Wound infection rates after invasive procedures in HIV-1 seropositive versus HIV-1 seronegative hemophiliacs

Breast Cancer and HIV in Sub-Saharan Africa: A Complex Relationship

Introduction

The number and lifespan of individuals living with HIV have increased significantly with the scale-up of antiretroviral therapy. Furthermore, the incidence of breast cancer in women with HIV is growing, especially in sub-Saharan Africa (SSA). However, the association between HIV infection and breast cancer is not well understood.

Methods

A literature search was performed to identify articles published in journals pertaining to breast cancer and HIV, with an emphasis on SSA. Selected US-based studies were also identified for comparison.

Results

Among the 56 studies reviewed, the largest study examined 314 patients with breast cancer and HIV in the United States. There is no consensus on whether HIV infection acts as a pro-oncogenic or antioncogenic factor in breast cancer, and it may have no relation to breast cancer. A higher incidence of breast cancer is reported in high-income countries than in SSA, although breast cancer in SSA presents at a younger age and at a more advanced stage. Some studies show that patients with breast cancer and HIV experience worse chemotherapy toxicity than do patients without HIV. Data on treatment outcomes are limited. The largest study showed worse treatment outcomes in patients with HIV, compared with their counterparts without HIV.

Conclusion

HIV infection has not been associated with different clinical presentation of breast cancer. However, some evidence suggests that concurrent diagnosis of HIV with breast cancer is associated with increased therapy-related toxicity and worse outcomes. Systematic prospective studies are needed to establish whether there is a specific association between breast cancer and HIV.

CD4 count is associated with postoperative infection in patients with orthopaedic trauma who are HIV positive

BACKGROUND

Since the advent of effective antiretroviral therapy, the number of people with AIDS has increased and a certain percentage of these patients will require emergent orthopaedic surgery. Little is known regarding orthopaedic infections and the association of CD4 counts with postoperative infection in patients with HIV infection who experience orthopaedic trauma.

QUESTIONS/PURPOSES

We questioned whether the postoperative infection rate is higher after orthopaedic trauma surgery for patients who are HIV positive than for patients who are HIV negative undergoing similar surgery and aimed to identify preoperative variables that may be important in predicting postoperative infection in patients who are HIV positive.

METHODS

We determined the postoperative infection rate in 64 patients who were HIV positive and who underwent orthopaedic surgery requiring instrumentation or an implant from January 2001 to May 2007. We compared this rate with historical control data from 2003 to 2007 for all orthopaedic procedures at Grady Memorial Hospital. We examined numerous preoperative variables for association with postoperative infection, including CD4 count, length of inpatient stay, polytrauma, and malnutrition.

RESULTS

Of the 64 patients, 15 had postoperative infections develop with an infection rate of 23%, compared with the 3.9% rate for the historical control subjects. Analysis of the 64 patients who were HIV positive revealed CD4 counts less than 300 were associated with development of postoperative infection. Hospital stay, polytrauma, and low serum albumin also were found to be associated with postoperative infection.

CONCLUSIONS

It is evident that patients who are HIV positive with low CD4 counts undergoing emergent orthopaedic intervention are a patient population at risk for infection. Further study is necessary to evaluate preoperative and perioperative interventions that may decrease infections in this population.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Postoperative infections: prevention and management

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

The role of prophylactic antibiotics in elective hand surgery

The current literature has poorly defined the role of antibiotic agents in elective hand surgery. The reason for this may be due to a small number of well-designed studies specifically addressing the efficacy of antibiotics in hand surgery. Our purpose is to critically review the current literature in an attempt to more precisely define the role of prophylactic antibiotics in elective hand surgery.

