ubon Ratchathani , Thailand
| | - Narisara Chantratita
- d Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,g Department of Microbiology and Immunology, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - Direk Limmathurotsakul
- d Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand.,h Department of Tropical Hygiene, Faculty of Tropical Medicine , Mahidol University , Bangkok , Thailand
| | - T Eoin West
- c Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine , University of Washington , Seattle , WA , USA.,i International Respiratory and Severe Illness Center , University of Washington , Seattle , WA , USA
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Moek F, Poe P, Charunwatthana P, Pan-Ngum W, Wattanagoon Y, Chierakul W. The reliability of the clinical examination in predicting hemodynamic status in acute febrile illness in a tropical, resource-limited setting. Trans R Soc Trop Med Hyg 2019; 112:200-205. [PMID: 29788457 DOI: 10.1093/trstmh/try042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 04/22/2018] [Indexed: 11/14/2022] Open
Abstract
Introduction The clinical examination alone is widely considered unreliable when assessing fluid responsiveness in critically ill patients. Little evidence exists on the performance of the clinical examination to predict other hemodynamic derangements or more complex hemodynamic states. Materials and methods Patients with acute febrile illness were assessed on admission, both clinically and per non-invasive hemodynamic measurement. Correlations between clinical signs and hemodynamics patterns were analyzed, and the predictive capacity of the clinical signs was examined. Results Seventy-one patients were included; the most common diagnoses were bacterial sepsis, scrub typhus and dengue infection. Correlations between clinical signs and hemodynamic parameters were only statistically significant for Cardiac Index (r=0.75, p-value <0.01), Systemic Vascular Resistance Index (r=0.79, p-value <0.01) and flow time corrected (r=0.44, p-value 0.03). When assessing the predictive accuracy of clinical signs, the model identified only 62% of hemodynamic states correctly, even less if there was more than one hemodynamic abnormality. Discussion The clinical examination is not reliable to assess a patient's hemodynamic status in acute febrile illness. Fluid responsiveness, cardiodepression and more complex hemodynamic states are particularly easily missed.
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Affiliation(s)
- Felix Moek
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok
| | - Poe Poe
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok
| | | | - Wirichada Pan-Ngum
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Thailand
| | - Yupaporn Wattanagoon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok
| | - Wirongrong Chierakul
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok
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8
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Ashton PM, Thanh LT, Trieu PH, Van Anh D, Trinh NM, Beardsley J, Kibengo F, Chierakul W, Dance DAB, Rattanavong S, Davong V, Hung LQ, Chau NVV, Tung NLN, Chan AK, Thwaites GE, Lalloo DG, Anscombe C, Nhat LTH, Perfect J, Dougan G, Baker S, Harris S, Day JN. Three phylogenetic groups have driven the recent population expansion of Cryptococcus neoformans. Nat Commun 2019; 10:2035. [PMID: 31048698 PMCID: PMC6497710 DOI: 10.1038/s41467-019-10092-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/15/2019] [Indexed: 01/04/2023] Open
Abstract
Cryptococcus neoformans (C. neoformans var. grubii) is an environmentally acquired pathogen causing 181,000 HIV-associated deaths each year. We sequenced 699 isolates, primarily C. neoformans from HIV-infected patients, from 5 countries in Asia and Africa. The phylogeny of C. neoformans reveals a recent exponential population expansion, consistent with the increase in the number of susceptible hosts. In our study population, this expansion has been driven by three sub-clades of the C. neoformans VNIa lineage; VNIa-4, VNIa-5 and VNIa-93. These three sub-clades account for 91% of clinical isolates sequenced in our study. Combining the genome data with clinical information, we find that the VNIa-93 sub-clade, the most common sub-clade in Uganda and Malawi, was associated with better outcomes than VNIa-4 and VNIa-5, which predominate in Southeast Asia. This study lays the foundation for further work investigating the dominance of VNIa-4, VNIa-5 and VNIa-93 and the association between lineage and clinical phenotype.
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Affiliation(s)
- P M Ashton
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T Thanh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - P H Trieu
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - D Van Anh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - N M Trinh
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Beardsley
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Marie Bashir Institute, University of Sydney, Sydney, 2050, NSW, Australia
| | - F Kibengo
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - W Chierakul
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - D A B Dance
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - S Rattanavong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - V Davong
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos
| | - L Q Hung
- Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - N V V Chau
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - N L N Tung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - A K Chan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, M4N 3M5, ON, Canada
- Dignitas International, Zomba, Malawi
| | - G E Thwaites
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - D G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - C Anscombe
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
| | - L T H Nhat
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
| | - J Perfect
- Department of Medicine and Department of Molecular Genetics and Microbiology, Division of Infectious Diseases, Duke University, Durham, NC, 27710, USA
| | - G Dougan
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Baker
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK
- Wellcome Trust-Cambridge Centre for Global Health Research, Cambridge, CB2 0XY, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - S Harris
- Pathogen Genomics, The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, Cambridgeshire, UK
| | - J N Day
- Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam.
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX3 7FZ, UK.
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9
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Wangrangsimakul T, Althaus T, Mukaka M, Kantipong P, Wuthiekanun V, Chierakul W, Blacksell SD, Day NP, Laongnualpanich A, Paris DH. Causes of acute undifferentiated fever and the utility of biomarkers in Chiangrai, northern Thailand. PLoS Negl Trop Dis 2018; 12:e0006477. [PMID: 29852003 PMCID: PMC5978881 DOI: 10.1371/journal.pntd.0006477] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 04/24/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tropical infectious diseases like dengue, scrub typhus, murine typhus, leptospirosis, and enteric fever continue to contribute substantially to the febrile disease burden throughout Southeast Asia while malaria is declining. Recently, there has been increasing focus on biomarkers (i.e. C-reactive protein (CRP) and procalcitonin) in delineating bacterial from viral infections. METHODOLOGY/PRINCIPAL FINDINGS A prospective observational study was performed to investigate the causes of acute undifferentiated fever (AUF) in adults admitted to Chiangrai Prachanukroh hospital, northern Thailand, which included an evaluation of CRP and procalcitonin as diagnostic tools. In total, 200 patients with AUF were recruited. Scrub typhus was the leading bacterial cause of AUF (45/200, 22.5%) followed by leptospirosis (15/200, 7.5%) and murine typhus (7/200, 3.5%), while dengue was the leading viral cause (23/200, 11.5%). Bloodstream infections contributed to 7/200 (3.5%) of the study cohort. There were 9 deaths during this study (4.5%): 3 cases of scrub typhus, 2 with septicaemia (Talaromyces marneffei and Haemophilus influenzae), and 4 of unknown aetiologies. Rickettsioses, leptospirosis and culture-attributed bacterial infections, received a combination of 3rd generation cephalosporin plus a rickettsia-active drug in 53%, 73% and 67% of cases, respectively. Low CRP and white blood count were significant predictors of a viral infection (mainly dengue) while the presence of an eschar and elevated aspartate aminotransferase and alkaline phosphatase were important predictors of scrub typhus. INTERPRETATION Scrub typhus and dengue are the leading causes of AUF in Chiangrai, Thailand. Eschar, white blood count and CRP were beneficial in differentiating between bacterial and viral infections in this study. CRP outperformed procalcitonin although cut-offs for positivity require further assessment. The study provides evidence that accurate, pathogen-specific rapid diagnostic tests coupled with biomarker point-of-care tests such as CRP can inform the correct use of antibiotics and improve antimicrobial stewardship in this setting.
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Affiliation(s)
- Tri Wangrangsimakul
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Mavuto Mukaka
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Pacharee Kantipong
- Department of Medicine, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas P. Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Daniel H. Paris
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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10
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Hinjoy S, Hantrakun V, Kongyu S, Kaewrakmuk J, Wangrangsimakul T, Jitsuronk S, Saengchun W, Bhengsri S, Akarachotpong T, Thamthitiwat S, Sangwichian O, Anunnatsiri S, Sermswan RW, Lertmemongkolchai G, Sitthidet Tharinjaroen C, Preechasuth K, Udpaun R, Chuensombut P, Waranyasirikul N, Anudit C, Narenpitak S, Jutrakul Y, Teparrukkul P, Teerawattanasook N, Thanvisej K, Suphan A, Sukbut P, Ploddi K, Sirichotirat P, Chiewchanyon B, Rukseree K, Hongsuwan M, Wongsuwan G, Sunthornsut P, Wuthiekanun V, Sachaphimukh S, Wannapinij P, Chierakul W, Chewapreecha C, Thaipadungpanit J, Chantratita N, Korbsrisate S, Taunyok A, Dunachie S, Palittapongarnpim P, Sirisinha S, Kitphati R, Iamsirithaworn S, Chaowagul W, Chetchotisak P, Whistler T, Wongratanacheewin S, Limmathurotsakul D. Melioidosis in Thailand: Present and Future. Trop Med Infect Dis 2018; 3:38. [PMID: 29725623 PMCID: PMC5928800 DOI: 10.3390/tropicalmed3020038] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/21/2018] [Indexed: 12/29/2022] Open
Abstract
A recent modelling study estimated that there are 2800 deaths due to melioidosis in Thailand yearly. The Thailand Melioidosis Network (formed in 2012) has been working closely with the Ministry of Public Health (MoPH) to investigate and reduce the burden of this disease. Based on updated data, the incidence of melioidosis is still high in Northeast Thailand. More than 2000 culture-confirmed cases of melioidosis are diagnosed in general hospitals with microbiology laboratories in this region each year. The mortality rate is around 35%. Melioidosis is endemic throughout Thailand, but it is still not uncommon that microbiological facilities misidentify Burkholderia pseudomallei as a contaminant or another organism. Disease awareness is low, and people in rural areas neither wear boots nor boil water before drinking to protect themselves from acquiring B. pseudomallei. Previously, about 10 melioidosis deaths were formally reported to the National Notifiable Disease Surveillance System (Report 506) each year, thus limiting priority setting by the MoPH. In 2015, the formally reported number of melioidosis deaths rose to 112, solely because Sunpasithiprasong Hospital, Ubon Ratchathani province, reported its own data (n = 107). Melioidosis is truly an important cause of death in Thailand, and currently reported cases (Report 506) and cases diagnosed at research centers reflect the tip of the iceberg. Laboratory training and communication between clinicians and laboratory personnel are required to improve diagnosis and treatment of melioidosis countrywide. Implementation of rapid diagnostic tests, such as a lateral flow antigen detection assay, with high accuracy even in melioidosis-endemic countries such as Thailand, is critically needed. Reporting of all culture-confirmed melioidosis cases from every hospital with a microbiology laboratory, together with final outcome data, is mandated under the Communicable Diseases Act B.E.2558. By enforcing this legislation, the MoPH could raise the priority of this disease, and should consider implementing a campaign to raise awareness and melioidosis prevention countrywide.
