Original Article

Wang ZH, Wu SM
Correspondence: Dr Wu Shuming, zhenhuaw@sjtu.edu.cn

ABSTRACT
Introduction This study aimed to compare the efficacy and safety of quadruple therapy containing doxycycline and routine quadruple therapy for Helicobacter (H.) pylori rescue eradication in patients who had failed the one-week triple therapy.
Methods Patients who failed the first-line eradication therapy were allocated into two groups. Group A patients (n = 43) were administered esomeprazole 20 mg, bismuth potassium citrate 220 mg, amoxicillin 1 g and doxycycline 100 mg, all bid for ten days, while Group B patients (n = 42) were administered esomeprazole 20 mg bid, bismuth potassium citrate 220 mg bid, metronidazole 400 mg bid and tetracycline 750 mg q.6h, for ten days. The results of H. pylori eradication were assessed with 13C urea breath test four weeks after the therapy, and the side effects were recorded.
Results A total of 85 patients (average age 46.9 years) were enrolled in the study. Successful eradication rate for H. pylori was 72.5% in Group A and 64.1% in Group B, with no significant difference between the two groups. 11.6% (5/43) of patients from group A and 31.0% (13/42) from group B reported at least one adverse event. The adverse events of all 18 patients disappeared after the therapy ceased.
Conclusion Quadruple therapy containing doxycycline is as effective as routine quadruple therapy for H. pylori rescue eradication. The regimen is well tolerated by most patients and causes fewer adverse events than routine quadruple therapy. Hence, it may be recommended as a suitable alternative H. pylori rescue regimen in China.

Keywords:  doxycycline, Helicobacter pylori, quadruple therapy, rescue therapy
Singapore Med J 2012; 53(4): 273–276

Peripi SB, Thadepalli VGR, Khagga M, Tripuraribhatla PK, Bharadwaj DK
Correspondence: Dr Thadepalli V Gopala Rao, gopalraotv@yahoo.com

ABSTRACT
Introduction Antibiotics are an important category of drugs in which indiscriminate use can affect the susceptibility patterns among infectious organisms, resulting in antibiotic resistance.
Methods Data on antibiotic usage and susceptibility patterns were collected from public and private health centres in Vijayawada, Andhra Pradesh, India, through the use of questionnaires. The data collected were then coded, tabulated,computed and evaluated using statistical analysis.
Results The consumption profile of the different categories of drugs used in public and private hospitals was as follows: nutrition and metabolism products 19.0%; gastrointestinal disorder-related drugs 18.5%; antibiotics 16.8%; antipyretics and anti-analgesics 20.6%. These drugs were found to be in high demand. Among the antibiotics, aminoglycosides (amikacin), quinolones (ofloxacin, ciprofloxacin), tetracyclines (doxycycline), penicillin (ampicillin) and sulphonamides (co-trimoxazole) were the most commonly prescribed drugs for antibiotic therapy. 46% of the culture laboratory reports were positive with the following organism profile: Escherichia coli (36%), Klebsiella pneumoniae (16%), Staphylococcus aureus (29%), Enterocccus faecalis (9%) and Pseudomonas aeruginosa (10%). In terms of the sensitivity profile of antibacterials,amikacin (66.9%) was the only antibiotic showing sensitivity patterns, while the majority of antibiotics, such as cotrimoxazole, nalidixic acid, amoxicillin, gentamycin and norfloxacin, had acquired a resistance rate of 55.1%–80.6%.
Conclusion The results of this study suggest that indiscriminate prescription and consumption of new broad-spectrum antibiotics against sensitive organisms results in the development of antimicrobial resistance. Therefore, there is an urgent need to curb the excessive use of antibiotics in local hospitals in order to control the trend of increasing antimicrobial resistance to antibiotics.