Septic arthritis in males with haemophilia

We used data collected as part of the Universal Data Collection (UDC) surveillance project in haemophilia treatment centers (HTC) to study the incidence, risk factors and impact of septic arthritis among males with haemophilia. Patients participating in UDC on two or more occasions were included. Cases were defined as patients with documented joint infection. Characteristics of the cases were compared with those of haemophilia patients without infection. Among the 8026 eligible patients with 36 015 person-years of follow-up, 30 (0.37%) had a documented joint infection (incidence rate 83 per 100 000 person-years). In a logistic regression model, only increasing age (OR = 6.1 for age > or =30), race/ethnicity other than white (OR = 3.9), presence of inhibitor (OR = 3.9), invasive procedure in the past year (OR = 2.7) and presence of one or more target joints (OR = 3.2) remained statistically significant. Central venous access devices use and hepatitis C virus and HIV infection were not associated with septic arthritis risk after adjusting for potential confounders. Study limitations include possible underestimation of septic arthritis rate in this population and its retrospective design. We conclude that septic arthritis is an uncommon complication of haemophilia occurring primarily in joints most affected by bleeding and reparative surgical interventions.

Radical prostatectomy in patients infected with human immunodeficiency virus

OBJECTIVE

To present the complications and early outcomes in a small series of men infected with human immunodeficiency virus (HIV) and treated with radical prostatectomy (RP) for prostate cancer, and to review reports on surgery in HIV-positive patients.

PATIENTS AND METHODS

During 2002-2005, seven men infected with HIV underwent RP at our institution. For the five patients whose HIV status was known before surgery, we retrospectively examined preoperative variables, including HIV-specific data (clinical category, CD4+ lymphocyte count, viral load, duration of HIV diagnosis, and opportunistic infections), and the complications and early outcomes after RP.

RESULTS

Before RP all the patients were in the Center for Disease Control clinical category A (asymptomatic HIV infection). The CD4+ counts before RP ranged from 269-870 cells/microL and viral loads ranged from <50-18 700 copies/mL. Three patients were on highly active anti-retroviral therapy (HAART) at the time of surgery. After RP, two patients had incisional wound infections, including one requiring re-hospitalization for intravenous antibiotics. During the follow-up (median 26 months) none of the patients progressed to acquired immunodeficiency syndrome or developed biochemical recurrence of prostate cancer. One healthcare worker was exposed to contaminated urine and placed on prophylactic therapy, but has not sero-converted.

CONCLUSIONS

The risk of peri-operative complications in HIV-positive patients can be minimized by carefully selecting the patient and procedure, and by measuring routine and HIV-specific preoperative variables. The two infectious complications in this series were in patients with less favourable preoperative factors, i.e. the lowest CD4+ count and the highest viral load. Further experience is needed to determine whether the risk of surgical infections is higher in this cohort. However, our results are consistent with reports from other surgical specialities that surgery in asymptomatic HIV-positive patients is safe and effective.

Spectrum of spine infections in patients with HIV: a case report and review of the literature

Because of the increase in patients with human immunodeficiency virus, practitioners are likely to see a concordant increase of infections. Spontaneous spinal infections can result from a variety of organisms. A common pathogen is Staphylococcus aureus, which is the most frequent cause of pyogenic spinal infection in patients who test positive for the human immunodeficiency virus. Human immunodeficiency virus has caused a resurgence of spinal tuberculosis and other infections. The pandemic of human immunodeficiency virus has caused a rise in extremely rare spinal infections caused by fungus, virus, and atypical bacteria that usually are nonpathogenic. As the number of elective and emergent spinal surgeries become more frequent, spinal practitioners also must become more familiar with the particularities of preoperative and perioperative decision making. Patients' CD4 cell counts are a useful preoperative parameter to stratify the risk for postoperative wound infection because counts less than 200/mm3 seem to be a critical threshold. A case of a patient with the human immunodeficiency virus is presented. The patient had a chronic, postoperative infection and posttraumatic post-laminectomy kyphosis; he was successfully treated with staged procedures including debridement, deformity correction, stabilization, and appropriate antibiotic therapy.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Elective spinal surgery in asymptomatic HIV-seropositive persons: perioperative complications and outcomes

STUDY DESIGN

This is a retrospective study consisting of medical records review and evaluation of pertinent radiographs.

