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Krisada Khunkitti,1,* Wantin Sribenjalux,2,3,* Waewta Kuwatjanakul,4 Itthiphat Arunsurat,5 Apichart So-ngern,6 Atibordee Meesing2,3 1Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand; 4Microbiology Unit, Clinical Laboratory Section, Srinagarind Hospital Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 5Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 6Division of Sleep Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand*These authors contributed equally to this workCorrespondence: Wantin Sribenjalux, Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, 123 Moo 16 Mittraphap Road, Nai-Muang, Muang District, Khon Kaen, 40002, Thailand, Tel +66 4300 9700, Email Wantsr@kku.ac.th; Wantinmd34@gmail.comPurpose: To evaluate risk factors and develop a prediction score for community-acquired pneumonia caused by third-generation cephalosporin-resistant Enterobacterales (3GCR EB-CAP).Patients and Methods: A retrospective study was conducted by reviewing the medical records of patients hospitalized with community-acquired pneumonia caused by Enterobacterales (EB-CAP) between January 2015 and August 2021 at Srinagarind Hospital, Khon Kaen University, Thailand. Logistic regression was used to analyze clinical parameters associated with 3GCR EB-CAP. The coefficients of significant parameters were simplified to the nearest whole number for a prediction score, called the CREPE (third-generation Cephalosporin Resistant Enterobacterales community-acquired Pneumonia Evaluation).Results: A total of 245 patients with microbiologically confirmed EB-CAP (100 in the 3GCR EB group) were analyzed. Independent risk factors for 3GCR EB-CAP included in the CREPE score were (1) recent hospitalization within the past month (1 point), (2) multidrug-resistant EB colonization (1 point), and (3) recent intravenous antibiotic use (2 points for within the past month or 1.5 points for between one and twelve months). The CREPE score had an area under the receiver operating characteristic curve (ROC) of 0.88 (95% CI 0.84– 0.93). Using a cut-off point of 1.75, the score had a sensitivity and specificity of 73.5% and 84.6%, respectively.Conclusion: In areas with high prevalence of EB-CAP, the CREPE score can assist clinicians in selecting appropriate empirical therapy and reducing overuse of broad-spectrum antibiotics.Keywords: community acquired pneumonia, Enterobacterales, third-generation cephalosporin-resistance, empirical antibiotics, CREPE score

Background: Jet nebulizers are commonly used for bronchodilator therapy in COPD. High-flow nasal cannula with vibrating mesh nebulizer (HFNC-VMN) is a recently developed system; however, few studies have compared the efficacy of bronchodilator administration via HFNC-VMN to jet nebulizer in stable COPD. This study aimed to compare the effect of salbutamol administered via HFNC-VMN versus jet nebulizer on airway and lung function in subjects with stable COPD., Methods: This randomized non-inferiority crossover physiologic study enrolled subjects with stable COPD. Salbutamol was nebulized via HFNC-VMN or jet nebulizer in random order with a 4-h washout period between crossover sequences. Spirometry, lung volume, and impulse oscillometry were performed at baseline and after each intervention. The primary outcome was change in FEV 1 from baseline. Secondary outcomes included changes in other respiratory-related parameters and nebulization time compared between the 2 devices., Results: Seventeen subjects were enrolled. HFNC-VMN and jet nebulizer both significantly improved FEV 1 from baseline ( P = .005 and P = .002, respectively). The difference between respiratory resistance at 5 Hz and 20 Hz significantly decreased after HFNC-VMN compared to baseline ( P = .02), while no significant change was observed after jet nebulizer ( P = .056). Area of reactance and resonant frequency of reactance were both significantly decreased ( P = .035 and P = .03, respectively), and respiratory reactance at 5 Hz significantly increased ( P = .02) in the HFNC-VMN group compared to baseline indicating improved lung mechanics, with no significant changes with the jet nebulizer. HFNC-VMN had a shorter nebulization time (6 [5-9] min vs 20 [16-22] min, respectively, P < .001)., Conclusions: Bronchodilator therapy via HFNC-VMN was not inferior to jet nebulizer for subjects with stable COPD and can significantly improve airway oscillometry mechanics and decrease nebulization time compared to jet nebulizer., Competing Interests: Dr Brochard discloses relationships with Medtronic Covidien, Fisher & Paykel, Philips, Sentec, Air Liquide Medical Systems, GE Healthcare, and St. Michael's Hospital. Dr Chow discloses relationships with Thorasys Thoracic Medical Systems and AstraZeneca Canada. The remaining authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: Ventilator-associated pneumonia (VAP) is a common nocosomial infection in intensive care unit (ICU). Local microbiological surveillance of pathogens and resistance patterns for early-onset VAP (EOVAP) and late-onset VAP (LOVAP) will help to choose appropriate empiric antibiotics., Objective: To compare the multi-drug resistant (MDR) pathogens, treatment outcomes, and factors associated with hospital mortality of VAP., Method: A cross-sectional study between 1 January 2015 and 31 December 2017 at Srinagarind hospital, Khon Kaen University was conducted. The demographic data, causative pathogens, hospital length of stay (LOS), ICU LOS, mechanical ventilator (MV) days, and hospital mortality were retrospectively reviewed., Results: One hundred and ninety patients were enrolled; 42 patients (22%) were EOVAP and 148 patients (78%) were LOVAP. Acinetobacter baumannii was the most common pathogen in both groups (50% EOVAP vs 52.7% LOVAP). MDR pathogens were significant greater in LOVAP (81.8%) than EOVAP (61.9%) (p = 0.007). The EOVAP had a significantly better ICU LOS [median (interquartile range, IQR) 20.0 (11.0, 30.0) vs. 26.5 (17.0, 43.0) days], hospital LOS [median (IQR) 26.5 (15.0, 44.0) vs. 35.5 (24.0, 56.0) days] shorter MV days [median (IQR) 14.0 (10.0, 29.0) vs. 23.0 (14.0, 35.5) days] and lower hospital mortality (16.7% vs 35.1%) than LOVAP (p < 0.05). The factor associated with hospital mortality was having simplified acute physiology (SAP) II score ≥ 40 with an adjusted odds ratio (aOR) of 2.22 [95% confidence interval (CI), 1.08-4.54, p = 0.02]., Conclusion: LOVAP had significantly higher MDR pathogens, MV days, ICU LOS, hospital LOS and hospital mortality than EOVAP. A broad-spectrum antibiotic to cover MDR pathogens should be considered in LOVAP. The factor associated with hospital mortality of VAP was a SAPII score ≥ 40.

