[Recommendation of GESIDA (AIDS Study Group)/National Plan on AIDS with respect to the anti-retroviral treatment in adult patients infected with the human immunodeficiency virus in the year 2000 (I)]

OBJECTIVE

To update the recommendations for antiretroviral therapy in adult HIV-infected persons according to the new scientific advances and the existence of new antiretroviral drugs in the last two years.

METHODS

The antiretroviral therapy recommendations have been condensed by a panel of experts from the Spanish AIDS Study Group (Grupo de Estudio de sida-GESIDA) of the Spanish Infectious Diseases and Clinical Microbiology Society (SEIMC) and from the Clinical Advisory Panel of the Secretariat of the Spanish National Plan on AIDS (SPNS) of the Ministry of Health. Three levels of evidence have been established depending if the data came from randomised and controlled studies, from cohort or case-control studies or from descriptive studies and expert opinions. For that purpose we have reviewed the advances in HIV pathophysiology and results of efficacy (clinical, virologic and immunologic) and security (toxicity) from clinical trials involving antiretroviral therapy lasting at least 12 months, from cohort studies and pharmacokinetic and security data of antiretroviral drugs, presented in international conferences or published in biomedical journals in the last two years. In each situation we have established either to recommend or to consider or not recommend antiretroviral therapy.

RESULTS

Nowadays, antiretroviral therapy consisting of at least three drugs constitutes the election therapy for chronic HIV infection, since it delays clinical progression, increases significantly the survival and diminishes hospital admissions and associated costs. The decision to start antiretroviral therapy must be based upon three elements: presence or absence of symptoms, plasma viral load and CD4+ cells counts. Thus, in asymptomatic cases with a high CD4+ cells count (> 500/microL) and low viral load (< 10,000 copies/ml by branched DNA [bDNA] or < 20,000 copies/ml by reverse-transcription polymerase chain reaction [RT-PCR] or nucleic acid sequence based amplification [NASBA]) we recommend to delay antiretroviral therapy. In symptomatic patients we recommend to start it, and in asymptomatic patients, we could recommend or consider antiretroviral therapy initiation depending on the risk of progression, established by the viral load and the CD4+ cells count. In any case, if therapy is started, the objective must be to reach an undetectable viral load (< 50 copies/ml). The adherence to antiretroviral therapy plays a key role for its initial moment and for the duration of the antiviral response, antiretroviral therapy can achieve a restoration of cellular immunity in the advanced patients. There are few therapeutic options in failing patients due to cross-resistance. Resistance studies can be useful in this setting. The toxicity is a new and limiting factor of antiretroviral therapy which requires to look for new therapeutic options. Antiretroviral therapy criteria for acute infection, pregnancy, post-exposure prophylaxis and when to use resistance testing are discussed.

CONCLUSIONS

In this moment, there is a more conservative attitude towards starting antiretroviral therapy than in previous recommendations in which a virus eradication was considered. On the other hand, the high number of disposable drugs, the more sensitive monitorization methods (plasma viral load) and the possibility of performing resistance studies make therapeutic strategies more dynamic and individualised for each patient and situation. In any case, it is mandatory to ensure a perfect adherence to antiretroviral therapy from the patients.

[Diagnosis and treatment of mycobacterial infections in patients with HIV/AIDS]