Keywords: antibiotics, drugs, indiscriminate prescription, resistance, sensitivity
Singapore Med J 2012; 53(4): 268–272

Deorukhkar S, Katiyar R, Saini S
Correspondence: Dr Meliha Meric, drmelihameric@gmail.com

ABSTRACT
Introduction This study aimed to determine the incidence and risk factors of infections among patients admitted to intensive care units (ICUs) in tertiary care hospitals in Turkey.
Methods Adult patients who were admitted to the ICUs of five tertiary care hospitals for over 48 hours between June and December 2007 were monitored daily. Potential risk factors such as age, gender, comorbidities, diagnosis at admission, severity of disease (Acute Physiology and Chronic Health Evaluation II scores), exposure to antibiotics, history of invasive procedures and significant medical interventions were evaluated. A multivariate analysis of these risk factors was carried out using Cox regression.
Results A total of 313 patients with a median ICU stay of 12 days were selected for the study. 236 infectious episodes (33.8/1,000 ICU-days) were diagnosed among 134 patients (42.8/100 patients) in this group. Multivariate analysis revealed that exposure to a cephalosporin antibiotic (hazard ratio [95% confidence interval] 1.55 [1.10–2.19]) was an independent risk factor, whereas having a tracheostomy cannula (0.53 [0.36–0.81]) or nasogastric tube (0.48 [0.33–0.70]) was protective. Patients admitted to the ICUs from surgical wards were significantly more exposed to cephalosporins. 
Conclusion ICU-associated infections, which are quite high in Turkey, are largely due to inadequate infrastructure and facilities and understaffing. Abuse of antibiotics, particularly in patients who have undergone surgery, and prolonged ICU stays are significant risk factors for such infections.

Keywords: aetiology, corneal scraping, corneal ulceration, microbial keratitis, ocular trauma
Singapore Med J 2012; 53(4): 264–267

Meric M, Baykara N, Aksoy S, Kol IO, Yilmaz G, Beyazit N, Mete B, Vahaboglu H
Correspondence: Dr Meliha Meric, drmelihameric@gmail.com

ABSTRACT
Introduction This study aimed to determine the incidence and risk factors of infections among patients admitted to intensive care units (ICUs) in tertiary care hospitals in Turkey.
Methods Adult patients who were admitted to the ICUs of five tertiary care hospitals for over 48 hours between June and December 2007 were monitored daily. Potential risk factors such as age, gender, comorbidities, diagnosis at admission, severity of disease (Acute Physiology and Chronic Health Evaluation II scores), exposure to antibiotics, history of invasive procedures and significant medical interventions were evaluated. A multivariate analysis of these risk factors was carried out using Cox regression.
Results A total of 313 patients with a median ICU stay of 12 days were selected for the study. 236 infectious episodes (33.8/1,000 ICU-days) were diagnosed among 134 patients (42.8/100 patients) in this group. Multivariate analysis revealed that exposure to a cephalosporin antibiotic (hazard ratio [95% confidence interval] 1.55 [1.10–2.19]) was an independent risk factor, whereas having a tracheostomy cannula (0.53 [0.36–0.81]) or nasogastric tube (0.48 [0.33–0.70]) was protective. Patients admitted to the ICUs from surgical wards were significantly more exposed to cephalosporins.
Conclusion ICU-associated infections, which are quite high in Turkey, are largely due to inadequate infrastructure and facilities and understaffing. Abuse of antibiotics, particularly in patients who have undergone surgery, and prolonged ICU stays are significant risk factors for such infections.

Keywords: cephalosporins, intensive care units, multicentre study, nosocomial infections, risk factors
Singapore Med J 2012; 53(4): 260–263

Lwin S, Low SW, Choy D, Yeo TT, Chou N
Correspondence: Dr Sein Lwin, cfssl@nus.edu.sg