Introduction: Standard regimens for scleroderma interstitial lung diseases (SSc-ILDs) are pulse intravenous (IV) and oral daily cyclophosphamide (CYC). However, IV CYC has limited access to diffuse cutaneous SSc, and oral daily CYC is associated with febrile neutropenia and hemorrhagic cystitis. Pulse oral CYC regimen has never been studied., Objective: To determine the effectiveness of pulse oral CYC therapy in SSc-ILDs, predictors of effectiveness, and side-effects., Methods: A historical cohort study enrolled SSc-ILDs from the SSc database registry at Srinagarind Hospital, Thailand from 1 January 2012 to 1 October 2018. All patients received monthly oral dosages of CYC 600-750 mg/m 2 , Mesna, and daily prednisolone of 10 mg for 2 years. Changes of FVC, chest radiography, HRCT, 6MWT, and side effects were recorded for the baseline and at the end of the treatment. Response to treatment was defined by (a) stable FVC or a decline ≤ 10% of predicted, (b) unchanged or improved radiographic findings, or (c) a decline 6MWT of ≤ 30 m compared with the baseline., Results: A total of 76 patients with female 52 patients (68.4%) and with a median age of 54.2 years (IQR 46.6-59.6). The majority was dcSSc subset (59 patients; 78.6%). Fifty-four patients (71%) were defined as responsive to therapy. The mean FVC improvement was 1 ml (SD 9.5). The only factor associated with treatment response was limited cutaneous SSc (OR 7.69, 95% CI (1.01, 339.68), p = 0.029). Hemorrhagic cystitis was found in 1 patient., Conclusions: Nearly three-quarters of SSc-ILDs patients had a good response to the pulse oral CYC therapy for 2 years with a few serious side effects. Pulse oral CYC therapy had been effective for SSc-ILDs in case of difficult IV access. Key Point • Pulse oral cyclophosphamide has been used for scleroderma lung disease. It has shown efficacy and safety in scleroderma patients. In patients who have difficulty with intravenous access, pulse oral cyclophosphamide can be an alternative regimen.

Obstructive Sleep Apnea (OSA) is a common disease associated with major cardiovascular diseases. Male subjects are more at higher risk for OSA than female subjects. The Berlin questionnaire is a beneficial screening tool for OSA and has 14 items. The Berlin questionnaire may need some adjustment for Thai or Asian populations. We aimed to find items that should be asked in the Berlin questionnaire to identify high risk for obstructive sleep apnea among Thai male healthcare workers. This study was performed in Thai male healthcare workers over the age of 35 and currently working at the Faculty of Medicine, Khon Kaen University. The Thai version of the Berlin questionnaire was randomly distributed. A study population of 273 subjects was required to provide a confidence value of 95%. An item analysis of the Berlin questionnaire was evaluated as independent factors for being high risk of OSA by using a multivariate logistic regression analysis. Of the 273 distributed questionnaires, 135 subjects returned then (49.5% response rate). Of those, 41 (30.4%) were identified as being at high risk of OSA. Only three items of the Berlin questionnaire, including frequent snoring, high body mass index and hypertension, were independently associated with being at high risk for OSA. In conclusion, the Berlin questionnaire can be shortened to identify high risk for OSA by itself; not polysomnography.