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Affiliation(s)
- Soawapak Hinjoy
- Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Nonthaburi 11000, Thailand; (S.H.); (S.K.)
| | - Viriya Hantrakun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Somkid Kongyu
- Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Nonthaburi 11000, Thailand; (S.H.); (S.K.)
| | - Jedsada Kaewrakmuk
- Faculty of Science, Prince of Songkla University, Songkla 90110, Thailand;
| | - Tri Wangrangsimakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK;
| | - Siroj Jitsuronk
- Faculty of Medicine, Prince of Songkla University, Songkla, 90110, Thailand;
| | - Weerawut Saengchun
- Department of Clinical Pathology, Chiang Rai Prachanukroh Hospital, Chiang Rai 57000, Thailand;
| | - Saithip Bhengsri
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi 11000, Thailand; (S.B.); (T.A.); (S.T.); (O.S.); (T.W.)
| | - Thantapat Akarachotpong
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi 11000, Thailand; (S.B.); (T.A.); (S.T.); (O.S.); (T.W.)
| | - Somsak Thamthitiwat
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi 11000, Thailand; (S.B.); (T.A.); (S.T.); (O.S.); (T.W.)
| | - Ornuma Sangwichian
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi 11000, Thailand; (S.B.); (T.A.); (S.T.); (O.S.); (T.W.)
| | - Siriluck Anunnatsiri
- Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; (S.A.); (R.W.S.); (P.C.); (S.W.)
| | - Rasana W Sermswan
- Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; (S.A.); (R.W.S.); (P.C.); (S.W.)
| | - Ganjana Lertmemongkolchai
- The Centre for Research & Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen 40002, Thailand;
| | - Chayada Sitthidet Tharinjaroen
- Division of Clinical Microbiology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand; (C.S.T.); (K.P.); (R.U.)
| | - Kanya Preechasuth
- Division of Clinical Microbiology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand; (C.S.T.); (K.P.); (R.U.)
| | - Ratchadaporn Udpaun
- Division of Clinical Microbiology, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand; (C.S.T.); (K.P.); (R.U.)
| | - Poomin Chuensombut
- Department of Clinical Pathology, Chiangkham Hospital, Phayao, 56110 Thailand;
| | - Nisarat Waranyasirikul
- Department of Clinical Pathology, Somdejphrajaotaksin Maharaj Hospital, Tak 63000, Thailand;
| | - Chanihcha Anudit
- Department of Clinical Pathology, Uthai Thani Hospital, Uthai Thani 61000, Thailand;
| | - Surapong Narenpitak
- Department of Internal Medicine, Udon Thani Hospital, Udon Thani 41000, Thailand;
| | - Yaowaruk Jutrakul
- Department of Clinical Pathology, Udon Thani Hospital, Udon Thani 41000, Thailand;
| | - Prapit Teparrukkul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani 34000, Thailand; (P.T.); (W.C)
| | - Nittaya Teerawattanasook
- Department of Clinical Pathology, Sunpasitthiprasong Hospital, Ubon Ratchathani 34000, Thailand;
| | - Kittisak Thanvisej
- Department of Internal Medicine, Nakhon Panom Hospital, Nakhon Panom 48000, Thailand;
| | - Alisa Suphan
- Ubon Ratchathani Provincial Public Health Office, Ubon Ratchathani 34000, Thailand;
| | - Punchawee Sukbut
- Mukdahan Provincial Public Health Office, Mukdahan 49000, Thailand;
| | - Kritchavat Ploddi
- The Office of Disease Prevention and Control 8, Udon Thani 41000, Thailand;
| | - Poolsri Sirichotirat
- The Office of Disease Prevention and Control 10, Ubon Ratchathani 34000, Thailand;
| | | | | | - Maliwan Hongsuwan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Gumphol Wongsuwan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Pornpan Sunthornsut
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Sandy Sachaphimukh
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Prapass Wannapinij
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Claire Chewapreecha
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Janjira Thaipadungpanit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
| | - Narisara Chantratita
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Sunee Korbsrisate
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Apichai Taunyok
- Department of Infectious Diseases & Immunology, Emerging Pathogens Institute, University of Florida, Gainesville, FL 32611, USA;
| | - Susanna Dunachie
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK;
| | - Prasit Palittapongarnpim
- National Science and Technology Development Agency (NSTDA), Pathum Thani 12120, Thailand;
- Department of Microbiology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand;
| | - Stitaya Sirisinha
- Department of Microbiology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand;
| | - Rungrueng Kitphati
- Institute for Urban Disease Control and Prevention, Department of Disease Control, Ministry of Public Health, Bangkok 10220, Thailand;
| | - Sopon Iamsirithaworn
- Bureau of General Communicable Diseases, Department of Disease Control, Ministry of Public Health, Nonthaburi 11000, Thailand;
| | - Wipada Chaowagul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani 34000, Thailand; (P.T.); (W.C)
| | - Ploenchan Chetchotisak
- Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand; (S.A.); (R.W.S.); (P.C.); (S.W.)
| | - Toni Whistler
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi 11000, Thailand; (S.B.); (T.A.); (S.T.); (O.S.); (T.W.)
| | | | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (V.H.); (T.W.); (M.H.); (G.W.); (P.S.); (V.W.); (S.S.); (P.W.); (W.C.); (C.C.); (J.T.); (N.C)
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK;
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11
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Wattanakul T, Teerapong P, Plewes K, Newton PN, Chierakul W, Silamut K, Chotivanich K, Ruengweerayut R, White NJ, Dondorp AM, Tarning J. Pharmacokinetic properties of intramuscular versus oral syrup paracetamol in Plasmodium falciparum malaria. Malar J 2016; 15:244. [PMID: 27118212 PMCID: PMC4847232 DOI: 10.1186/s12936-016-1283-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/12/2016] [Indexed: 12/03/2022] Open
Abstract
Background Fever is an inherent symptom of malaria in both adults and children. Paracetamol (acetaminophen) is the recommended antipyretic as it is inexpensive, widely available and has a good safety profile, but patients may not be able to take the oral drug reliably. A comparison between the pharmacokinetics of oral syrup and intramuscular paracetamol given to patients with acute falciparum malaria and high body temperature was performed. Methods A randomized, open-label, two-treatment, crossover, pharmacokinetic study of paracetamol dosed orally and intramuscularly was conducted. Twenty-one adult patients with uncomplicated falciparum malaria were randomized to receive a single 600 mg dose of paracetamol either as syrup or intramuscular injection on day 0 followed by a single dose administered by the alternative route on day 1. Paracetamol plasma concentrations were quantified frequently and modelled simultaneously using nonlinear mixed-effects modelling. The final population pharmacokinetic model was used for dose optimization simulations. Relationships between paracetamol concentrations with temperature and parasite half-life were investigated using linear and non-linear regression analyses. Results The population pharmacokinetic properties of paracetamol were best described by a two-compartment disposition model, with zero-order and first-order absorption for intramuscular and oral syrup administration, respectively. The relative bioavailability of oral syrup was 84.4 % (95 % CI 68.2–95.1 %) compared to intramuscular administration. Dosing simulations showed that 1000 mg of intramuscular or oral syrup administered six-hourly reached therapeutic steady state concentrations for antipyresis, but more favourable concentration–time profiles were achieved with a loading dose of 1500 mg, followed by a 1000 mg maintenance dose. This ensured that maximum therapeutic concentrations were reached rapidly during the first 6 h. No significant relationships between paracetamol concentrations and temperature or parasite half-life were found. Conclusions Paracetamol plasma concentrations after oral syrup and intramuscular administration in patients with acute falciparum malaria were described successfully by a two-compartment disposition model. Relative oral bioavailability compared to intramuscular dosing was estimated as 84.4 % (95 % CI 68.2–95.1 %). Dosing simulations showed that a loading dose followed by six-hourly dosing intervals reduced the time delay to reach therapeutic drug levels after both routes of administration. The safety and efficacy of loading dose paracetamol antipyretic regimens now needs to be established in larger studies.
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Affiliation(s)
- Thanaporn Wattanakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Pramote Teerapong
- Primary Care Unit, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Paul N Newton
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kesinee Chotivanich
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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12
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Hantrakun V, Chierakul W, Chetchotisakd P, Anunnatsiri S, Currie BJ, Peacock SJ, Day NPJ, Cheah PY, Limmathurotsakul D, Lubell Y. Cost-effectiveness analysis of parenteral antimicrobials for acute melioidosis in Thailand. Trans R Soc Trop Med Hyg 2016; 109:803. [PMID: 26626343 DOI: 10.1093/trstmh/trv093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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13
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Poovorawan K, Thu AM, Sutherat M, Phumratanaprapin W, Wisedopas N, Luvira V, Chierakul W. HEPATIC LYMPHOMA AND SPLENIC ASPERGILLOSIS MIMICKING HEPATOSPLENIC ABSCESSES FROM MELIOIDOSIS IN THAILAND. Southeast Asian J Trop Med Public Health 2016; 47:223-226. [PMID: 27244960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We report here a case of hepatic lymphoma and splenic aspergillosis in an elderly patient with diabetes mellitus, exhibiting hepatosplenic abscesses mimicking melioidosis. Immunohistochemistry confirmed the diagnosis of a diffuse hepatic large B-cell lymphoma. Biopsy of the spleen revealed a clump of fungus with a slender shape and dichotomous branching, morphologically consistent with aspergillosis. Hepatosplenic abscesses are a common presentation in melioidosis, but this case reveals this assumption can lead to misdiagnosis. Histological and microbiological confirmation are required, especially in patients with hepatosplenic lesions.
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Beardsley J, Wolbers M, Kibengo FM, Ggayi ABM, Kamali A, Cuc NTK, Binh TQ, Chau NVV, Farrar J, Merson L, Phuong L, Thwaites G, Van Kinh N, Thuy PT, Chierakul W, Siriboon S, Thiansukhon E, Onsanit S, Supphamongkholchaikul W, Chan AK, Heyderman R, Mwinjiwa E, van Oosterhout JJ, Imran D, Basri H, Mayxay M, Dance D, Phimmasone P, Rattanavong S, Lalloo DG, Day JN. Adjunctive Dexamethasone in HIV-Associated Cryptococcal Meningitis. N Engl J Med 2016; 374:542-54. [PMID: 26863355 PMCID: PMC4778268 DOI: 10.1056/nejmoa1509024] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cryptococcal meningitis associated with human immunodeficiency virus (HIV) infection causes more than 600,000 deaths each year worldwide. Treatment has changed little in 20 years, and there are no imminent new anticryptococcal agents. The use of adjuvant glucocorticoids reduces mortality among patients with other forms of meningitis in some populations, but their use is untested in patients with cryptococcal meningitis. METHODS In this double-blind, randomized, placebo-controlled trial, we recruited adult patients with HIV-associated cryptococcal meningitis in Vietnam, Thailand, Indonesia, Laos, Uganda, and Malawi. All the patients received either dexamethasone or placebo for 6 weeks, along with combination antifungal therapy with amphotericin B and fluconazole. RESULTS The trial was stopped for safety reasons after the enrollment of 451 patients. Mortality was 47% in the dexamethasone group and 41% in the placebo group by 10 weeks (hazard ratio in the dexamethasone group, 1.11; 95% confidence interval [CI], 0.84 to 1.47; P=0.45) and 57% and 49%, respectively, by 6 months (hazard ratio, 1.18; 95% CI, 0.91 to 1.53; P=0.20). The percentage of patients with disability at 10 weeks was higher in the dexamethasone group than in the placebo group, with 13% versus 25% having a prespecified good outcome (odds ratio, 0.42; 95% CI, 0.25 to 0.69; P<0.001). Clinical adverse events were more common in the dexamethasone group than in the placebo group (667 vs. 494 events, P=0.01), with more patients in the dexamethasone group having grade 3 or 4 infection (48 vs. 25 patients, P=0.003), renal events (22 vs. 7, P=0.004), and cardiac events (8 vs. 0, P=0.004). Fungal clearance in cerebrospinal fluid was slower in the dexamethasone group. Results were consistent across Asian and African sites. CONCLUSIONS Dexamethasone did not reduce mortality among patients with HIV-associated cryptococcal meningitis and was associated with more adverse events and disability than was placebo. (Funded by the United Kingdom Department for International Development and others through the Joint Global Health Trials program; Current Controlled Trials number, ISRCTN59144167.).
