Note: ID-RAMA workshop 2017 (18-19 May 2017)

18/May/2017 -- infectious disease workshop

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Aj.boonmee

At the first beginning around 1980, there was the boom of antibiotics and  

Evident based medicine in infectious disease

The infectious disease;

Host, environment and microorganism

Aging pop, is the immunocompromised by itself and we have to be aware of this one

Or even the cancer patient that receive immunosuppressive or even ppl who receive drug to relieve autoimmune disease, acquired immunodeficiency, hiv and non hiv, or synthetic organ that can cause infection..new modern technology.

Resistant organism will be the big problem in the future...esp the drugs being used..., or even the microbes that not used to be the pathogen and becoming the pathogens bc the host health status change, like on immunosuppressive drug.

NTM.. non tuberculous Mycobacterium

The situation that she concerns is the resistant of TB, she suggested to sent culture in order to get the sensitivity result, she mention to treat he full stream and then after getting the result then adjust the dose..from the lab result. As can see in the charge that there are new patients who have the resistant strains or even the patients who have been treated... they develop the resistant. Besides that, there are the social impact on the TB, like ppl in jail or even ppl who live at the country edge.

MDR TB 1 year/case --- a million we need to stop the spreading/also we are about to step out from the developing country, so the grant from who will be cut and we have to support by ourself.

Culture is too slow and some time we can use the genetic test that can reflect to the resistant...the problem is we need to do it fast.

The vaccine is very expensive (talking in general)

Leishmania siamenesis -- new case that can be found in 

Diagnostic --

Less sophisticate

Can be applied to the rural area

Super easy

Get all the answers

Economical

Types --

Genetic

Mass spec (actually she does not much, but she tried to understand it, she said this is something might be very promising ... but have to culture anyway, besides that need to get the right database anyway.

Biomarker/Biosignature in the term of host when response to the pathogens. 

Looking for the future, there might be some tests in the host indicating that the patients have what kind of diseases..one easy test either infectious or cancer or whatever...or in the term of infectious which groups of microbes being infected..

She also mentioned that always have the prediction first before sending to the test...because most if the time the tests are given the fault positive.., used the own guts and starting the treatment right away while waiting for the result.

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Aj.Kumthorn

He is talking about CRE, carbapenem resistant bact. He is talking about the spreading around the world but we lack the information in Thailand. They have the 

Clostridium difficile --  most case reported in Europe and it affected the aging population. There are several drugs on these..chemical or even microbe stool that change the microbiota..and relapse of this pathogen. Monoclonal antibody is also available. Thailand situation... not many cases so far but it is climbing up and since the aging population is 

Health Care-Surveillance 

Guideline in the CDC is always changed. Need to keep up to date, in order to prevent the infection during the nursing or operating with the sterile zone in the patients.

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Aj.Aungsana

If the drug binds to the protein,  but the rest conc. higher than the mic, then it should be ok.

The resistant can be the developed by he change in the influx and efflux of pathogen, the mutation at the site of action..

To access the resistant, collect the strains and sequence...looking at the trend and relating to the clinical

Drug target, unique to the pathogen, important function in pathogen, from the host factor -- get rid by the host easily, good distribution not bind to the plasma protein, not toxic for sure esp kidney..

 New drug will be very expensive, using the generic is sometimes the only choice.

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Aj. Sasisopin

New hiv drugs guideline is now launched, check whether how much VL, or CD4 level...

Some drugs require HLA check (sometimes are expensive to check this genotype, better to observe the clinical symptom and told the patient to stop and don't re-challenge since the patient might have the severe side effect.

The person who having hiv, it is very important to have very good adherence..

The availability of the accessibility...the price and also the approval throughout the system. Not sure whether there 

Bf that hiv patient has to take 3 pills -- some drugs having very severe affect, right we can reduce the pills which can reduce the cost, good adherence and less side affect.

Right now, there is the injection form now for the hiv but it is in the clinical trail -- improve adherence since hiv patient have to take drug through out their life...if there are the drug that just on shot can stay for 2 months... better than to take the pills...

Drugs that having super side affect...cheap and easy but usa does not use it anymore but since thailand poor and cannot afford... we have to use other strategy to make the best benefit out of it. 

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Symposium

Characterize of patient

Cd4 count, viral load

Comorbidities

Pregnant status

Good kidney function?

