24 research outputs found
Septic Pulmonary Embolism Following Appendectomy Surgery
Septic Pulmonary embolism is a rare condition where there were numerous pulmonary infarcts resulting from blood clot emboli that also contains microorganism. This disorder is insidious onset, Its clinical features usually unspecific and the diagnosis usually difficult to establish. A 43 old woman who underwent an appendicitis surgery, reentered the hospital at the sixth day after surgery presented with fever, pain at the surgical site, progressive severe dyspnea and chest tightness. From the physical examination finding there were tachycardia, tachypneu, wet rough basal rhonki on the right rear and tenderness at right lower region of the abdomen. The thorax-abdomen CT scan result was pleuropneumonial with minimal effusion in the right side. ACT angiography scan of the chest and abdomen showed intralumen emboli in medial lobe segmen of right pulmonary artery, right pleuropneumonia with segmental lession in segmen 10 right lobe and inflammation process along right lateral wall of the abdomen. Laboratory results that also supported diagnosis were D dimer 3442 ng/mL and culture result from surgical site pus showed E. Coli ESBL (+). Base on these findings, this case was established as a septic pulmonary embolism.Key words: septic pulmonary embolism, appendicitis surgery, E. coli ESBL (+)
Intestinal Amebiasis: Diagnosis and Management
Intestinal amebiasis is an infection due to Entamoeba Histolytica and has the highest prevalence in tropical countries, including Indonesia. Amebiasis is responsible for approximately 70,000 deaths annually every year. High prevalence is found especially in endemic area which had poor hygiene and sanitation or crowded population. Human is the main reservoir, while the disease can be transmited by mechanical vector such as cokckroach and flies. Making diagnosis of intestinal amebiasis sometimes can be a problem. Clinical presentation and disease severity may be varied. Complication due to late management of the disease can be fatal. Lifestyle education, early diagnosis and proper management of amebiasis are very important measures to promote by health workers
Nosocomial Clostridium Difficile Diarrhea in Patient with Malignancy
Clostridium difficile (C. difficile) is the main pathogen causing antibiotics associated diarrhea and colitis. This bacterium increases with hospitalization with incidence of 20-60 cases per 100,000 patients/day. C. difficile is gram positive bacilli which produce toxins in 2,700 cases in every 100,000 exposures to particular antibiotics, such as clindamycin, cephalosporin, and ampicillin. These antibiotics disrupt the intestinal normal flora and predispose to colonization of C. difficile. This case described a 53-year old male patient with squamous cell carcinoma in his left ear who came to Department of Internal Medicine, Cipto Mangunkusumo Hospital, with the complain of diarrhea since two weeks after one month hospitalization in Department of Ear, Nose, and Throat. The characteristics of the diarrhea were 10 times per day ± 100 mL, watery consistency, green yellowish in color, and no blood in the feces. Additionally, the patient also complained of pain in all parts of his stomach, especially in the epigastric area. Earlier, patient was given ceftazidime for 30 days of hospitalization. The serology examination of C. difficile in the feces showed positive result (titer = 0.790 and control = 0.190). During the colonoscopy examination, pancolitis was found and the pathologic anatomy result was found appropriate for infective colitis. Thereafter, antibiotic administration was ceased and metronidazole was administered intravenously three times a day. The diarrhea stopped after seven days and the patient was discharged
Candidiasis in Malignancy
Esophageal candidiasis presents with a range of clinical findings and is rarely found among immunocompetent patient without predisposing factors. Between 20-50% of patient may be asymptomatic. One of predisposing factor of candidiasis is immunocompromised condition due to Malignancy. Dysphagia is the most frequently presented feature of esophageal carcinoma. We demonstrated a case of esophageal candidiasis as one of early clinical presentation in patient with esophageal carcinoma
Clinical Characteristic and Prevalence of Invasive Candidiasis Patient in Cipto Mangunkusumo Hospital
Introduction. Incidence of invasive fungal infections (IFI) are reportedly increasing in many countries. Candida is the most common cause of IFI. This study was conducted to determine the prevalence, clinical characteristics, and etiologic pathogen in adult patients with invasive candidiasis (IC) at Cipto Mangunkusumo Hhospital.
Methods. This was a cross sectional study with restropective data collection fromof septic patients that’ medical records hospitalized in January 2012 until June 2014. Subjects were selected based on EORTC/MSG 2008 diagnostic criteria for IC. Demographic data, clinical and supporting data, diagnosis, etiologic pathogens, antibiotics, antifungal, outcome, and length of stay were recorded.