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Affiliation(s)
- Justin Beardsley
- From the Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Vietnam (J.B., M.W., J.F., L.M., G.T., J.N.D.), Hospital for Tropical Diseases (N.T.K.C., N.V.V.C.), Cho Ray Hospital (T.Q.B., L.P.), Ho Chi Minh City, and the National Hospital for Tropical Diseases (N.V.K.) and Bach Mai Hospital (P.T.T.), Hanoi - all in Vietnam; Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford (J.B., M.W., J.F., L.M., G.T., M.M., D.D., J.N.D.), University College London, London (R.H.), and Liverpool School of Tropical Medicine, Liverpool (D.G.L.) - all in the United Kingdom; MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda (F.M.K., A.-B.M.G., A.K.); Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok (W.C.), Ubon Sappasithiprasong Hospital, Ubon (S.S., W.S.), and Udon Thani Hospital, Udon Thani (E.T., S.O.) - all in Thailand; Dignitas International, Zomba (A.K.C., E.M., J.J.O.), and Malawi-Liverpool-Wellcome Trust, Clinical Research Programme (R.H., D.G.L.), and University of Malawi College of Medicine (R.H., J.J.O.), Blantyre - all in Malawi; Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); Cipto Mangunkusumo Hospital (D.I.) and Eijkman Oxford Clinical Research Unit (H.B.) - both in Jakarta, Indonesia; and Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital (M.M., D.D., P.P., S.R.), and University of Health Sciences (M.M.) - both in Vientiane, Laos
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Thaipadungpanit J, Chierakul W, Pattanaporkrattana W, Phoodaeng A, Wongsuvan G, Huntrakun V, Amornchai P, Chatchen S, Kitphati R, Wuthiekanun V, Day NP, Peacock SJ, Limmathurotsakul D. Burkholderia pseudomallei in water supplies, southern Thailand. Emerg Infect Dis 2015; 20:1947-9. [PMID: 25340393 PMCID: PMC4215545 DOI: 10.3201/eid2011.140832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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16
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Lim C, Paris DH, Blacksell SD, Laongnualpanich A, Kantipong P, Chierakul W, Wuthiekanun V, Day NPJ, Cooper BS, Limmathurotsakul D. How to Determine the Accuracy of an Alternative Diagnostic Test when It Is Actually Better than the Reference Tests: A Re-Evaluation of Diagnostic Tests for Scrub Typhus Using Bayesian LCMs. PLoS One 2015; 10:e0114930. [PMID: 26024375 PMCID: PMC4449177 DOI: 10.1371/journal.pone.0114930] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 11/18/2014] [Indexed: 11/18/2022] Open
Abstract
Background The indirect immunofluorescence assay (IFA) is considered a reference test for scrub typhus. Recently, the Scrub Typhus Infection Criteria (STIC; a combination of culture, PCR assays and IFA IgM) were proposed as a reference standard for evaluating alternative diagnostic tests. Here, we use Bayesian latent class models (LCMs) to estimate the true accuracy of each diagnostic test, and of STIC, for diagnosing scrub typhus. Methods/Principal Findings Data from 161 patients with undifferentiated fever were re-evaluated using Bayesian LCMs. Every patient was evaluated for the presence of an eschar, and tested with blood culture for Orientia tsutsugamushi, three different PCR assays, IFA IgM, and the Panbio IgM immunochromatographic test (ICT). True sensitivity and specificity of culture (24.4% and 100%), 56kDa PCR assay (56.8% and 98.4%), 47kDa PCR assay (63.2% and 96.1%), groEL PCR assay (71.4% and 93.0%), IFA IgM (70.0% and 83.8%), PanBio IgM ICT (72.8% and 96.8%), presence of eschar (42.7% and 98.9%) and STIC (90.5% and 82.5%) estimated by Bayesian LCM were considerably different from those obtained when using STIC as a reference standard. The IgM ICT had comparable sensitivity and significantly higher specificity compared to IFA (p=0.34 and p<0.001, respectively). Conclusions The low specificity of STIC was caused by the low specificity of IFA IgM. Neither STIC nor IFA IgM can be used as reference standards against which to evaluate alternative diagnostic tests. Further evaluation of new diagnostic tests should be done with a carefully selected set of diagnostic tests and appropriate statistical models.
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Affiliation(s)
- Cherry Lim
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Daniel H. Paris
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Ben S. Cooper
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
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Hantrakun V, Chierakul W, Chetchotisakd P, Anunnatsiri S, Currie BJ, Peacock SJ, Day NPJ, Cheah PY, Cheah P, Limmathurotsakul D, Lubell Y. Cost-effectiveness analysis of parenteral antimicrobials for acute melioidosis in Thailand. Trans R Soc Trop Med Hyg 2015; 109:416-8. [PMID: 25972345 PMCID: PMC4553702 DOI: 10.1093/trstmh/trv002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/23/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Melioidosis is a common community-acquired infectious disease in northeast Thailand associated with overall mortality of approximately 40% in hospitalized patients, and over 70% in severe cases. Ceftazidime is recommended for parenteral treatment in patients with suspected melioidosis. Meropenem is increasingly used but evidence to support this is lacking. METHODS A decision tree was used to estimate the cost-effectiveness of treating non-severe and severe suspected acute melioidosis cases with either ceftazidime or meropenem. RESULTS Empirical treatment with meropenem is likely to be cost-effective providing meropenem reduces mortality in severe cases by at least 9% and the proportion with subsequent culture-confirmed melioidosis is over 20%. CONCLUSIONS In this context, treatment of severe cases with meropenem is likely to be cost-effective, while the evidence to support the use of meropenem in non-severe suspected melioidosis is not yet available.
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Affiliation(s)
- Viriya Hantrakun
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Wirongrong Chierakul
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Ploenchan Chetchotisakd
- Melioidosis Research Centre, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 4002, Thailand
| | - Siriluck Anunnatsiri
- Melioidosis Research Centre, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 4002, Thailand
| | - Bart J Currie
- Royal Darwin Hospital and Menzies School of Health Research, Darwin, Northern Territory 0811, Australia
| | - Sharon J Peacock
- Department of Medicine, University of Cambridge, Cambridge, CB2 1TN, UK
| | - Nicholas P J Day
- Center for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LE, UK
| | - Phaik Yeong Cheah
- Center for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LE, UK
| | | | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
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Day J, Imran D, Ganiem AR, Tjahjani N, Wahyuningsih R, Adawiyah R, Dance D, Mayxay M, Newton P, Phetsouvanh R, Rattanavong S, Chan AK, Heyderman R, van Oosterhout JJ, Chierakul W, Day N, Kamali A, Kibengo F, Ruzagira E, Gray A, Lalloo DG, Beardsley J, Binh TQ, Chau TTH, Chau NVV, Cuc NTK, Farrar J, Hien TT, Van Kinh N, Merson L, Phuong L, Tho LT, Thuy PT, Thwaites G, Wertheim H, Wolbers M. CryptoDex: a randomised, double-blind, placebo-controlled phase III trial of adjunctive dexamethasone in HIV-infected adults with cryptococcal meningitis: study protocol for a randomised control trial. Trials 2014; 15:441. [PMID: 25391338 PMCID: PMC4289250 DOI: 10.1186/1745-6215-15-441] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/16/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a severe AIDS-defining illness with 90-day case mortality as high as 70% in sub-Saharan Africa, despite treatment. It is the leading cause of death in HIV patients in Asia and Africa.No major advance has been made in the treatment of CM since the 1970s. The mainstays of induction therapy are amphotericin B and flucytosine, but these are often poorly available where the disease burden is highest. Adjunctive treatments, such as dexamethasone, have had dramatic effects on mortality in other neurologic infections, but are untested in CM. Given the high death rates in patients receiving current optimal treatment, and the lack of new agents on the horizon, adjuvant treatments, which offer the potential to reduce mortality in CM, should be tested.The principal research question posed by this study is as follows: does adding dexamethasone to standard antifungal therapy for CM reduce mortality? Dexamethasone is a cheap, readily available, and practicable intervention. METHOD A double-blind placebo-controlled trial with parallel arms in which patients are randomised to receive either dexamethasone or placebo, in addition to local standard of care. The study recruits patients in both Asia and Africa to ensure the relevance of its results to the populations in which the disease burden is highest. The 10-week mortality risk in the control group is expected to be between 30% and 50%, depending on location, and the target hazard ratio of 0.7 corresponds to absolute risk reductions in mortality from 30% to 22%, or from 50% to 38%. Assuming an overall 10-week mortality of at least 30% in our study population, recruitment of 824 patients will be sufficient to observe the expected number of deaths. Allowing for some loss to follow-up, the total sample size for this study is 880 patients. To generate robust evidence across both continents, we aim to recruit roughly similar numbers of patients from each continent. The primary end point is 10-week mortality. Ethical approval has been obtained from Oxford University's Tropical Research Ethics Committee (OxTREC), and as locally mandated at each site. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: ISRCTN59144167 26-July-2012.
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Affiliation(s)
- Jeremy Day
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Darma Imran
- />Cipto Mangunkusum Hospital, Jakarta, Indonesia
| | | | | | - Retno Wahyuningsih
- />Cipto Mangunkusum Hospital, Jakarta, Indonesia
- />Department of Parasitology, Indonesia Christian University, School of Medicine, Jakarta, Indonesia
| | - Robiatul Adawiyah
- />Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - David Dance
- />Laos Oxford Mahosot Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Laos
| | - Mayfong Mayxay
- />Laos Oxford Mahosot Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Laos
| | - Paul Newton
- />Laos Oxford Mahosot Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Laos
| | | | - Sayaphet Rattanavong
- />Laos Oxford Mahosot Wellcome Trust Research Unit, Mahosot Hospital, Vientiane, Laos
| | | | - Robert Heyderman
- />Malawi-Liverpool-Wellcome Trust, Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Wirongrong Chierakul
- />Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Nick Day
- />Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Anatoli Kamali
- />MRC/UVRI Uganda Research Unit on AIDS, Entebbe/Masaka, Uganda
| | - Freddie Kibengo
- />MRC/UVRI Uganda Research Unit on AIDS, Entebbe/Masaka, Uganda
| | - Eugene Ruzagira
- />MRC/UVRI Uganda Research Unit on AIDS, Entebbe/Masaka, Uganda
| | - Alastair Gray
- />Nuffield Department of Population Health, University of Oxford Health Economics Research Centre, Oxford, UK
| | - David G Lalloo
- />Wellcome Trust Tropical Centre Liverpool, Liverpool, UK
| | - Justin Beardsley
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Tran Thi Hong Chau
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Jeremy Farrar
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Tinh Hien
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Laura Merson
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Lan Phuong
- />Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Loc Truong Tho
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Guy Thwaites
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Heiman Wertheim
- />National Hospital for Tropical Diseases Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Marcel Wolbers
- />Wellcome Trust Major Overseas Programme Vietnam, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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Kyaw SS, Drake T, Ruangveerayuth R, Chierakul W, White NJ, Newton PN, Lubell Y. Cost of treating inpatient falciparum malaria on the Thai-Myanmar border. Malar J 2014; 13:416. [PMID: 25351915 PMCID: PMC4218997 DOI: 10.1186/1475-2875-13-416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/09/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite demonstrated benefits and World Health Organization (WHO) endorsement, parenteral artesunate is the recommended treatment for patients with severe Plasmodium falciparum malaria in only one fifth of endemic countries. One possible reason for this slow uptake is that a treatment course of parenteral artesunate is costlier than quinine and might, therefore, pose a substantial economic burden to health care systems. This analysis presents a detailed account of the resources used in treating falciparum malaria by either parenteral artesunate or quinine in a hospital on the Thai-Myanmar border. METHODS The analysis used data from four studies, with random allocation of inpatients with falciparum malaria to treatment with parenteral artesunate or quinine, conducted in Mae Sot Hospital, Thailand from 1995 to 2001. Detailed resource use data were collected during admission and unit costs from the 2008 hospital price list were applied to these. Total admission costs were broken down into five categories: 1) medication; 2) intravenous fluids; 3) disposables; 4) laboratory tests; and 5) services. RESULTS While the medication costs were higher for patients treated with artesunate, total admission costs were similar in those treated with quinine, US$ 243 (95% CI: 167.5-349.7) and in those treated with artesunate US$ 190 (95% CI: 131.0-263.2) (P=0.375). For cases classified as severe malaria (59%), the total cost of admission was US$ 298 (95% CI: 203.6-438.7) in the quinine group as compared with US$ 284 (95% CI: 181.3-407) in the artesunate group (P=0.869). CONCLUSION This analysis finds no evidence for a difference in total admission costs for malaria inpatients treated with artesunate as compared with quinine. Assuming this is generalizable to other settings, the higher cost of a course of artesunate should not be considered a barrier for its implementation in the treatment of malaria.