Mycobacterial infection remains as a frequent complication associated to HIV infection. Although the widespread use of HAART has intensely decreased incidence of disseminated Mycobacterium avium (MAC) infection, it does not seem that it has affected tuberculosis occurrence so intensely. In spite of the intense search of new methods of rapid diagnosis, in the clinical practice the diagnosis of the mycobacterial illnesses continues based on culture, although the appearance of new media has allowed to shorten the time of growth. The combination of isoniazid (INH), rifampin (RIF) and pirazinamide (PZ) (with ethambutol [ETB] when primary resistance to INH is higher than 4%), remains as the elective treatment for tuberculosis in HIV infected patients. Due to the interaction between RIF and some antiretovirals drugs, such as proteasa inhibitors, a change in the usual regimens could be necessary. Combinations without RIF or antiretroviral therapy with drugs not interacting with RIF (nucleosides, ritonavir or nevirapin) have been suggested. The emergence of strains of Mycobacterium tuberculosis resistant to the antituberculosis drugs, the lack of adherence to treatment, and the frequency of adverse events hinders even more the control of the tuberculosis and they demand a narrow follow up of these patients. The treatment of the disseminated infection by MAC has improved in the last years with the generalization of the combinations including macrolides as claritromicin or azitromicin with ETB. The doubt persists about what combination is more effective, although like in other opportunists infections associated with a severe immunodeficiency, using antiretrovirals combinations that enhance the immune system could be a fundamental therapeutic approach.

[Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases]

BACKGROUND

To assess the clinical, radiologic and microbiological features of lung cavitation and HIV infection. Evaluation of the differences related to this disease in the last years.

PATIENTS AND METHODS

Retrospective review of all patients with lung cavitation and HIV infection admitted at our hospital from January 1989 until December 1994 and prospective study of all patients with the same characteristics during 1995 and 1996. Lung cavitation was defined as any parenchymal lesion, with air content, visible in a simple X-ray and greater than 1 cm of diameter. Criteria for confirmed, probable or possible diagnosis were defined.

RESULTS

78 cases of lung cavitation have been identified in 73 patients. The radiologic patterns included unilobar and multilobular involvement in 31 and 47 cases, respectively. Cavities were multiple and single in 40 and 38 cases respectively. Findings with fine needle aspiration biopsy (FNAB) were diagnostic in 11 out of 14 cases. A clinical diagnosis was performed in all 78 cases, with microbiological results in 69 cases (88.5%): Mycobacterium tuberculosis in 20, Pneumocystis carinii in nine, Pseudomonas aeruginosa in nine, Staphylococcus aureus in eight (5 endocarditis with cavitary septic emboli), Rhodococcus equi in six, P. aeruginosa and S. aureus in three, Salmonella enteritidis in three, Cryptococcus neoformans in two, Aspergillus fumigatus in two and others in 7 cases. Confirmed, probable and possible diagnosis was considered in 54, 15 and 9 cases, respectively. Thirteen episodes of spontaneous pneumothorax were found.

CONCLUSIONS

The lung cavitation rate is low, compared with the number of admissions related to HIV infection; nevertheless, many of them are in close relationship with HIV infection, and most of them are caused by treatable infections. It is important to know the clinical and radiological characteristics, in order to establish an early diagnosis and an appropriate therapy. Pseudomonas aeruginosa is becoming an important cause of lung cavitation. In our series, spontaneous pneumo-thorax was not related to Pneumocystis carinii pneumonia in 61.5% of cases.

Candidal meningitis in HIV-infected patients: treatment with fluconazole

Although mucocutaneous candidiasis is a common occurrence in HIV-infected patients, candidal meningitis is uncommon. We report 3 cases of candidal meningitis in HIV-positive patients, all intravenous drug abusers, and we discuss the clinical course and outcome, the treatment with fluconazole and possible prophylaxis.

[The usefulness of the desensitization to rifampin in the treatment of mycobacterial disease in patients with AIDS]

BACKGROUND

Hypersensitivity reactions to rifampin are relatively uncommon, but they may result in cessation of therapeutic medications.

PATIENTS AND METHODS

We report our experience with oral desensitization protocol to rifampin in a group of 35 HIV-positive patients with mycobacterial disease who had some hypersensitivity reaction to this drug.

RESULTS

Adverse reactions with this protocol were few and easily treated.

CONCLUSIONS

Oral desensitization to rifampin is safe and effective, allowing some of these patients (60%) to reintroduce the drug and to reduce the time of treatment.