Results. The IC prevalence at Cipto Mangunkusumo hospital was 12,3% (91 patients from total of 738 sepsis patients). Subjects consisted of 35 proven, 31 probable, and 25 possible invasive candidiasis patients. Candidemia was the most common form of IC and C. albicans was the most common etiologic pathogen. Mean age were 47,9 years, dominated with medical non-neutropenic, and septic shock patient. Most patients had malignancy with lung infection. The most common medical intervention was urinary catheter. Most patients were given 3rd generation cephalosporin and the most common antifungal used was fluconazole. Forty four percent of IC patients did not get systemic antifungal treatment. Mortality rate was 64.8% and median length of stay were 27 days.
Conclusions. IC prevalence was 12,3%. Mortality due to IC was high and C. albicans was the most common etiologic pathogen
The Role of Lactate Clearance in Severe Septic Patients Survival
Introduction. Severe Sepsis is a major health problem that known to results high mortality rate, and still its incidents continue to rise. Lactate clearance represents kinetics alteration of anaerobic metabolism in severe septic patients that makes it to become a potential parameter to evaluate severity of one’s illness and intervention adequacy that received by the patient. However, the relationship between lactate clearance and occurrence of death in severe septic patients is still unknown.
Methods. This is a prospective cohort study that conducted in Ciptomangunkusumo Hospital, from March to May 2011. Patients were categorized into high lactate clearance group if there were differences in lactate levels ≥ 10% in which occurred within the first 6 hours of the treatment, and contrary were categorized into low lactate clearance group. Occurrences of death were observed within the first 10 days. Afterward, the data were analyzed by means of survival analysis, Kapplan Meier curve were made, survival rate and median survival rate were determined, statistical test were calculated using log-rank test, and hazard ratios were calculated using Cox regression model test. Analysis of Confounder Variable was also performed using multivariate Cox regression test.
Results. The survival rate for high and low lactate clearance group were 60.0% vs. 26.7%, respectively (p=0,004). In low lactate clearance group the median survival was 3 days, while the mortality rate did not reach 50% in high lactate clearance group. The first Interquartile for these two groups was 1 day and 4 days, respectively. The hazard ratio that obtained from the analysis was 2.87 (95% CI, 1.41 - 5.83). On multivariate analysis the presence of septic shock, SOFA score, the use of vasopresor/inotropic, blood transfusion, fluid resuscitation didn’t change the hazard ratio value more than 10%. For that reason, these parameters were not considered as confounder.
Conclusions. Patients with high lactate clearance have a better survival rate compared to patients with low lactate clearance, and its relationship is not influenced by confounder
Enhanced bedside mortality prediction combining point-of-care lactate and the quick Sequential Organ Failure Assessment (qSOFA) score in patients hospitalised with suspected infection in southeast Asia: a cohort study
Background: Simple, bedside prediction of infection-related mortality in low-resource settings is crucial for triage and resource-utilisation decisions. We aimed to evaluate mortality prediction by combining point-of-care venous lactate with the quick Sequential Organ Failure Assessment (qSOFA) score in adult patients admitted to hospital with suspected infection in southeast Asia.
Methods: We performed a cohort study by prospectively enrolling patients aged 18 years or older who had been admitted to hospital within the previous 24 h for suspected infection (with at least three documented systemic manifestations of infection according to the 2012 Surviving Sepsis Campaign) at Sunpasitthiprasong Hospital in Ubon Ratchathani, Thailand (derivation cohort). Venous lactate concentration was determined by a point-of-care device and multiple scores were developed. We then evaluated candidate 28-day mortality prediction models combining qSOFA and the lactate scores. A final model was compared with the qSOFA score, a lactate score, and a modified Sequential Organ Failure Assessment (SOFA) score for mortality discrimination using the area under the receiver operating characteristic curve (AUROC). Mortality discrimination of the qSOFA-lactate score was then verified in an external, prospectively enrolled, multinational cohort in southeast Asia.
Findings: Between March 1, 2013, and Jan 26, 2017, 5001 patients were enrolled in the derivation cohort; 4980 had point-of-care lactate data available and were eligible for analysis, and 816 died within 28 days of enrolment. The discrimination for 28-day mortality prediction of a qSOFA-lactate score combining the qSOFA score and a lactate score was superior to that of the qSOFA score alone (AUROC 0·78 [95% CI 0·76–0·80] vs 0·68 [0·67–0·70]; p<0·0001) and similar to a modified SOFA score (0·77 [0·75–0·78]; p=0·088). A lactate score alone had superior discrimination compared with the qSOFA score (AUROC 0·76 [95% CI 0·74–0·78]; p<0·0001). 815 patients were enrolled in the external validation cohort and 792 had point-of-care lactate data and were included in the analysis; the qSOFA-lactate score (AUROC 0·77 [95% CI 0·73–0·82]) showed significantly improved 28-day mortality discrimination compared with the qSOFA score alone (0·69 [0·63–0·74]; p<0·0001).