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Affiliation(s)
- Shwe Sin Kyaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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20
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West TE, Myers ND, Chantratita N, Chierakul W, Limmathurotsakul D, Wuthiekanun V, Miao EA, Hajjar AM, Peacock SJ, Liggitt HD, Skerrett SJ. NLRC4 and TLR5 each contribute to host defense in respiratory melioidosis. PLoS Negl Trop Dis 2014; 8:e3178. [PMID: 25232720 PMCID: PMC4169243 DOI: 10.1371/journal.pntd.0003178] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 08/09/2014] [Indexed: 02/02/2023] Open
Abstract
Burkholderia pseudomallei causes the tropical infection melioidosis. Pneumonia is a common manifestation of melioidosis and is associated with high mortality. Understanding the key elements of host defense is essential to developing new therapeutics for melioidosis. As a flagellated bacterium encoding type III secretion systems, B. pseudomallei may trigger numerous host pathogen recognition receptors. TLR5 is a flagellin sensor located on the plasma membrane. NLRC4, along with NAIP proteins, assembles a canonical caspase-1-dependent inflammasome in the cytoplasm that responds to flagellin (in mice) and type III secretion system components (in mice and humans). In a murine model of respiratory melioidosis, Tlr5 and Nlrc4 each contributed to survival. Mice deficient in both Tlr5 and Nlrc4 were not more susceptible than single knockout animals. Deficiency of Casp1/Casp11 resulted in impaired bacterial control in the lung and spleen; in the lung much of this effect was attributable to Nlrc4, despite relative preservation of pulmonary IL-1β production in Nlrc4−/− mice. Histologically, deficiency of Casp1/Casp11 imparted more severe pulmonary inflammation than deficiency of Nlrc4. The human NLRC4 region polymorphism rs6757121 was associated with survival in melioidosis patients with pulmonary involvement. Co-inheritance of rs6757121 and a functional TLR5 polymorphism had an additive effect on survival. Our results show that NLRC4 and TLR5, key components of two flagellin sensing pathways, each contribute to host defense in respiratory melioidosis. Melioidosis is an infection caused by Burkholderia pseudomallei, a bacterium that is found in tropical soil and water. Melioidosis can present in a variety of ways, but lung involvement is common and usually severe. The host response to infection governs outcome. In this study, we examined the role of two host sensors of bacterial components–TLR5 and NLRC4–to determine their necessity in respiratory melioidosis. Although both proteins are involved in detection of bacterial flagellin, in mice we defined specific and individual roles for TLR5 and NLRC4 in protecting against death from melioidosis. In humans with melioidosis involving the lung, genetic variation in these receptors also had independent associations with survival. These results underscore the importance of these elements of host defense in respiratory melioidosis and support further studies of the underlying mechanisms.
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Affiliation(s)
- T. Eoin West
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, United States of America
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
| | - Nicolle D. Myers
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Narisara Chantratita
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Edward A. Miao
- Department of Microbiology and Immunology, Lineberger Comprehensive Cancer Center, and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Adeline M. Hajjar
- Department of Comparative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Sharon J. Peacock
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - H. Denny Liggitt
- Department of Comparative Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Shawn J. Skerrett
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
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Chetchotisakd P, Chierakul W, Chaowagul W, Anunnatsiri S, Phimda K, Mootsikapun P, Chaisuksant S, Pilaikul J, Thinkhamrop B, Phiphitaporn S, Susaengrat W, Toondee C, Wongrattanacheewin S, Wuthiekanun V, Chantratita N, Thaipadungpanit J, Day NP, Limmathurotsakul D, Peacock SJ. Trimethoprim-sulfamethoxazole versus trimethoprim-sulfamethoxazole plus doxycycline as oral eradicative treatment for melioidosis (MERTH): a multicentre, double-blind, non-inferiority, randomised controlled trial. Lancet 2014; 383:807-14. [PMID: 24284287 PMCID: PMC3939931 DOI: 10.1016/s0140-6736(13)61951-0] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Melioidosis, an infectious disease caused by the Gram-negative bacillus Burkholderia pseudomallei, is difficult to cure. Antimicrobial treatment comprises intravenous drugs for at least 10 days, followed by oral drugs for at least 12 weeks. The standard oral regimen based on trial evidence is trimethoprim-sulfamethoxaxole (TMP-SMX) plus doxycycline. This regimen is used in Thailand but is associated with side-effects and poor adherence by patients, and TMP-SMX alone is recommended in Australia. We compared the efficacy and side-effects of TMP-SMX with TMP-SMX plus doxycycline for the oral phase of melioidosis treatment. METHODS For this multi-centre, double-blind, non-inferiority, randomised placebo-controlled trial, we enrolled patients (aged ≥15 years) from five centres in northeast Thailand with culture-confirmed melioidosis who had received a course of parenteral antimicrobial drugs. Using a computer-generated sequence, we randomly assigned patients to receive TMP-SMX plus placebo or TMP-SMX plus doxycycline for 20 weeks (1:1; block size of ten, stratified by study site). We followed patients up every 4 months for 1 year and annually thereafter to the end of the study. The primary endpoint was culture-confirmed recurrent melioidosis, and the non-inferiority margin was a hazard ratio (HR) of 1.7. This study is registered with www.controlled-trials.com, number ISRCTN86140460. FINDINGS We enrolled and randomly assigned 626 patients: 311 to TMP-SMX plus placebo and 315 to TMP-SMX plus doxycycline. 16 patients (5%) in the TMP-SMX plus placebo group and 21 patients (7%) in the TMP-SMX plus doxycycline group developed culture-confirmed recurrent melioidosis (HR 0.81; 95% CI 0.42-1.55). The criterion for non-inferiority was met (p=0.01). Adverse drug reactions were less common in the TMP-SMX plus placebo group than in the TMP-SMX plus doxycycline group (122 [39%] vs 167 [53%]). INTERPRETATION Our findings suggest that TMP-SMX is not inferior to TMP-SMX plus doxycycline for the oral phase of melioidosis treatment, and is preferable on the basis of safety and tolerance by patients. FUNDING Thailand Research Fund, the Melioidosis Research Center, the Center of Excellence in Specific Health Problems in Greater Mekong Sub-region cluster, and the Wellcome Trust.
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Affiliation(s)
- Ploenchan Chetchotisakd
- Faculty of Medicine, Khon Kaen University, Thailand; Melioidosis Research Centre, Khon Kaen University, Thailand
| | | | | | - Siriluck Anunnatsiri
- Faculty of Medicine, Khon Kaen University, Thailand; Melioidosis Research Centre, Khon Kaen University, Thailand
| | | | | | | | | | | | | | | | | | - Surasakdi Wongrattanacheewin
- Faculty of Medicine, Khon Kaen University, Thailand; Melioidosis Research Centre, Khon Kaen University, Thailand
| | | | | | | | - Nicholas P Day
- Faculty of Tropical Medicine, Mahidol University, Thailand; University of Oxford, Churchill Hospital, Oxford, UK
| | | | - Sharon J Peacock
- Faculty of Tropical Medicine, Mahidol University, Thailand; University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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Chantratita N, Tandhavanant S, Myers ND, Chierakul W, Wuthiekanun V, Mahavanakul W, Limmathurotsakul D, Peacock SJ, West TE. Common TLR1 genetic variation is not associated with death from melioidosis, a common cause of sepsis in rural Thailand. PLoS One 2014; 9:e83285. [PMID: 24392083 PMCID: PMC3879377 DOI: 10.1371/journal.pone.0083285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 11/12/2013] [Indexed: 11/18/2022] Open
Abstract
Melioidosis, infection caused by the Gram-negative bacterium Burkholderia pseudomallei, is a common cause of sepsis in northeast Thailand. In white North Americans, common functional genetic variation in TLR1 is associated with organ failure and death from sepsis. We hypothesized that TLR1 variants would be associated with outcomes in Thais with melioidosis. We collated the global frequencies of three TLR1 variants that are common in white North American populations: rs5743551 (-7202A/G), rs4833095 (742A/G), and rs5743618 (1804G/T). We noted a reversal of the minor allele from white North American subjects to Asian populations that was particularly pronounced for rs5743618. In the Utah residents of European ancestry, the frequency of the rs5743618 T allele was 17% whereas in Vietnamese subjects the frequency was >99%. We conducted a genetic association study in 427 patients with melioidosis to determine the association of TLR1 variation with organ failure or death. We genotyped rs5743551 and rs4833095. The variants were in high linkage disequilibrium but neither variant was associated with organ failure or in-hospital death. In 300 healthy Thai individuals we further tested the association of TLR1 variation with ex vivo blood responses to Pam3CSK4, a TLR1 agonist. Neither variant was robustly associated with blood cytokine responses induced by Pam3CSK4. We identified additional common variation in TLR1 by searching public databases and the published literature and screened three additional TLR1 variants for associations with Pam3CSK4-induced responses but found none. We conclude that the genetic architecture of TLR1 variation differs substantially in southeast Asians compared to other populations and common variation in TLR1 in Thais is not associated with outcome from melioidosis or with altered blood responses to Pam3CSK4. Our findings highlight the need for additional studies of TLR1 and other innate immune genetic modulators of the inflammatory host response and determinants of sepsis in southeast Asian populations.
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Affiliation(s)
- Narisara Chantratita
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sarunporn Tandhavanant
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicolle D. Myers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Weera Mahavanakul
- Department of Medicine, Sappasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sharon J. Peacock
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - T. Eoin West
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, United States of America
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23
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Myers ND, Chantratita N, Berrington WR, Chierakul W, Limmathurotsakul D, Wuthiekanun V, Robertson JD, Liggitt HD, Peacock SJ, Skerrett SJ, West TE. The role of NOD2 in murine and human melioidosis. J Immunol 2013; 192:300-7. [PMID: 24298015 DOI: 10.4049/jimmunol.1301436] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Nucleotide-binding oligomerization domain 2 (NOD2) is a cytosolic pathogen recognition receptor that regulates susceptibility to a variety of infections and chronic diseases. Burkholderia pseudomallei, a facultative intracellular bacterium, causes the tropical infection melioidosis. We hypothesized that NOD2 may participate in host defense in melioidosis. We performed a series of in vitro assays and in vivo experiments and analyzed the association of human genetic variation with infection to delineate the contribution of NOD2 to the host response to B. pseudomallei. We found that transfection with NOD2 mediated NF-κB activation induced by B. pseudomallei stimulation of HEK293 cells. After low-dose inoculation with aerosolized B. pseudomallei, Nod2-deficient mice showed impaired clinical responses and permitted greater bacterial replication in the lung and dissemination to the spleen compared with wild-type mice. IL-6 and KC levels were higher in the lungs of Nod2-deficient mice. In a cohort of 1562 Thai subjects, a common genetic polymorphism in the NOD2 region, rs7194886, was associated with melioidosis, and this effect was most pronounced in women. rs7194886 was not associated with differences in cytokine production induced by whole-blood stimulation with the NOD2 ligand, muramyl dipeptide, or B. pseudomallei. To our knowledge, these findings are the first to characterize the role of NOD2 in host defense in mammalian melioidosis.
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Affiliation(s)
- Nicolle D Myers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195
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Sonthayanon P, Chierakul W, Wuthiekanun V, Limmathurotsakul D, Amornchai P, Smythe LD, Day NP, Peacock SJ. Molecular confirmation of co-infection by pathogenic Leptospira spp. and Orientia tsutsugamushi in patients with acute febrile illness in Thailand. Am J Trop Med Hyg 2013; 89:797-799. [PMID: 24002486 PMCID: PMC3795116 DOI: 10.4269/ajtmh.13-0402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Leptospirosis and scrub typhus are major causes of acute febrile illness in rural Asia, where co-infection is reported to occur based on serologic evidence. We re-examined whether co-infection occurs by using a molecular approach. A duplex real-time polymerase chain reaction was developed that targeted a specific 16S ribosomal RNA gene of pathogenic Leptospira spp. and Orientia tsutsugamushi. Of 82 patients with an acute febrile illness who had dual infection on the basis of serologic tests, 5 (6%) had polymerase chain reaction results positive for both pathogens. We conclude that dual infection occurs, but that serologic tests may overestimate the frequency of co-infections.