OBJECTIVES

In this study, complications and outcomes are reviewed in a series of HIV-positive patients undergoing spinal surgery. Surgery was performed for conditions that were unrelated to HIV infection.

METHODS

From the period 1996 to 2000, we identified 10 seropositive patients who underwent spinal procedures for conditions that did not arise as a complication of HIV infection. A retrospective review was done, which included inpatient and out patient records.

RESULTS

A total of 6 women and 5 men who were HIV-positive underwent spinal surgery during the time period reviewed. Surgery was performed for a variety of conditions, including lumbar disc herniaition, degenerative disc disease, cervical disc herniation, spinal fractures, and Arnold-Chiari malformation. The mean CD4 count was 279 cells/mm3 before surgery. All patients had at least 6 months of conservative management before surgery, except in the case of those who had spinal fractures. Two patients sustained postoperative complications: 1 patient developed a superficial wound infection, which was successfully treated with antibiotics, and 1 patient experienced prolonged fever (7 days) after surgery, which resolved without a clear diagnosis. All patients were improved after surgery (mean follow-up, 29.3 months)

CONCLUSIONS

Many physicians have held a nihilistic approach, when it comes to the treatment of HIV-positive persons. However, our results in this small series of patients suggest that spinal surgery may be appropriate and can be performed with acceptable outcomes in selected patients.

One-year follow-up of orthopaedic implants in HIV-positive patients

We followed prospectively 38 orthopaedic implants in 36 HIV-positive patients. X-rays and clinical examination were used to assess union, and observation was made for early and late wound sepsis for 12 months from the time of surgery. Two patients died of causes unrelated to the implantation, two patients had implants removed for reasons other than infection and eight cases were lost to follow-up. Of the 26 cases that were reviewed at 1 year, no late sepsis was identified. All of the fractures, non-unions, osteotomies and arthrodeses united. The literature indicates that late sepsis following arthroplasty occurs more frequently in haemophiliacs who are HIV positive than their HIV-negative counterparts. It is still not certain whether or not such a risk also applies to HIV-positive patients who are not haemophiliacs and have undergone internal fixation of fractures or non-unions. This study increases the confidence that fixation in immune-compromised patients with intact skin is safe, at least for the time period that the implant is required. Further studies are required to know whether or not fixation implants should be removed.

Amoxycillin/clavulanic acid combinations increase transmigration of leucocytes through endothelial cell monolayers: endothelial cells play a key role

Postoperative inflammation is still viewed as an unresolved problem. During inflammation, leucocytes play a tremendous role and migrate from intravascular spaces into the tissue to attack microorganisms. Different agents, e.g. anaesthetic drugs, are able to influence leucocyte recruitment. Previous studies have investigated the influence of amoxycillin on chemotaxis of leucocytes alone. The aim of our study was to examine the effect of amoxycillin/clavulanic acid (co-amoxiclav) on leucocyte migration through endothelial cell monolayers (ECMs). Human umbilical endothelial cells were cultured on microporous membranes, achieving a monolayer. Polymorphonuclear neutrophil leucocytes (PMNLs) were used in a migration assay. The numbers of untreated PMNLs migrating through untreated ECMs were used as control and set as 100%. PMNLs and/or ECMs were pretreated with co-amoxiclav using clinically relevant as well as higher and lower concentrations. Co-amoxiclav was able to increase PMNL migration through ECMs significantly (P<0.05) when both cell types were treated (291+/-18.7%). When PMNLs or ECMs were treated alone, it could be shown that ECMs were more affected than PMNLs. The greatest effect was shown when both cell types, PMNLs and ECMs, were treated. In conclusion, co-amoxiclav was identified as a potent drug to increase leucocyte transmigration through ECMs. ECMs were also critically involved. Co-amoxiclav also affects endothelial cells.