Interpretation: In southeast Asia, rapid, bedside assessments based on point-of-care lactate concentration combined with the qSOFA score can identify patients at risk of sepsis-related mortality with greater accuracy than the qSOFA score alone, and with similar accuracy to a modified SOFA score.
Funding: National Institutes of Health, Wellcome Trust
Colonic Tuberculosis: a High Index of Suspicion
Tuberculosis remains to be one of the most common problems in developing countries such as Indonesia. It can involve many organs including gastrointestinal tract. Colonic tuberculosis is an ancient disease and has long been recognized. However, it is sometimes difficult to make early diagnosis due to nonspecific sign and symptoms. In endemic areas, correct diagnoses were made only 50% of the time. Without a high index of suspicion of the disease, it has been rarely diagnosed correctly. We reported a case of colonic tuberculosis in 18 years old female patient with lung tuberculosis.Endoscopic examination showed ulcerative mucosa, ‘halo lesion\u27, and pseudopolyp while PPD skin test, sputum smear and histopathological examination of endoscopic biopsy revealed negative for tuberculosis infection. The presence of lung tuberculosis had made high index of suspicion of colonic tuberculosis. Standard regimen of antituberculosis therapy was given and the patient showed good clinical response
Association between Early Antibiotic Administration and In-Hospital Mortality in Moderate and Severe COVID-19 Patients
Introduction. Patients with moderate and severe COVID-19 generally receive antibiotic therapy with consideration of the possibility of co-infection or secondary bacterial infection which clinically is difficult to distinguish from COVID-19 symptoms. Overuse of antibiotics can lead to an increased risk of bacterial resistance to antibiotics which is associated with poor outcomes in COVID-19 patients. This study aimed to assess the effect of early antibiotic administration on mortality in moderate and severe COVID-19 patients. Methods. An observational study with a retrospective cohort design was conducted at Dr. Cipto Mangunkusumo Hospital. Data were obtained from medical records of patients admitted from March to September 2020. Patients who received early antibiotics were defined as patients who received antibiotics hospital, 108 subjects were included in this study, 74 (68.5%) with moderate degrees and 34 (31.5%) with severe degrees. Early antibiotics were administered to 79 (73.1%) subjects with a median start time of one day. The results of the bivariate analysis did not find a significant effect of early antibiotic administration on mortality in moderate or severe COVID-19 patients (p=0.42). Subgroup analysis based on the degree of disease also found no significant results. Conclusion. There is no relationship between early antibiotic administration and mortality of moderate and severe COVID-19 patients
Diagnostic and antibiotic use practices among COVID-19 and non-COVID-19 patients in the Indonesian National Referral Hospital
Background:Â Little is known about diagnostic and antibiotic use practices in low and middle-income countries (LMICs) before and during COVID-19 pandemic. This information is crucial for monitoring and evaluation of diagnostic and antimicrobial stewardships in healthcare facilities.
Methods:Â We linked and analyzed routine databases of hospital admission, microbiology laboratory and drug dispensing of Indonesian National Referral Hospital from 2019 to 2020. Patients were classified as COVID-19 cases if their SARS-CoV-2 RT-PCR result were positive. Blood culture (BC) practices and time to discontinuation of parenteral antibiotics among inpatients who received a parenteral antibiotic for at least four consecutive days were used to assess diagnostic and antibiotic use practices, respectively. Fine and Grey subdistribution hazard model was used.
Results: Of 1,311 COVID-19 and 58,917 non-COVID-19 inpatients, 333 (25.4%) and 18,837 (32.0%) received a parenteral antibiotic for at least four consecutive days. Proportion of patients having BC taken within ±1 calendar day of parenteral antibiotics being started was higher in COVID-19 than in non-COVID-19 patients (21.0% [70/333] vs. 18.7% [3,529/18,837]; p<0.001). Cumulative incidence of having a BC taken within 28 days was higher in COVID-19 than in non-COVID-19 patients (44.7% [149/333] vs. 33.2% [6,254/18,837]; adjusted subdistribution-hazard ratio [aSHR] 1.71, 95% confidence interval [CI] 1.47–1.99, p<0.001). The median time to discontinuation of parenteral antibiotics was longer in COVID-19 than in non-COVID-19 patients (13 days vs. 8 days; aSHR 0.73, 95%Cl 0.65–0.83, p<0.001).
Conclusions:Â Routine electronic data could be used to inform diagnostic and antibiotic use practices in LMICs. In Indonesia, the proportion of timely blood culture is low in both COVID-19 and non-COVID-19 patients, and duration of parenteral antibiotics is longer in COVID-19 patients. Improving diagnostic and antimicrobial stewardship is critically needed