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Affiliation(s)
- Piengchan Sonthayanon
- *Address correspondence to Piengchan Sonthayanon, Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand. E-mails: or
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25
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Sagaki P, Thanachartwet V, Desakorn V, Sahassananda D, Chamnanchanunt S, Chierakul W, Pitisuttithum P, Ruangkanchanasetr P. Clinical factors for severity of Plasmodium falciparum malaria in hospitalized adults in Thailand. PLoS One 2013; 8:e71503. [PMID: 23951178 PMCID: PMC3741184 DOI: 10.1371/journal.pone.0071503] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/01/2013] [Indexed: 11/28/2022] Open
Abstract
Plasmodium falciparum is a major cause of severe malaria in Southeast Asia, however, there is limited information regarding clinical factors associated with the severity of falciparum malaria from this region. We performed a retrospective case-control study to compare clinical factors and outcomes between patients with severe and non-severe malaria, and to identify clinical factors associated with the requirement for intensive care unit (ICU) admission of patients with severe falciparum malaria among hospitalized adults in Southeast Asia. A total of 255 patients with falciparum malaria in the Hospital for Tropical Diseases in Bangkok, Thailand between 2006 and 2012 were included. We identified 104 patients with severe malaria (cases) and 151 patients with non-severe malaria (controls). Patients with falciparum malaria with following clinical and laboratory characteristics on admission (1) referrals, (2) no prior history of malaria, (3) body temperature of >38.5°C, (4) white blood cell counts >10×109/µL, (5) presence of schizonts in peripheral blood smears, and (6) albumin concentrations of <3.5 g/dL, were more likely to develop severe malaria (P<0.05). Among patients with severe malaria, patients who met ≥3 of the 2010 WHO criteria had sensitivity of 79.2% and specificity of 81.8% for requiring ICU admission. Multivariate analysis identified the following as independent associated factors for severe malaria requiring ICU admission; (1) ethnicity of Thai [odds ratio (OR) = 3.601, 95% confidence interval (CI) = 1.011–12.822] or Myanmar [OR = 3.610, 95% CI = 1.138–11.445]; (2) referrals [OR = 3.571, 95% CI = 1.306–9.762]; (3) no prior history of malaria [OR = 5.887, 95% CI = 1.354–25.594]; and (4) albumin concentrations of <3.5 g/dL [OR = 7.200, 95% CI = 1.802–28.759]. Our findings are important for the clinical management of patients with malaria because it can help early identification of patients that could develop severe malaria and require ICU admission. Early identification and the timely initiation of appropriate treatments may well improve the outcomes and reduce the mortality of these patients.
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Affiliation(s)
- Patrick Sagaki
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Amudat Hospital, Amudat, Uganda
| | - Vipa Thanachartwet
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
| | - Varunee Desakorn
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Duangjai Sahassananda
- Information Technology Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Supat Chamnanchanunt
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirongrong Chierakul
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Punnee Pitisuttithum
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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26
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Newton PN, Stepniewska K, Dondorp A, Silamut K, Chierakul W, Krishna S, Davis TME, Suputtamongkol Y, Angus B, Pukrittayakamee S, Ruangveerayuth R, Hanson J, Day NPJ, White NJ. Prognostic indicators in adults hospitalized with falciparum malaria in Western Thailand. Malar J 2013; 12:229. [PMID: 23829311 PMCID: PMC3711784 DOI: 10.1186/1475-2875-12-229] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/23/2013] [Indexed: 11/17/2022] Open
Abstract
Background Severe malaria remains a major cause of death and morbidity amongst adults in the Asiatic tropics. Methods A retrospective analysis of the clinical and laboratory data of 988 adult patients, hospitalized with Plasmodium falciparum malaria and prospectively recruited to malaria studies in western Thailand between 1986 and 2002, was performed to assess the factors associated with a fatal outcome. Different severity scores and classifications for defining severe malaria were compared and, using multiple logistic regression, simple models for predicting mortality developed. Results The proportion of patients fulfilling the WHO 2000 definition of severe malaria was 78.1%, and their mortality was 10%. Mortality in patients given parenteral artesunate or artemether (16/317, 5%) was lower than in those given parenteral quinine (59/442, 13%) (P < 0.001). Models using parameter sets based on WHO 1990, 2000 and Adapted AQ criteria plus blood smear parasite-stage assessment gave the best mortality prediction. A malaria prognostic index (MPI), derived from the dataset using five clinical or laboratory variables gave similar prognostic accuracy. Conclusions The mortality of severe malaria in adults has fallen and the switch from quinine to artesunate has probably been an important contributor. Prognostic indices based on WHO 2000 definitions, and other simpler indices based on fewer variables, provide clinically useful predictions of outcome in Asian adults with severe malaria.
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Affiliation(s)
- Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.
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27
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Aung KLL, Thanachartwet V, Desakorn V, Chamnanchanunt S, Sahassananda D, Chierakul W, Pitisuttithum P. Factors associated with severe clinical manifestation of dengue among adults in Thailand. Southeast Asian J Trop Med Public Health 2013; 44:602-612. [PMID: 24050093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A retrospective study was conducted by reviewing medical records of 323 adult patients hospitalized with dengue infection at the Hospital for Tropical Diseases, Bangkok, Thailand between 2006 and 2010 in order to determine factors associated with severe clinical manifestations of dengue. Of 323 patients, 95 (29.4%) had dengue fever (DF) and 228 (70.6%) had DHF, which were categorized as grade I (67 patients, 29.4%), grade II (62 patients, 27.2%), grade III (95 patients, 41.7%) and grade IV (4 patients, 1.8%) following 1997 WHO definitions. Using the revised 2009 WHO definitions, 233 patients (72.1%) had non-severe dengue infection and 90 patients (27.9%) had severe dengue infection. Of the 233 patients with non-severe dengue infection, 193 (82.8%) were classified as having non-severe dengue infection with warning signs and 40 (17.2%) were classified as having non-severe dengue infection without warning signs. Using stepwise multivariate logistic regression analysis, having a hematocrit >2% above the reference range [odds ratio (OR) 3.235; 95% confidence interval (CI) 1.807-5.793] or having an alanine aminotransferase level >120 IU/l (OR 1.896; 95% CI 1.018-3.531) were associated with having DHF grades II-IV, whereas female gender (OR 2.042; 95% CI 1.143-3.648) or having a mean arterial pressure <80 mmHg (OR 2.275; 95% CI 1.302-3.975) were associated with severe dengue. These findings may help clinicians to determine patients at risk for severe manifestations of dengue infection, which could lead to proper management of these cases.
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Affiliation(s)
- Kyi Lai Lai Aung
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Bhengsri S, Lertiendumrong J, Baggett HC, Thamthitiwat S, Chierakul W, Tisayaticom K, Tanwisaid K, Chantra S, Kaewkungwal J. Economic burden of bacteremic melioidosis in eastern and northeastern, Thailand. Am J Trop Med Hyg 2013; 89:369-73. [PMID: 23798583 DOI: 10.4269/ajtmh.13-0148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Melioidosis is among the most common causes of septicemia in Thailand, but data on economic burden are limited. We describe the economic impact of bacteremic melioidosis hospitalizations in two Thailand provinces during 2006-2008. Costs are presented in US dollars ($1 = 30.49 Thai Baht). The average annual incidence of bacteremic melioidosis cases per 100,000 persons in Sa Kaeo and Nakhon Phanom was 4.6 and 14.4, respectively. The annual cost of bacteremic melioidosis hospitalizations from the societal perspective, including direct and indirect costs, was $152,159 in Sa Kaeo and $465,303 in Nakhon Phanom. The average cost per fatal case was $14,182 and $14,858 in Sa Kaeo and Nakhon Phanom, respectively. In addition to the high morbidity and mortality, the substantial economic burden of melioidosis further supports the need for investments to identify improved prevention and control strategies for melioidosis.
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Affiliation(s)
- Saithip Bhengsri
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Kyaw NL, Thanachartwet V, Kiertiburanakul S, Desakorn V, Chamnanchanunt S, Chierakul W, Manosuthi W, Pitisuttithum P, Sungkanuparph S. Baseline CD4 cell counts and outcomes among adult treatment naive HIV patients after taking fixed dose combination GPO-VIR-S and GPO-VIR-Z in Thailand. Southeast Asian J Trop Med Public Health 2013; 44:232-243. [PMID: 23691633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A retrospective study was conducted by reviewing 459 medical records of adult treatment naive HIV patients who received a fixed dose combination of GPO-VIR-S (stavudine, lamivudine and nevirapine) or GPO-VIR-Z (zidovudine, lamivudine and nevirapine) at Ramathibodi Hospital in Bangkok, Thailand during 2002-2009 following Thai National Treatment Guideline for adults with HIV. The aim of this study was to assess the association between the baseline CD4 cell count and outcome. The median CD4 cell count at baseline, 6, 12 and 102 months were 102 cells/microl, 213 cells/microl, 274 cells/microl and 423 cells/microl. The virologic response (p=0.327), virologic rebound (p=0.626), adverse effects of anti-retroviral therapy (ART) (p=0.976), switching to other ART (p=0.245), occurrence of immune reconstitution inflammatory syndrome (IRIS) (p>0.05) and occurrence of drug resistance (p=0.952) were not significantly associated with baseline CD4 count. The Kaplan-Meier estimate showed the median time (95% CI) to achieve virologic response was 10.4 (9.8-11.0) months and the median time to achieve virologic rebound was 30.0 (21.6-38.4) months after initiation of ART. Analysis showed the median time to achieved virologic response (p=0.401) and virologic rebound (p=0.562) were not significantly associated with the baseline CD4 count. This study shows the outcome after onset of ART did not vary by baseline CD4 cell count.
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Affiliation(s)
- Nyan Lin Kyaw
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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West TE, Chantratita N, Chierakul W, Limmathurotsakul D, Wuthiekanun V, Myers ND, Emond MJ, Wurfel MM, Hawn TR, Peacock SJ, Skerrett SJ. Impaired TLR5 functionality is associated with survival in melioidosis. J Immunol 2013; 190:3373-9. [PMID: 23447684 DOI: 10.4049/jimmunol.1202974] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Melioidosis is infection caused by the flagellated saprophyte Burkholderia pseudomallei. TLR5 is a pathogen recognition receptor activated by bacterial flagellin. We studied a genetic variant that encodes a defective TLR5 protein, TLR5(1174C)>T, to elucidate the role of TLR5 in melioidosis. We measured NF-κB activation induced by B. pseudomallei in human embryonic kidney-293 cells transfected with TLR5 and found that B. pseudomallei induced TLR5(1174C)- but not TLR5(1174T)-dependent activation of NF-κB. We tested the association of TLR5(1174C)>T with outcome in 600 Thai subjects with melioidosis. In a dominant model, TLR5(1174C)>T was associated with protection against in-hospital death (adjusted odds ratio: 0.20; 95% confidence interval: 0.08-0.50; p = 0.001) and organ failure (adjusted odds ratio: 0.37; 95% confidence interval: 0.19-0.71; p = 0.003). We analyzed blood cytokine production induced by flagellin or heat-killed B. pseudomallei by TLR5(1174C)>T genotype in healthy subjects. Flagellin induced lower monocyte-normalized levels of IL-6, IL-8, TNF-α, IL-10, MCP-1, IL-1ra, G-CSF, and IL-1β in carriers of TLR5(1174T) compared with carriers of TLR5(1174C). B. pseudomallei induced lower monocyte-normalized levels of IL-10 in carriers of TLR5(1174T). We conclude that the hypofunctional genetic variant TLR5(1174C)>T is associated with reduced organ failure and improved survival in melioidosis. This conclusion suggests a deleterious immunoregulatory effect of TLR5 that may be mediated by IL-10 and identifies this receptor as a potential therapeutic target in melioidosis.
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Affiliation(s)
- T Eoin West
- International Respiratory and Severe Illness Center, University of Washington, Seattle, WA 98104, USA.