HIV infection: problems with patientsʼ anaesthetic management and healthcare workersʼ exposure

Although infection with HIV has become a global epidemic, current research has provided a better understanding of the virus and its effect on the immune system. Combinations of new antiretroviral agents have been shown to be effective in prolonging the life of infected individuals, and chemoprophylactic regimens have been useful in preventing opportunistic infections. Risk factors associated with the occupational transmission of HIV have been identified and prevention strategies proposed.

Nosocomial infections in HIV infected patients. Gruppo HIV e Infezioni Ospedaliere

OBJECTIVES

To determine the incidence of nosocomial infections (NI) in HIV-infected patients and to analyse some of the associated risk factors.

DESIGN AND SETTING

Multicentre prospective study on consecutive HIV-infected patients admitted to 19 Italian acute-care infectious disease wards.

METHODS

All patients admitted during a 1-year period were followed-up for NI until their discharge. Univariate and multivariate analyses were performed for NI risk factors.

RESULTS

As of June 1998 a total of 344 NI occurred in 4330 admissions, with at least one NI in 273 admissions (6.3%). The incidence rate of NI was 3.6 per 1000 patient days [95% confidence interval (CI), 3.2-4.1]. Overall distribution by site was 36.6% bloodstream infections (BSI), 30.5% urinary tract infections, 18.4% pneumonia, 5.2% skin/soft tissue infections, 2.0% surgical wound infections and 7.3% others. Fifty-five out of the 126 BSI were related to a central venous catheter (CVC); the rate of CVC-associated infections was eight infections per 1000 devices. At multivariate analysis, variables independently associated with NI included CD4 T-lymphocyte count < 200 x 10(6)/l [odds ratio (OR), 2.21; 95% CI, 1.35-3.62], Karnofsky Performance Status < 40 (OR, 1.89; 95% CI, 1.28-2.78), therapy with corticosteroids (OR, 1.78; 95% CI, 1.29-2.45), CVC (OR, 3.24; 95% CI, 2.41-4.35), urinary catheter (OR, 6.53; 95% CI, 4.81-8.86) and surgery (OR, 3.13; 95% CI, 1.90-5.15).

CONCLUSIONS

Results suggest that NI occur commonly in HIV-infected patients. As the number of cases of HIV continues to increase, the number of HIV-infected patients requiring hospitalization may also increase. Clinicians need to be aware of the risk factors for NI and must consider these infections in the overall management of HIV-infected, hospitalized patients.

Dental lesions: diagnosis and treatment

Oral health care has been an integral part of the care of patients with HIV infection and AIDS since the disease was first identified in the early eighties. The spectrum of HIV-associated opportunistic diseases occurring in the oral cavity propelled dental health care providers to the forefront of patient care. Infection control issues soon became important in oral health care for patients infected with HIV, and for the first decade these two issues overshadowed the concerns about appropriate management of the dental needs of HIV-infected patients. Several concerns need to be considered in the management of dental care for patients infected with HIV. These include decreased salivary flow and increased sugar intake, prevention and management of routine inflammatory gingival and periodontal disease as well as the atypical forms of gingival and periodontal disease associated with HIV infection (linear gingival erythema [LGE], necrotizing ulcerative gingivitis [NUG] and necrotizing ulcerative periodontitis [NUP]). Finally, although reports of complications secondary to dental treatment of HIV-infected individuals are rare, it is important to consider those factors related to the medical status of HIV-infected patients which may interfere with oral health care. These include potential bleeding problems related to thrombocytopenia and disease or medication related liver abnormalities, increased risk of local infection particularly in patients with severe neutropenia and adverse effects of multiple medications taken by HIV patients. Prevention and management of dental and periodontal disease in HIV-infected individuals is important to self esteem, quality of life and maintenance of adequate nutritional intake. Oral health care continues to be an important component of overall health care for HIV-infected patients.