AIDS-associated cholangiopathy in a series of ten patients

OBJECTIVE

To present the clinical, biological, radiologic and cholangiographic findings in patients with clinical suspicion of AIDS associated cholangiopathy in our hospital.

PATIENTS AND METHODS

We have revised the clinical charts of 10 patients admitted in our hospital from 1991 to 1995.

RESULTS

Ultrasonography and/or abdominal CT were carried out on all the patients. Biliary tract dilatation was observed in 11 cases. From the 12 ERCP, biliary tract was fulfilled in 11. In 5 cases papillary stenosis was diagnosed, sclerosing cholangitis in 2, normal biliary tract in 3 and acute cholangitis in one case. Sphincterotomy was done in 5 patients, with clinical improvement. In one case, another sphincterotomy was needed because of reestenosis.

CONCLUSIONS

ERCP is very important in the diagnosis of AIDS associated cholangiopathy. Endoscopic sphincterotomy relieves abdominal pain in these patients. Cholangiopathy occurs in very immunocompromised HIV positive patients. Survival is very short.

[Prospective 3-month study of intravascular catheter complications in HIV-infected patients: relation between phlebitis and infection]

BACKGROUND

The aim of this study was to evaluate the etiology of phlebitis (chemical or infectious) and the prevalence of infections related to intravascular catheters (IRIC) in patients with HIV infection admitted to a 22-bed Infectious Disease Unit with a high rate of HIV infection.

MATERIAL AND METHODS

A 3-month prospective study from November 1, 1994 to January 31, 1995 was carried out following a formula for data collection of all the intravenous catheters used during that time period. Cultures of the catheters withdrawn on Wednesdays and those with signs of phlebitis were performed.

RESULTS

One hundred fifty-two intravenous catheters in 71 patients with HIV infection with a mean age of 37 years (range: 21-73) and mean hospital stay of 10.2 days were reported. During the study period 42 phlebitis were produced, of which 37 catheters (7 central and 30 peripheral) were processed. Of the 37 phlebitis processed, 29 (78.9%) were considered to be of physiochemical origin. Of the 21 catheters withdrawn Wednesday, 18 were processed, 8 with phlogotic signs, 2 with IRCI, equivalent to 1.9 IRCI/100 days of catheterization. During the study period no local or severe systemic infections related to the catheter were reported. Staphylococcus epidermidis was the organism involved in all the cases of IRCI.

CONCLUSIONS

Despite the high number of immunosuppressed patients in related to HIV infection, a greater incidence of IRCI was not found in these patients. The most frequent cause of phlebitis by catheter was of chemical origin.

[Coinfection by mycobacteria in HIV-positive patients]

BACKGROUND

The aim of this study was to describe the clinical characteristics and therapeutic management of coinfection by mycobacteria in the authors hospital.

METHODS

Two cases of coinfection detected in mixed cultures in agar 7H11 or simultaneous positive cultures in several evaluable clinical samples (blood cultures for MAI and M. kansasii and sputum or stools for M. tuberculosis).

RESULTS

One coinfection by MAI and M. tuberculosis and another by MAI and M. kansasii in two severely immunosuppressed HIV positive patients with less than 0.010 CD4 lymphocytes/10(9)/l. The clinical manifestations were unspecific, with fever and deterioration of the general state predominating over the 30-45 days of evolution. One of the patients improved with treatment which, in both cases, included a macrolide. Survival was very short and death was by intercurrent causes.

CONCLUSIONS

For the diagnostic of coinfection in severely immunosuppressed patients multiple organic samples should be taken and appropriately processed to detect the mixed cultures or the presence of different mycobacteria in different samples from the same patients. Although the diagnosis of the species is fundamental, the empiric treatment of a disease by mycobacteria in severely immunosuppressed patients should include at least: ethambutol and clarithromycin or azithromycin in addition to other first line tuberculostatic drugs until definitive identification.