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Limmathurotsakul D, Turner EL, Wuthiekanun V, Thaipadungpanit J, Suputtamongkol Y, Chierakul W, Smythe LD, Day NPJ, Cooper B, Peacock SJ. Fool's gold: Why imperfect reference tests are undermining the evaluation of novel diagnostics: a reevaluation of 5 diagnostic tests for leptospirosis. Clin Infect Dis 2012; 55:322-31. [PMID: 22523263 PMCID: PMC3393707 DOI: 10.1093/cid/cis403] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 03/21/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We observed that some patients with clinical leptospirosis supported by positive results of rapid tests were negative for leptospirosis on the basis of our diagnostic gold standard, which involves isolation of Leptospira species from blood culture and/or a positive result of a microscopic agglutination test (MAT). We hypothesized that our reference standard was imperfect and used statistical modeling to investigate this hypothesis. METHODS Data for 1652 patients with suspected leptospirosis recruited during three observational studies and one randomized control trial that described the application of culture, MAT, immunofluorescence assay (IFA), lateral flow (LF) and/or PCR targeting the 16S rRNA gene were reevaluated using Bayesian latent class models and random-effects meta-analysis. RESULTS The estimated sensitivities of culture alone, MAT alone, and culture plus MAT (for which the result was considered positive if one or both tests had a positive result) were 10.5% (95% credible interval [CrI], 2.7%-27.5%), 49.8% (95% CrI, 37.6%-60.8%), and 55.5% (95% CrI, 42.9%-67.7%), respectively. These low sensitivities were present across all 4 studies. The estimated specificity of MAT alone (and of culture plus MAT) was 98.8% (95% CrI, 92.8%-100.0%). The estimated sensitivities and specificities of PCR (52.7% [95% CrI, 45.2%-60.6%] and 97.2% [95% CrI, 92.0%-99.8%], respectively), lateral flow test (85.6% [95% CrI, 77.5%-93.2%] and 96.2% [95% CrI, 87.7%-99.8%], respectively), and immunofluorescence assay (45.5% [95% CrI, 33.3%-60.9%] and 96.8% [95% CrI, 92.8%-99.8%], respectively) were considerably different from estimates in which culture plus MAT was considered a perfect gold standard test. CONCLUSIONS Our findings show that culture plus MAT is an imperfect gold standard against which to compare alterative tests for the diagnosis of leptospirosis. Rapid point-of-care tests for this infection would bring an important improvement in patient care, but their future evaluation will require careful consideration of the reference test(s) used and the inclusion of appropriate statistical models.
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Affiliation(s)
- Direk Limmathurotsakul
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Desakorn V, Wuthiekanun V, Thanachartwet V, Sahassananda D, Chierakul W, Apiwattanaporn A, Day NP, Limmathurotsakul D, Peacock SJ. Accuracy of a commercial IgM ELISA for the diagnosis of human leptospirosis in Thailand. Am J Trop Med Hyg 2012; 86:524-527. [PMID: 22403329 PMCID: PMC3284374 DOI: 10.4269/ajtmh.2012.11-0423] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Leptospira immunoglobulin M enzyme-linked immunosorbent assay (IgM ELISA) has been recommended for the rapid diagnosis of leptospirosis in endemic areas. We conducted a retrospective case-control study of 218 patients (109 leptospirosis cases confirmed by Leptospira culture and/or microscopic agglutination test and 109 control patients with acute febrile illness) to evaluate the diagnostic accuracy of a commercial IgM ELISA (Panbio) in northeast Thailand. Paired serum samples taken on admission and at least 10 days after the onset of symptoms were tested. Using the cutoff value recommended by the manufacturer (11 Panbio units), sensitivity and specificity of IgM ELISA on paired sera were 90.8% and 55.1%. A receiver operating characteristic curve was used to determine the optimal cutoff value. This was 20 Panbio units, which gave a sensitivity and specificity of 76.1% and 82.6%, respectively, on paired sera. We conclude that using either cutoff value, the accuracy of IgM ELISA is limited in our setting.
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Affiliation(s)
- Varunee Desakorn
- *Address correspondence to Varunee Desakorn, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, 420/6, Rajvithi Road, Bangkok, 10400 Thailand. E-mail:
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Mahavanakul W, Nickerson EK, Srisomang P, Teparrukkul P, Lorvinitnun P, Wongyingsinn M, Chierakul W, Hongsuwan M, West TE, Day NP, Limmathurotsakul D, Peacock SJ. Feasibility of modified surviving sepsis campaign guidelines in a resource-restricted setting based on a cohort study of severe S. aureus sepsis [corrected]. PLoS One 2012; 7:e29858. [PMID: 22363410 PMCID: PMC3283614 DOI: 10.1371/journal.pone.0029858] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 12/07/2011] [Indexed: 01/20/2023] Open
Abstract
Background The Surviving Sepsis Campaign (SSC) guidelines describe best practice for the management of severe sepsis and septic shock in developed countries, but most deaths from sepsis occur where healthcare is not sufficiently resourced to implement them. Our objective was to define the feasibility and basis for modified guidelines in a resource-restricted setting. Methods and Findings We undertook a detailed assessment of sepsis management in a prospective cohort of patients with severe sepsis caused by a single pathogen in a 1,100-bed hospital in lower-middle income Thailand. We compared their management with the SSC guidelines to identify care bundles based on existing capabilities or additional activities that could be undertaken at zero or low cost. We identified 72 patients with severe sepsis or septic shock associated with S. aureus bacteraemia, 38 (53%) of who died within 28 days. One third of patients were treated in intensive care units (ICUs). Numerous interventions described by the SSC guidelines fell within existing capabilities, but their implementation was highly variable. Care available to patients on general wards covered the fundamental principles of sepsis management, including non-invasive patient monitoring, antimicrobial administration and intravenous fluid resuscitation. We described two additive care bundles, one for general wards and the second for ICUs, that if consistently performed would be predicted to improve outcome from severe sepsis. Conclusion It is feasible to implement modified sepsis guidelines that are scaled to resource availability, and that could save lives prior to the publication of international guidelines for developing countries.
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Affiliation(s)
- Weera Mahavanakul
- Department of Medicine, Sappasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Emma K. Nickerson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Pramot Srisomang
- Department of Pediatrics, Sappasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Prapit Teparrukkul
- Department of Medicine, Sappasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Pichet Lorvinitnun
- Department of Medicine, Sappasithiprasong Hospital, Ubon Ratchathani, Thailand
| | - Mingkwan Wongyingsinn
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
- Department of Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Maliwan Hongsuwan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
| | - T. Eoin West
- Department of Medicine and the International Respiratory and Severe Illness Center, Harborview Medical Center, University of Washington, Seattle, Washington, United States of America
| | - Nicholas P. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail: (SP); (DL)
| | - Sharon J. Peacock
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail: (SP); (DL)
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Boonsilp S, Thaipadungpanit J, Amornchai P, Wuthiekanun V, Chierakul W, Limmathurotsakul D, Day NP, Peacock SJ. Molecular detection and speciation of pathogenic Leptospira spp. in blood from patients with culture-negative leptospirosis. BMC Infect Dis 2011; 11:338. [PMID: 22151687 PMCID: PMC3297668 DOI: 10.1186/1471-2334-11-338] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 12/13/2011] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Pathogenic Leptospira spp. present in the blood of patients with leptospirosis during the first week of symptoms can be detected using culture or PCR. A proportion of patients who are positive by PCR are negative by culture. Leptospira spp. are fastidious bacteria, and we hypothesized that a false-negative culture result may represent infection with a distinct bacterial subset that fail to grow in standard culture medium. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Siriphan Boonsilp
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
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Paris DH, Blacksell SD, Nawtaisong P, Jenjaroen K, Teeraratkul A, Chierakul W, Wuthiekanun V, Kantipong P, Day NPJ. Diagnostic accuracy of a loop-mediated isothermal PCR assay for detection of Orientia tsutsugamushi during acute Scrub Typhus infection. PLoS Negl Trop Dis 2011; 5:e1307. [PMID: 21931873 PMCID: PMC3172190 DOI: 10.1371/journal.pntd.0001307] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 07/22/2011] [Indexed: 02/07/2023] Open
Abstract
Background There is an urgent need to develop rapid and accurate point-of-care (POC) technologies for acute scrub typhus diagnosis in low-resource, primary health care settings to guide clinical therapy. Methodology/Principal Findings In this study we present the clinical evaluation of loop-mediated isothermal PCR assay (LAMP) in the context of a prospective fever study, including 161 patients from scrub typhus-endemic Chiang Rai, northern Thailand. A robust reference comparator set comprising following ‘scrub typhus infection criteria’ (STIC) was used: a) positive cell culture isolate and/or b) an admission IgM titer ≥1∶12,800 using the ‘gold standard’ indirect immunofluorescence assay (IFA) and/or c) a 4-fold rising IFA IgM titer and/or d) a positive result in at least two out of three PCR assays. Compared to the STIC criteria, all PCR assays (including LAMP) demonstrated high specificity ranging from 96–99%, with sensitivities varying from 40% to 56%, similar to the antibody based rapid test, which had a sensitivity of 47% and a specificity of 95%. Conclusions/Significance The diagnostic accuracy of the LAMP assay was similar to realtime and nested conventional PCR assays, but superior to the antibody-based rapid test in the early disease course. The combination of DNA- and antibody-based detection methods increased sensitivity with minimal reduction of specificity, and expanded the timeframe of adequate diagnostic coverage throughout the acute phase of scrub typhus. There is an urgent need for alternative diagnostic methods for scrub typhus, but evaluation of these is hampered because the current serological gold standard (IFA) is imperfect. In a study from Thailand, 3 of 20 (15%) patients with fever had a positive Orientia tsutsugamushi PCR result despite negative serology. These findings could reflect potential benefits of the PCR assay in detecting rickettsaemia before antibody responses set in and/or a diagnostic advantage in endemic areas with high background levels of antibody in the population. Serology is complicated by the heterogeneity of strains present in Southeast Asia, but high resource costs and training make realtime PCR assays impractical for many areas where scrub typhus is endemic. This is where the new LAMP methodology has potential: it is inexpensive, simple to perform and requires only a waterbath or simple heating block instead of a thermocycler. In the context of a prospective fever study in a scrub typhus-endemic area in Thailand, the results support the validity of LAMP methodology for the diagnosis of scrub typhus, highlight the difficulties in comparing antibody- with DNA-based methods and also contribute towards understanding the dynamics of bacteraemia in this under recognised and under studied disease.
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Affiliation(s)
- Daniel H. Paris
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Headington, Oxford, United Kingdom
- * E-mail:
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Headington, Oxford, United Kingdom
| | - Pruksa Nawtaisong
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kemajittra Jenjaroen
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Wirongrong Chierakul
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Programme, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Center for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Headington, Oxford, United Kingdom
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Sonthayanon P, Chierakul W, Wuthiekanun V, Thaipadungpanit J, Kalambaheti T, Boonsilp S, Amornchai P, Smythe LD, Limmathurotsakul D, Day NP, Peacock SJ. Accuracy of loop-mediated isothermal amplification for diagnosis of human leptospirosis in Thailand. Am J Trop Med Hyg 2011; 84:614-20. [PMID: 21460019 PMCID: PMC3062458 DOI: 10.4269/ajtmh.2011.10-0473] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
There is a lack of diagnostic tests for leptospirosis in technology-restricted settings. We developed loop-mediated isothermal amplification (LAMP) specific for the 16S ribosomal RNA gene (rrs) of pathogenic and intermediate group Leptospira species. The lower limit of detection was 10 genomic equivalents/reaction, and analytical specificity was high; we observed positive reactions for pathogenic/intermediate groups and negative reactions for non-pathogenic Leptospira species and other bacterial species. We evaluated this assay in Thailand by using a case–control study of 133 patients with laboratory-proven leptospirosis and 133 patients with other febrile illnesses. Using admission blood, we found that the rrs LAMP showed positive results in 58 of 133 cases (diagnostic sensitivity = 43.6, 95% confidence interval [CI] = 35.0–52.5) and in 22 of 133 controls (diagnostic specificity = 83.5, 95% CI = 76.0–89.3). Sensitivity was high for 39 patients who were culture positive for Leptospira spp. (84.6, 95% CI = 69.5–94.1). The rrs LAMP can provide an admission diagnosis in approximately half of patients with leptospirosis, but its clinical utility is reduced by a lower specificity.