Human Immunodeficiency Virus Infection: Complications and Outcome of Orthopaedic Surgery

Orthopaedic surgeons practicing in areas with a high prevalence of human immunodeficiency virus (HIV) infection may expect that up to 7% of their patients who undergo emergent procedures and 1% to 3% of those who undergo elective surgery will be HIV-positive. Although basic science studies have demonstrated impairment of defenses to routine orthopaedic pathogens as well as to opportunistic organisms, clinical studies have shown that this impairment has not resulted in an increased incidence of postoperative infections or failure of wound healing in the asymptomatic HIV-positive patient. Even for the symptomatic patient, current medical management appears adequate to reduce the risk of early postoperative infection. The HIV-positive patient with a pros-thetic implant may be at increased risk for late hematogenous implant infection as host defenses diminish. Regular medical attention, prophylactic antibiotic therapy before dental work and invasive procedures, and early evaluation and treatment of possible infections are especially important in this setting. Decisions regarding elective surgery should be made on a risk-benefit basis. Because the risk of surgical complications increases with progression of the dis-ease, guidelines for elective surgery should include an assessment of the HIV-positive patient's immune status, including the CD4 lymphocyte count, history of opportunistic infection, serum albumin level, the presence of skin anergy, and the state of nutrition and general health.

Human immunodeficiency virus and the trauma patient: factors influencing postoperative infectious complications

OBJECTIVE

While immunosuppression 2 degrees to human immunodeficiency virus (HIV) infection should logically render HIV+ trauma victims more prone to infection after injury, little data is available regarding trauma outcome in this group of patients. Since the helper CD4+ lymphocyte count is a marker for progression of HIV-associated diseases, we examined the relationship between CD4+ counts, Injury Severity Score (ISS), and bacterial infectious complications in HIV+ trauma patients.

METHOD

Retrospective review of 56 consecutive HIV+ trauma patients treated at a Level I trauma center.

RESULTS

Nine patients (15%) developed significant infectious complications (four pneumonias, three soft-tissue infections, one urinary tract infection, one wound infection) with no pattern to the causative agents. Evaluation of CD4+ counts, white blood cell counts, serum albumin levels, blood transfusion requirements, and ISS revealed that only the ISS was associated with infectious complications.

CONCLUSION

Despite the profound immunosuppression in this group of patients, the incidence of bacterial infectious complications was independent of the CD4+ count (p = 0.958), but was associated with increases in the ISS (p = 0.003).

Postoperative infection following orthopaedic surgery in human immunodeficiency virus-infected hemophiliacs with CD4 counts < or = 200/mm3

Human immunodeficiency virus-infected hemophiliacs are at risk for bacterial and opportunistic infections with worsening immunosuppression. Thus, the risk of postoperative infection following orthopaedic surgery is of considerable concern. A survey of United States hemophilia treatment centers was conducted to determine the incidence of postoperative infection in human immunodeficiency virus-positive hemophiliacs with CD4 counts of 200 mm3 or less undergoing orthopaedic surgery. A total of 115 centers from 37 states reported that postoperative infection occurred in 10 (15.1%) of 66 patients undergoing 74 orthopaedic procedures, between several weeks and 5 months following surgery. In five (50%), pre-operative infection preceded postoperative joint infection. Staphylococcus was the most common organism isolated in a prosthetic joint infection, in 6 of 10 (60.0%), and the knee was the most commonly affected joint, in 9 of 10 (90.0%). Joint arthroplasty appeared to have 10 times the risk of nonarthroplasty procedures for postoperative infection (9 of 34 [26.5%] and 1 of 40 [2.5%], respectively, P < .01). Two subjects developed chronic osteomyelitis. The rate of postoperative infection in human immunodeficiency virus-positive hemophiliacs with CD4 counts of 200/mm3 or less appears to be high, when compared with the general population. Early, vigorous treatment should be instituted for suspected infection, antibiotic prophylaxis considered for invasive procedures, and surgical intervention individualized based on the balance of risks and benefits.