ABSTRACT
Introduction External ventricular drain (EVD) infections can cause serious complications. We performed an audit of EVD infections within our neurosurgical unit. Through this study, we aimed to reduce the incidence of external ventricular drain-related infection, including ventriculities in neurosurgical patients.
Methods We conducted an audit of the EVD infections in our institution observed over a one-and-a-half year period. This was conducted in three phases. A baseline EVD infection rate was determined for Phase I, from January to June 2007. We introduced the following measures to reduce EVD infection rate in Phase II, from July to December 2007: (1) For Neurosurgery doctors: performing proper surgical techniques to minimise intra-operative infections; educating junior doctors on proper CSF sampling from the EVD; and minimising the number of days the EVD is maintained in situ; (2) For Neurosurgery nurse clinicians: developing Standard Operating Procedures on nursing management of EVDs; conducting EVD care workshops for nurses working in neurosurgical wards; and competency skill checks on the management of EVDs for nurses working in the neurosurgical wards. Silver-coated EVDs were introduced in Phase III of the study from January to June 2008.
Results The EVD infection rate decreased from a baseline of 6.1% to 3.8% in Phase II; a further reduction from 3.8% to 0% was achieved during Phase III.
Conclusion Good teamwork among doctors and nurses is essential for reducing EVD infection rate. We managed to reduce EVD infections substantially and would continue to strive to remain infection-free in the future.

Keywords: cerebrospinal fluid, external ventricular drain, infection
Singapore Med J 2012; 53(4): 255–259

Yap J, Qadir A, Liu I, Loh J, Tan BH, Lee VJ
Correspondence: Dr Vernon J Lee, vernonljm@hotmail.com

ABSTRACT
Introduction Norovirus gastrointestinal disease (GID) outbreaks occur frequently in closed settings, with high attack rates. On October 16, 2008, a norovirus GID outbreak occurred at a Singapore military camp. This study describes the epidemiological investigations conducted to determine the cause of outbreak and the efficacy of the public health measures implemented.
Methods Epidemiologic investigations included a case-control study of exposure to different food items and an environmental exposure survey. Stool samplings of patients and food handlers for common pathogens, and microbiologic testing of food and water samples were performed. Inspection of dining facilities and health screening of all food-handlers were also conducted.
Results A total of 156 GID cases were reported on October 15–31, 2008. 24 (15.4%) personnel were positive for norovirus. The predominant symptoms were diarrhoea (76.3%) and abdominal pain (69.2%). There was no clinical correlation between any food item and the affected personnel. Testing of food and water samples, dining facility inspections and health screening of food handlers showed satisfactory results. The environmental exposure survey indicated possible transmission due to environmental contamination by vomitus in common areas. Comprehensive environmental decontamination was performed with hypochlorite solution, and personal hygiene measures were enforced. The outbreak lasted 17 days, with a decline in cases post intervention.
  CpmcConclusion Timely notification and prompt response can curtail disease transmission. Swift implementation of public health measures, such as emphasis on personal hygiene, isolation of affected cases and comprehensive disinfection ofthe environment, effectively stopped norovirus transmission and may be adapted for future GID outbreaks.

Keywords: diarrhoea, gastrointestinal disease, norovirus, outbreak, public health interventions
Singapore Med J 2012; 53(4): 249–254

Cheong C, Tan ML, Ngo RY
Correspondence: Dr Raymond Ngo, raymond_ngo@nuhs.edu.sg

ABSTRACT
Introduction Otorrhoea is a common complaint in Ear, Nose and Throat clinics. This study aimed to establish the pathogens involved in cases of otorrhoea in Singapore, their sensitivity patterns and the effectiveness of empirical  management. 
Methods A retrospective chart review was conducted on 91 patients with otorrhoea who had undergone swab cultures between July 2010 and February 2011. 
Results Of the 91 cases, 53% were diagnosed empirically as bacterial otitis externa and 25% as otomycosis. Aerobic bacteria accounted for 35.8% of the microorganisms cultured, while 34.7% were fungi and 29.5% were anaerobic bacteria. Pseudomonas (P.) aeruginosa and Staphylococcus (S.) aureus made up 31.6% and 21.0% of the microorganisms, respectively. 20% of S. aureus grown was methicillin-resistant. Aspergillus was the most common fungus and 19% of cultures were polymicrobial. 38% of patients had their treatment changed on the basis of culture results, as no improvement was observed on follow-up. P. aeruginosa was sensitive to ciprofloxacin and gentamicin in 81.8% and 76.0% of patients, respectively, while S. aureus was sensitive to cloxacillin in 93.8% and clindamycin in 87.5% of patients. 
Conclusion The common microorganisms involved in otorrhoea in Singapore are P. aeruginosa, Aspergillus and S. aureus. Resistant strains of Pseudomonas spp. are now present. Methicillin-resistant S. aureus is increasingly prevalent and highly sensitive to vancomycin. Aminoglycoside and fluoroquinolone-containing eardrops are suitable first-line topical antimicrobials. Cloxacillin may be started should a concomitant oral antimicrobial be warranted empirically or for S. aureus infections. Otomycosis should be considered in patients who show no improvement with antibiotics.