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Affiliation(s)
- Piengchan Sonthayanon
- Department of Clinical Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, 420/6 Rajvithi Road, Mahidol University, Bangkok, Thailand.
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Koh GCKW, Maude RR, Schreiber MF, Limmathurotsakul D, Wiersinga WJ, Wuthiekanun V, Lee SJ, Mahavanakul W, Chaowagul W, Chierakul W, White NJ, van der Poll T, Day NPJ, Dougan G, Peacock SJ. Glyburide is anti-inflammatory and associated with reduced mortality in melioidosis. Clin Infect Dis 2011; 52:717-25. [PMID: 21293047 PMCID: PMC3049341 DOI: 10.1093/cid/ciq192] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Patients with diabetes have better survival from septic melioidosis than patients who without diabetes. This difference was seen only in patients taking glyburide prior to presentation and was associated with an anti-inflammatory effect of glyburide. Background. Patients with diabetes mellitus are more prone to bacterial sepsis, but there are conflicting data on whether outcomes are worse in diabetics after presentation with sepsis. Glyburide is an oral hypoglycemic agent used to treat diabetes mellitus. This KATP-channel blocker and broad-spectrum ATP-binding cassette (ABC) transporter inhibitor has broad-ranging effects on the immune system, including inhibition of inflammasome assembly and would be predicted to influence the host response to infection. Methods. We studied a cohort of 1160 patients with gram-negative sepsis caused by a single pathogen (Burkholderia pseudomallei), 410 (35%) of whom were known to have diabetes. We subsequently studied prospectively diabetics with B. pseudomallei infection (n = 20) to compare the gene expression profile of peripheral whole blood leukocytes in patients who were taking glyburide against those not taking any sulfonylurea. Results. Survival was greater in diabetics than in nondiabetics (38% vs 45%, respectively, P = .04), but the survival benefit was confined to the patient group taking glyburide (adjusted odds ratio .47, 95% confidence interval .28–.74, P = .005). We identified differential expression of 63 immune-related genes (P = .001) in patients taking glyburide, the sum effect of which we predict to be antiinflammatory in the glyburide group. Conclusions. We present observational evidence for a glyburide-associated benefit during human melioidosis and correlate this with an anti-inflammatory effect of glyburide on the immune system.
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Affiliation(s)
- Gavin C K W Koh
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
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Thaipadungpanit J, Chierakul W, Wuthiekanun V, Limmathurotsakul D, Amornchai P, Boonslip S, Smythe LD, Limpaiboon R, Hoffmaster AR, Day NPJ, Peacock SJ. Diagnostic accuracy of real-time PCR assays targeting 16S rRNA and lipL32 genes for human leptospirosis in Thailand: a case-control study. PLoS One 2011; 6:e16236. [PMID: 21283633 PMCID: PMC3026019 DOI: 10.1371/journal.pone.0016236] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 12/12/2010] [Indexed: 12/28/2022] Open
Abstract
Background Rapid PCR-based tests for the diagnosis of leptospirosis can provide information that contributes towards early patient management, but these have not been adopted in Thailand. Here, we compare the diagnostic sensitivity and specificity of two real-time PCR assays targeting rrs or lipL32 for the diagnosis of leptospirosis in northeast Thailand. Methods/Principal Findings A case-control study of 266 patients (133 cases of leptospirosis and 133 controls) was constructed to evaluate the diagnostic sensitivity and specificity (DSe & DSp) of both PCR assays. The median duration of illness prior to admission of cases was 4 days (IQR 2–5 days; range 1–12 days). DSe and DSp were determined using positive culture and/or microscopic agglutination test (MAT) as the gold standard. The DSe was higher for the rrs assay than the lipL32 assay (56%, (95% CI 47–64%) versus 43%, (95% CI 34–52%), p<0.001). No cases were positive for the lipL32 assay alone. There was borderline evidence to suggest that the DSp of the rrs assay was lower than the lipL32 assay (90% (95% CI 83–94%) versus 93%, (95%CI 88–97%), p = 0.06). Nine controls gave positive reactions for both assays and 5 controls gave a positive reaction for the rrs assay alone. The DSe of the rrs and lipL32 assays were high in the subgroup of 39 patients who were culture positive for Leptospira spp. (95% and 87%, respectively, p = 0.25). Conclusions/Significance Early detection of Leptospira using PCR is possible for more than half of patients presenting with leptospirosis and could contribute to individual patient care.
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Affiliation(s)
- Janjira Thaipadungpanit
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Sonthayanon P, Peacock SJ, Chierakul W, Wuthiekanun V, Blacksell SD, Holden MTG, Bentley SD, Feil EJ, Day NPJ. High rates of homologous recombination in the mite endosymbiont and opportunistic human pathogen Orientia tsutsugamushi. PLoS Negl Trop Dis 2010; 4:e752. [PMID: 20651929 PMCID: PMC2907413 DOI: 10.1371/journal.pntd.0000752] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 06/03/2010] [Indexed: 11/19/2022] Open
Abstract
Orientia tsutsugamushi is an intracellular alpha-proteobacterium which resides in trombiculid mites, and is the causative agent of scrub typhus in East Asia. The genome sequence of this species has revealed an unprecedented number of repeat sequences, most notably of the genes encoding the conjugative properties of a type IV secretion system (T4SS). Although this observation is consistent with frequent intragenomic recombination, the extent of homologous recombination (gene conversion) in this species is unknown. To address this question, and to provide a protocol for the epidemiological surveillance of this important pathogen, we have developed a multilocus sequence typing (MLST) scheme based on 7 housekeeping genes (gpsA, mdh, nrdB, nuoF, ppdK, sucD, sucB). We applied this scheme to the two published genomes, and to DNA extracted from blood taken from 84 Thai scrub typhus patients, from 20 cultured Thai patient isolates, 1 Australian patient sample, and from 3 cultured type strains. These data demonstrated that the O. tsutsugamushi population was both highly diverse [Simpson's index (95% CI) = 0.95 (0.92-0.98)], and highly recombinogenic. These results are surprising given the intracellular life-style of this species, but are broadly consistent with results obtained for Wolbachia, which is an alpha-proteobacterial reproductive parasite of arthropods. We also compared the MLST data with ompA sequence data and noted low levels of consistency and much higher discrimination by MLST. Finally, twenty-five percent of patients in this study were simultaneously infected with multiple sequence types, suggesting multiple infection caused by either multiple mite bites, or multiple strains co-existing within individual mites.
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Affiliation(s)
- Piengchan Sonthayanon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
| | - Sharon J. Peacock
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Wirongrong Chierakul
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Vanaporn Wuthiekanun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stuart D. Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Edward J. Feil
- Department of Biology and Biochemistry, University of Bath, Bath, United Kingdom
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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Suputtamongkol Y, Pongtavornpinyo W, Lubell Y, Suttinont C, Hoontrakul S, Phimda K, Losuwanaluk K, Suwancharoen D, Silpasakorn S, Chierakul W, Day N. Strategies for diagnosis and treatment of suspected leptospirosis: a cost-benefit analysis. PLoS Negl Trop Dis 2010; 4:e610. [PMID: 20186324 PMCID: PMC2826401 DOI: 10.1371/journal.pntd.0000610] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 12/30/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Symptoms and signs of leptospirosis are non-specific. Several diagnostic tests for leptospirosis are available and in some instances are being used prior to treatment of leptospirosis-suspected patients. There is therefore a need to evaluate the cost-effectiveness of the different treatment strategies in order to avoid misuse of scarce resources and ensure best possible health outcomes for patients. METHODS The study population was adult patients, presented with uncomplicated acute febrile illness, without an obvious focus of infection or malaria or typical dengue infection. We compared the cost and effectiveness of 5 management strategies: 1) no patients tested or given antibiotic treatment; 2) all patients given empirical doxycycline treatment; patients given doxycycline when a patient is tested positive for leptospirosis using: 3) lateral flow; 4) MCAT; 5) latex test. The framework used is a cost-benefit analysis, accounting for all direct medical costs in diagnosing and treating patients suspected of leptospirosis. Outcomes are measured in length of fever after treatment which is then converted to productivity losses to capture the full economic costs. FINDINGS Empirical doxycycline treatment was the most efficient strategy, being both the least costly alternative and the one that resulted in the shortest duration of fever. The limited sensitivity of all three diagnostic tests implied that their use to guide treatment was not cost-effective. The most influential parameter driving these results was the cost of treating patients with complications for patients who did not receive adequate treatment as a result of incorrect diagnosis or a strategy of no-antibiotic-treatment. CONCLUSIONS Clinicians should continue treating suspected cases of leptospirosis on an empirical basis. This conclusion holds true as long as policy makers are not prioritizing the reduction of use of antibiotics, in which case the use of the latex test would be the most efficient strategy.
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Cheng AC, Wuthiekanun V, Limmathurotsakul D, Chierakul W, Peacock SJ. Intensity of exposure and incidence of melioidosis in Thai children. Trans R Soc Trop Med Hyg 2009; 102 Suppl 1:S37-9. [PMID: 19121683 DOI: 10.1016/s0035-9203(08)70010-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
There is a high background seroprevalence of antibodies to Burkholderia pseudomallei in Thailand that limits its use as a diagnostic tool. It is believed that this results from childhood exposure to the bacterium in mud and surface water. The increasing prevalence of antibodies with age is a marker of the intensity of exposure. A susceptible-infected-susceptible (SIS) model was calibrated with data on seroprevalence in children (<15 years) in Udon Thani and Ubon Ratchathani (n=2214). In this mathematical model, children were assumed to gain antibodies at a constant rate related to exposure events, and waning antibody response occurred at a constant rate. The intensity of exposure appeared to be higher in Udon Thani than in Ubon Ratchathani, with 24% vs. 11% of patients becoming seropositive each year. In Udon Thani children, antibodies appeared to be long-lasting, compared with those in Ubon Ratchathani, where the mean duration was 5.2 years. Based on an estimated paediatric disease incidence in Ubon Ratchathani of 4.15 per 100,000 population, it is estimated that approximately 1 in 4600 antibody-producing exposures results in clinical infection. Childhood seroprevalence can be used as a marker of intensity of exposure. Further work to separate the effect of exposure to B. thailandensis and cross-reactivity to B. pseudomallei is proposed.
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Affiliation(s)
- Allen C Cheng
- Department of Medicine, University of Melbourne, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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42
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Smythe LD, Wuthiekanun V, Chierakul W, Suputtamongkol Y, Tiengrim S, Dohnt MF, Symonds ML, Slack AT, Apiwattanaporn A, Chueasuwanchai S, Day NP, Peacock SJ. The microscopic agglutination test (MAT) is an unreliable predictor of infecting Leptospira serovar in Thailand. Am J Trop Med Hyg 2009; 81:695-7. [PMID: 19815889 DOI: 10.4269/ajtmh.2009.09-0252] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A prospective study in Thailand identified 106 patients with culture-proven leptospirosis. The accuracy of the microscopic agglutination test (MAT) in predicting the infecting serovar was evaluated in 78/106 (74%) patients with a diagnostic titer. MAT correctly determined the infecting serovar in 26 cases (33%), indicating that this assay is a poor predictor of infecting serovar in our setting.