Antibiotic prophylaxis in dermatologic surgery

Antibiotic prophylaxis is generally administered either to prevent wound infection or to hinder the development of endocarditis. Although the use of antibiotics in certain circumstances to prevent wound infection can be straightforward, there are other circumstances in which the decision to use antibiotics is much less clear. Endocarditis prophylaxis has traditionally been based on the American Heart Association's guidelines, which do not cover dermatologic surgery. This article discusses the rationale and controversies surrounding the use of antibiotic prophylaxis for prevention of both wound infection and endocarditis, reviews the few studies that pertain to dermatology, and provides recommendations for antibiotic prophylaxis on a case-by-case basis for those who perform dermatologic surgery.

Elective colostomy closure in an AIDS patient

This article describes a 27-year-old patient with acquired immunodeficiency syndrome (AIDS) who underwent emergency sigmoid colostomy, Hartmann's pouch, and presacral drainage for rectal perforation. Three months later, he underwent uneventful elective colostomy closure, a procedure previously unreported in an AIDS patient. He remained without gastrointestinal symptoms for 14 months after colostomy closure until he died from central nervous system toxoplasmosis. A diagnosis of AIDS alone should not preclude colostomy closure in AIDS patients.

Surgical issues in the management of the HIV-infected patient

As of 1992, approximately 1,000,000 Americans are infected with HIV. The natural history of the illness includes a relatively long latent period (about 10 years) between infection and development of AIDS. Surgeons are called on to participate in the management of these patients, usually for diagnostic biopsies, supportive measures, or intraabdominal events. Precautions and safe surgical practices will minimize the risk of HIV transmission from patient to surgeon (or surgeon to patient).

Immunological abnormalities in haemophiliacs

10 years ago, it became apparent that haemophiliacs were developing diseases which were indicative of underlying immunodeficiency. The results of investigation confirmed that many had abnormal immune systems, particularly with regard to cell-mediated immunity. These abnormalities were thought to be a consequence of the use of clotting factor concentrates, and indeed the discovery of HIV and its mode of transmission, confirmed these suspicions. However, it subsequently became clear that HIV infection did not explain all the abnormalities observed. Many in vivo studies have shown that the immune systems of HIV-negative haemophiliacs are not entirely normal, and in vitro studies have shown that clotting factor concentrates per se have a modulating effect on immune function. We have reviewed particularly the abnormalities seen in HIV-negative haemophiliacs and their possible causes, as well as the specific features of HIV infection in haemophiliacs.

Nosocomial infection rate as a function of human immunodeficiency virus type 1 status in hemophiliacs

As part of a prospective cohort study initiated in 1983, the human immunodeficiency virus type 1 (HIV-1) status has been periodically determined for patients with clotting disorders (hemophilia A or B, von Willebrand's disease, miscellaneous). The University of North Carolina Hospitals has conducted comprehensive surveillance for nosocomial infections (NI) using modified Centers for Disease Control criteria since 1980 and entered this information in a computerized data base. Cross-matching of our NI data base and hemophiliac/HIV-1 study data base for the time period 1980-1989 revealed that 13 NI occurred in 11 patients during 659 hospitalizations (5,723 hospital days). NI rates per 100 admissions (per 1,000 hospital days) by HIV-1 status were as follows: HIV-1 negative = 0.91 (1.18), HIV-1 positive pre-AIDS = 1.65 (1.84), and AIDS = 6.67 (6.48). NI occurred with a similar frequency in HIV-1 positive pre-AIDS hemophiliacs and HIV-1 negative hemophiliacs (Fisher's exact test, p greater than 0.10). However, NI occurred more frequently in hemophiliacs with AIDS versus HIV-1 positive or negative hemophiliacs (Fisher's exact test, p less than 0.05). We conclude that HIV-1 infection does not appreciably alter the risk of developing a NI, but that patients who have progressed to AIDS are at significantly increased risk of developing a NI per hospital day or per hospitalization.