Keywords: chronic suppurative otitis media, ear discharge, otitis externa, otomycosis, otorrhoea
Singapore Med J 2012; 53(4): 244–248

Monteiro FNP, Kanchan T, Bhagavath P, Kumar GP, Menezes RG, Yoganarasimha K
Correspondence: Dr Tanuj Kanchan, tanujkanchan@yahoo.co.in

ABSTRACT
Introduction Snakebite is an important and preventable health hazard. Viper bites are more common than other poisonous snakebites in human beings. The present study aimed to collate the victim profile of viper bite cases in the region and to determine the pattern, manifestations, complications and the associated risk factors of these bites.
Methods This was a prospective study of viper bite cases admitted to Kasturba Hospital, Manipal, India between August 2003 and November 2005. The demographic and clinical details of each case were obtained from the patients, their relatives and the patients’ hospital records, and analysed.
Results A total of 31 viper bite cases were reported during the study period. The victims were predominantly male and aged 25–55 years. The highest number of cases occurred during daytime in the months of September and October, which coincided with the harvesting season, and involved the lower limbs. 94% of the snakebite victims were farmers, suggesting that this was an occupational hazard. Envenomation was observed in patients with scratch marks, suggesting the importance of keeping the victim under observation in all alleged snakebite cases, even in the absence of clear fang marks. The mortality rate in our study was 6.5%.
Conclusion Immobilising and transporting snakebite victims to the hospital and prompt administration of anti-snake venom remain the best way to reduce morbidity and mortality. It is also important to practise correct first aid measures, as otherwise they may cause more harm than good.

Keywords: clinical features, envenomation, epidemiology, South India, viper bite
Singapore Med J 2012; 53(3): 203–207

Chan SC
Correspondence: Prof Dr Chan Sook Ching, csching@rcmp.unikl.edu.my

ABSTRACT
Introduction This study aimed to determine the views of Malaysian interns and their supervisors on whether undergraduate clinical skills training adequately equipped them for internship and their suggestions for improvement.
Methods Pre-tested questionnaires covering demographic characteristics, the participants’ views on clinical skills training (communication, history taking, physical examination, diagnosis, patient management and procedures) and their suggestions for improvement were sent to all interns and their supervisors through the hospital directors. Data compiled was analysed to determine any significant association.
Results Out of the 32 hospitals with interns, 22 participated in the study. 521 completed questionnaires (350 interns, 171 supervisors) were analysed. The majority of interns felt that their undergraduate clinical skills training was adequate in all the aspects studied. The majority of supervisors, however, felt that it was grossly inadequate to poor in the areas of communication: breaking bad news (77% supervisors versus 13% interns), dealing with angry patients (75% versus 20%), giving information (59% versus 3%), communicating with patients’ families (53% versus 7%); adult resuscitation: intubation (72% versus 23%), defibrillation (77% versus 31%), use of drugs (62% versus 19%); and all aspects of child resuscitation. This was statistically significant (p < 0.05). Suggestions for improvement included more clinical exposure, communication skills workshop and monitoring of logbooks.
Conclusion This study suggests that there are deficiencies, particularly in communication and resuscitation skills training, in undergraduate clinical skills training. In-depth studies are required to identify ways to improve training.

Keywords: clinical competence, education, internship and residency, medical, undergraduate
Singapore Med J 2012; 53(3): 196–202

Chong PH, Chan MY, Yusri LI
Correspondence: Dr Chong Poh Heng, chongpohheng@gmail.com