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Affiliation(s)
- Lee D Smythe
- WHO/FAO/OIE Collaborating Centre for Reference and Research on Leptospirosis, Western Pacific Region, Communicable Disease Unit, Queensland Health Scientific Services, Brisbane, Australia
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43
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Niwattayakul K, Kaewtasi S, Chueasuwanchai S, Hoontrakul S, Chareonwat S, Suttinont C, Phimda K, Chierakul W, Silpasakorn S, Suputtamongkol Y. An open randomized controlled trial of desmopressin and pulse dexamethasone as adjunct therapy in patients with pulmonary involvement associated with severe leptospirosis. Clin Microbiol Infect 2009; 16:1207-12. [PMID: 19732091 DOI: 10.1111/j.1469-0691.2009.03037.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary involvement in leptospirosis is emerging as a common complication of severe leptospirosis. A prospective randomized controlled trial of desmopressin or high-dose (pulse) dexamethasone as adjunctive therapy in 68 patients with pulmonary involvement associated with severe leptospirosis was conducted between July 2003 and October 2006 at five hospitals in Thailand. There were 23 patients in the desmopressin group, 22 in the pulse dexamethasone group, and 23 in a control group who received standard critical care alone. The diagnosis of leptospirosis was confirmed in 52 patients (77%). There were 15 deaths (22%), of which eight patients received desmopressin, four patients received pulse dexamethasone, and three patients received critical care alone (p 0.19). Eight patients with confirmed leptospirosis died (five patients in the desmopressin group, one in the pulse dexamethasone group and two in the control group). The mortality was not significantly different in the desmopressin group or pulse dexamethasone group compared to the control group in both intention-to-treat patients, and in patients with confirmed leptospirosis. There were no serious events associated with desmopressin treatment, although pulse dexamethasone treatment was associated with a significant increase in nosocomial infection. The results of logistic regression analysis revealed that serum bilirubin level was the only significant risk factor associated with mortality (OR 0.759, 95% CI 0.598-0.965, p 0.024). The results obtained in the present study do not support the use of either pulse dexamethasone or desmopressin as adjunct therapy for pulmonary involvement associated with severe leptospirosis.
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Affiliation(s)
- K Niwattayakul
- Medical Department, Loei Hospital, Loei Province, Thailand
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44
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Bicanic T, Muzoora C, Brouwer AE, Meintjes G, Longley N, Taseera K, Rebe K, Loyse A, Jarvis J, Bekker LG, Wood R, Limmathurotsakul D, Chierakul W, Stepniewska K, White NJ, Jaffar S, Harrison TS. Independent association between rate of clearance of infection and clinical outcome of HIV-associated cryptococcal meningitis: analysis of a combined cohort of 262 patients. Clin Infect Dis 2009; 49:702-9. [PMID: 19613840 PMCID: PMC2965403 DOI: 10.1086/604716] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Progress in therapy for cryptococcal meningitis has been slow because of the lack of a suitable marker of treatment response. Previously, we demonstrated the statistical power of a novel endpoint, the rate of clearance of infection, based on serial quantitative cultures of cerebrospinal fluid, to differentiate the fungicidal activity of alternative antifungal drug regimens. We hypothesized that the rate of clearance of infection should also be a clinically meaningful endpoint. METHODS We combined data from cohorts of patients with human immunodeficiency virus-associated cryptococcal meningitis from Thailand, South Africa, and Uganda, for whom the rate of clearance of infection was determined, and clinical and laboratory data prospectively collected, and explored the association between the rate of clearance of infection and mortality by Cox survival analyses. RESULTS The combined cohort comprised 262 subjects. Altered mental status at presentation, a high baseline organism load, and a slow rate of clearance of infection were independently associated with increased mortality at 2 and 10 weeks. Rate of clearance of infection was associated with antifungal drug regimen and baseline cerebrospinal fluid interferon-gamma levels. CONCLUSIONS The results support the use of the rate of clearance of infection or early fungicidal activity as a means to explore antifungal drug dosages and combinations in phase II studies. An increased understanding of how the factors determining outcome interrelate may help clarify opportunities for intervention.
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Affiliation(s)
- Tihana Bicanic
- Centre for Infection, St. George’s University of London, London, UK
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa and Department of Medicine, University of Cape Town, South Africa
| | - Conrad Muzoora
- Department of Medicine, Mbarara University Hospital, Mbarara, Uganda
| | - Annemarie E Brouwer
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Nijmegen, The Netherlands
| | - Graeme Meintjes
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa and Department of Medicine, University of Cape Town, South Africa
| | - Nicky Longley
- Centre for Infection, St. George’s University of London, London, UK
| | - Kabanda Taseera
- Department of Medicine, Mbarara University Hospital, Mbarara, Uganda
| | - Kevin Rebe
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa and Department of Medicine, University of Cape Town, South Africa
| | - Angela Loyse
- Centre for Infection, St. George’s University of London, London, UK
| | - Joseph Jarvis
- Centre for Infection, St. George’s University of London, London, UK
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa and Department of Medicine, University of Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | | | | | - Kasia Stepniewska
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford
| | - Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford
| | - Shabbar Jaffar
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
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45
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Suputtamongkol Y, Suttinont C, Niwatayakul K, Hoontrakul S, Limpaiboon R, Chierakul W, Losuwanaluk K, Saisongkork W. Epidemiology and clinical aspects of rickettsioses in Thailand. Ann N Y Acad Sci 2009; 1166:172-9. [PMID: 19538278 DOI: 10.1111/j.1749-6632.2009.04514.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Scrub typhus and murine typhus are widespread in Thailand. Clinical manifestations of both diseases are nonspecific and vary widely. Acute undifferentiated fever (AUF), with or without organ dysfunction, is a major clinical presentation of these two diseases. The epidemiology and clinical manifestations including severe complications of scrub typhus and murine typhus in Thailand are summarized. Sixteen hundred and sixty-three patients with AUF were studied in six hospitals in Thailand between 2000 and 2003. Scrub typhus and murine typhus were diagnosed in 16.1% and 1.7% of them, respectively. Clinical spectrum of murine typhus was similar to scrub typhus. Hepatic dysfunction and pulmonary involvement were common complications. Multi-organ dysfunction mimicking sepsis syndrome occurred in 11.9% of patients with scrub typhus. The mortality of severe scrub typhus varied from 2.6% to 16.7%. Awareness that scrub typhus and murine typhus are prominent causes of AUF in adults in Thailand improves the probability of an accurate clinical diagnosis. Early recognition and appropriate treatment reduces morbidity and mortality. Results from recent clinical studies from Thailand indicated that rational antimicrobial therapy would be doxycycline in mild cases and a combination of either cefotaxime or ceftriaxone and doxycycline in severe cases. Azithromycin could be considered as an alternative treatment when doxycycline allergy is suspected. This would be either curative, or have no ill effect, in the majority of instances. Failure to improve or defervesce within 48 hours would indicate the need to perform a thorough re-evaluation of clinical findings and initial laboratory investigation results, as well as a need to change antibiotic.
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Affiliation(s)
- Y Suputtamongkol
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok.
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46
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Wongsuvan G, Limmathurotsakul D, Wannapasni S, Chierakul W, Teerawattanasook N, Wuthiekanun V. Lack of correlation of Burkholderia pseudomallei quantities in blood, urine, sputum and pus. Southeast Asian J Trop Med Public Health 2009; 40:781-784. [PMID: 19842414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
We evaluated the correlation of Burkholderia pseudomallei quantities in blood versus urine, sputum or pus. Correlations between bacterial counts in blood and other samples were not found. It is likely that an initial seeding event to extracellular organs is followed by independent growth of B. pseudomallei, and that bacteria in the urine were not passively filtered from the bloodstream.
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47
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Teparrakkul P, Tsai JJ, Chierakul W, Gerstenmaier JF, Wacharaprechasgu T, Piyaphanee W, Limmathurotsakul D, Chaowagul W, Day NP, Peacock SJ. Rheumatological manifestations in patients with melioidosis. Southeast Asian J Trop Med Public Health 2008; 39:649-655. [PMID: 19058601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Melioidosis, an infection caused by the bacterium Burkholderia pseudomallei, has a wide range of clinical manifestations. Here, we describe rheumatological melioidosis (involving one or more of joint, bone or muscle), and compare features and outcome with patients without rheumatological involvement. A retrospective study of patients with culture-confirmed melioidosis admitted to Sappasithiprasong Hospital, Ubon Ratchathani during 2002 and 2005 identified 679 patients with melioidosis, of whom 98 (14.4%) had rheumatological melioidosis involving joint (n=52), bone (n = 5), or muscle (n = 12), or a combination of these (n=29). Females were over-represented in the rheumatological group, and diabetes and thalassemia were independent risk factors for rheumatological involvement (OR; 2.49 and 9.56, respectively). Patients with rheumatological involvement had a more chronic course, as reflected by a longer fever clearance time (13 vs 7 days, p = 0.06) and hospitalization (22 vs 14 days, p < 0.001), but lower mortality (28% vs 44%, p = 0.005). Patients with signs and symptoms of septic arthritis for longer than 2 weeks were more likely to have extensive infection of adjacent bone and muscle, particularly in diabetic patients. Surgical intervention was associated with a survival benefit, bur not a shortening of the course of infection.
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Affiliation(s)
- P Teparrakkul
- Medical Department, Sappasithiprasong Hospital, Ubon Ratchathani, Thailand.
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48
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Chierakul W, Tientadakul P, Suputtamongkol Y, Wuthiekanun V, Phimda K, Limpaiboon R, Opartkiattikul N, White NJ, Peacock SJ, Day NP. Activation of the coagulation cascade in patients with leptospirosis. Clin Infect Dis 2008; 46:254-60. [PMID: 18171258 DOI: 10.1086/524664] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is common among patients with sepsis. Leptospirosis is an important cause of sepsis in tropical areas, and pulmonary hemorrhage associated with thrombocytopenia is the major cause of death, but the coagulopathy in severe leptospirosis has not been further characterized. The aim of this study was to evaluate coagulation factors and the presence of DIC in patients with leptospirosis in northeast Thailand. METHODS We measured plasma concentrations of fibrinogen, D-dimer, thrombin-antithrombin III complexes, and prothrombin fragment 1,2 and evaluated the DIC score in 79 patients with culture-confirmed and/or serologically confirmed leptospirosis and in 33 healthy Thai control subjects. RESULTS The median concentrations of fibrinogen, D-dimer, thrombin-antithrombin III complexes, and prothrombin fragment 1,2 were significantly elevated in a cohort of 79 patients with leptospirosis, compared with healthy control subjects (P<or=.001 for all tests). Patients with leptospirosis had significantly longer prothrombin times, longer activated partial thromboplastin times, and lower platelet counts. Thrombocytopenia was present in 38% of case patients and occurred more frequently among patients with culture-negative leptospirosis; in multivariate analysis, it was the only hemostasis factor independently associated with clinical bleeding. Patients who were culture-negative for Leptospira species had higher Acute Physiology and Chronic Health Evaluation II and Sepsis-Related Organ Failure Assessment scores and more bleeding complications. Nearly one-half of patients with leptospirosis had overt DIC as defined by an International Society on Thrombosis and Hemostasis DIC score. CONCLUSIONS Activation of the coagulation system is an important feature of leptospirosis. Thrombocytopenia is an indicator of severe disease and risk of bleeding.
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Affiliation(s)
- Wirongrong Chierakul
- Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand.
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49
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Cheng AC, Currie BJ, Chaowagul W, Dance DAB, Peacock SJ, Chetchotisakd P, Chierakul W, Limmathurotsakul D. Consensus Guidelines for Dosing of Amoxicillin-Clavulanate in Melioidosis. Am J Trop Med Hyg 2008. [DOI: 10.4269/ajtmh.2008.78.208] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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50
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Cheng AC, Chierakul W, Chaowagul W, Chetchotisakd P, Limmathurotsakul D, Dance DAB, Peacock SJ, Currie BJ. Consensus guidelines for dosing of amoxicillin-clavulanate in melioidosis. Am J Trop Med Hyg 2008; 78:208-209. [PMID: 18256414 PMCID: PMC3034162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Melioidosis is an infectious disease endemic to northern Australia and Southeast Asia. In response to clinical confusion regarding the appropriate dose of amoxicillin-clavulanate, we have developed guidelines for the appropriate dosing of this second-line agent. For eradication therapy for melioidosis, we recommend 20/5 mg/kg orally, three times daily.
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Affiliation(s)
- Allen C Cheng
- Department of Medicine, University of Melbourne, Melbourne, Australia.
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