Regiment specific

Like this regimen is not good for kidney failure

Part of the problem is that the drugs are very expensive to treat the hiv patients, new drugs tend to have less resistant, good metabolic profile, less side affect, some drugs cause 10,000 bath/month/case

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Vaccine, thing to consider for the patients

Safety

Recommendation

Efficacy

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HIV drug resistant

Right now, it is not just finding the mutation is reflecting resistant to the particular drug but there might be some hidden finding that we don't know enough yet.

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Prep

Dealing a lot with the risk compensate, it might have risk to get infected from the infected ppl who have the primary resistant. The risk compensate is that with the treatment there are still hiv infected patients...therefore, what the point to be afraid of using prep since this is for the choice for the person who does not want to use the condom, however, it does not mean that we won't promote ppl, not using condom.., it is just another choice to prevent the infection.

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Post exposure

According to the guideline, the arc should be taken within 3 days and full dose will reduce much of the infection. 

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19 May 2017 -- infection disease

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Aj.Siriorn

Since the event of modern medicine, there is the effect on fungal infection.

Before that hey identify fungi by looking at morphology but lately they use molecular genetic to identify like its, and if not able to identify then they use the other gene to identify the species.

Now, it has been reported that ampB is not cause making the pore by binding to ergosterol but disrupt the membrane until the ergosterol is being pop out from the membrane and cause the cell death.

MIC --

For candida and bacteria -- looking for the clinical break point telling the resist and and sensitive to the drug and can predict the failure

For the aspergillus that doing the broth dilution by using the conidia, what they do they plot the distribution and making the cut off to see roughly which one is mutated from the wildtype not indicating the sensitive and resistant to the drugs

Right now, we have increasingly found the non-aspergillus 

Possible cause, they said the failing of giving the right drugs rather than the pathogen developing the resistant, must be the right drug, good compliance and good adherence.

We have to be aware on the effect on the environment like insecticide in agricultural or in painting -- making the evolution of asper keep changing and cause ineffective treatment. 

Aspergillosis -- right now -- it is very hard to treat and there are some medical practice  like looking for the morphology right away and starting treating not waiting for the culture result and start treating, etc.

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Aj.porpon

 He mentioned much about the status of immunosuppressive drug period and related infection..

First, he tried to understand the mechanism if the immunosuppressive drugs first and looking at the cause that can initiate the infection and how to treat the patient with drugs. He mentioned the case on immsup vs viral infection, some immsup can support the viral replication.

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Aj. Sirawat and Porpon

Focus in lupus disease, we have to understand the mechanism behind these drugs and the mechanism related to the drugs will be the selective pressure for the pathogen. We need to take considerations on all kinds of factors like the immsup drug, immune status of patients, other factors of patient itself, and possibility of microbes (including virus) that can infect with this kind of selective pressure in patient.

Sound like evident-based treatment is important to plan the treatment and they were mainly done in oversea. We have to update all the time in order to give the right treatment. Besides, we have to keep eye on the new drug mechanisms since it can have affect the different types of microbes to be infected.

There is the approach that giving the vaccination like some viral infection before giving the immunosup drugs?

Thinking -- should draw out information form this kind of thing, writing up the algorithm and predict which microbes will infect the host... probably have to put the factor from the environment as well ... so many factors to be put in the pipeline to generate the outcome prediction.

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Aj.Maria

Neutropenia -- related infection, how to give the right drugs in the person who have blood disease; neutropenia...keep looking on the evident based treatment that publish oversea..

Panfungal diagnostic -- diag filamentous fungi in broad range

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Sym1 -- Dengue vaccine (sanofi pasteur - dengvaxia)

Is the live attenuated vaccine, cover all 4 serotypes, the reason that we have to make all four kinds because it is really hard to predict which serotype is more prevalent. This vaccine has been done in thai patient as well..in rachaburee and kampangpet (6 years follow up).

For adult, for now, looking in GMT (immunological response observation only) -- giving the significant result...and testing with the patient maximum to 45 years of age. Even though, Australia have the trail to 60, still it is not the epidemic area so FDA in Thailand won't approve to use in thailand and right now we are testing with the thai population by extending to 60 years if age, have to wait a bit.  

Secondary enhancement for dengue infection (in the term if severity), is there the affect on the severe dengue infection if we receive the dengue vaccine...so far, the evident show there was no affect.

Actually Mahidol launch this one and selling the patent to the sanofi....there is the concern on the tricky