Prevalence of drug resistance among HIV-1 treatment-naive patients in Greece during 2003-2015: Transmitted drug resistance is due to onward transmissions

BACKGROUND

The prevalence of HIV-1 drug resistance among treatment-naïve patients ranges between 8.3% and 15% in Europe and North America. Previous studies showed that subtypes A and B were the most prevalent in the Greek HIV-1 epidemic. Our aim was to estimate the prevalence of resistance among drug naïve patients in Greece and to investigate the levels of transmission networking among those carrying resistant strains.

METHODS

HIV-1 sequences were determined from 3428 drug naïve HIV-1 patients, in Greece sampled during 01/01/2003-30/6/2015. Transmission clusters were estimated by means of phylogenetic analysis including as references sequences from patients failing antiretroviral treatment in Greece and sequences sampled globally.

RESULTS

The proportion of sequences with SDRMs was 5.98% (n=205). The most prevalent SDRMs were found for NNRTIs (3.76%), followed by N(t)RTIs (2.28%) and PIs (1.02%). The resistance prevalence was 22.2% based on all mutations associated with resistance estimated using the HIVdb resistance interpretation algorithm. Resistance to NNRTIs was the most common (16.9%) followed by PIs (4.9%) and N(t)RTIs (2.8%). The most frequently observed NNRTI resistant mutations were E138A (7.7%), E138Q (4.0%), K103N (2.3%) and V179D (1.3%). The majority of subtype A sequences (89.7%; 245 out of 273) with the dominant NNRTI resistance mutations (E138A, K103N, E138Q, V179D) were found to belong to monophyletic clusters suggesting regional dispersal. For subtype B, 68.1% (139 out of 204) of resistant strains (E138A, K103N, E138Q V179D) belonged to clusters. For N(t)RTI-resistance, evidence for regional dispersal was found for 27.3% and 21.6% of subtype A and B sequences, respectively.

CONCLUSIONS

The TDR rate based on the prevalence of SDRM is lower than the average rate in Europe. However, the prevalence of NNRTI resistance estimated using the HIVdb approach, is high in Greece and it is mostly due to onward transmissions among drug-naïve patients.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Acute prostatitis caused by Raoultella planticola in a renal transplant recipient: a novel case

We present a unique case of acute bacterial prostatitis caused by a very rare human pathogen, Raoultella planticola, in a renal allograft recipient 3.5 months post transplantation. Only a few cases of human infection by this pathogen have been reported worldwide. The present study reports the case of a 67-year-old man who was admitted to our transplant unit 3.5 months post transplantation with fever, dysuria, suprapubic pain, symptoms and signs of acute prostatitis, and elevated markers of inflammation and prostate-specific antigen. R. planticola was isolated in the urine culture. The patient was treated with ciprofloxacin (based on the antibiogram) and had a full recovery, with satisfactory renal function. To the best of our knowledge, this is not only the first reported case of R. planticola prostatitis, but also the first report of such an infection in a solid organ transplant recipient or in a patient on immunosuppressive medication.

Primary Staphylococcus aureus urinary tract infection: the role of undetected hematogenous seeding of the urinary tract

Staphylococcus aureus (SA) bacteriuria may accompany SA bacteremia, but primary SA urinary tract infection (UTI) may also occur. Our clinical observation of SA UTIs following intravenous catheter-related phlebitis lead us to review hematogenous and ascending route-related risk factors in patients with primary SA UTIs. The charts from all patients with SA UTIs over a 1.5-year period were reviewed for concurrent or recent hospitalization, intravenous catheterization, and for known UTI risk factors. Patients with concurrent SA bacteremia were excluded. Patients with Escherichia coli UTIs during the same period were included as controls. Twenty cases of primary SA UTI were compared with 43 E. coli UTI cases and they did not differ in age, diabetes mellitus, prostatic hypertrophy, previous UTI, or other urinary tract (UT) abnormality. However, cases were more likely than controls to have had recent or concurrent hospitalization, UT catheterization, and history of recent phlebitis. In multivariate analysis, UT catheterization and recent hospitalization retained significant association with SA UTI. Similar results were shown for the methicillin-resistant SA UTI subgroup. Even though UT catheterization is the main predisposing factor for primary SA UTI, some cases may be mediated through unrecognized preceding bacteremia related to intravascular device exposure or other healthcare-related factors.

Expanded postexposure prophylaxis for simultaneous multiple source HIV exposure in a health-care worker

We report an extreme case of high-grade needlestick exposure of a health-care worker to serum from multiple HIV-infected patients after trying to prematurely remove the respective tubes from an automated biochemical analyser. After review of the medical records of the eight source patients, we offered the health-care worker an expanded postexposure prophylaxis regimen including the entry inhibitor enfuvirtide. She refused to take subcutaneous injections, so we recommended the use of the integrase inhibitor raltegravir. She completed therapy without problems and periodic evaluation for HIV transmission up to nine months after the incident was negative.

Definite streptococcus bovis endocarditis: characteristics in 20 patients

OBJECTIVE

To determine the specific characteristics of Streptococcus bovis infective endocarditis (IE) by reviewing our own experience of S. bovis IE.

METHODS

Twenty episodes of definite S. bovis IE were reviewed in 20 patients hospitalized from 1980 to 1996.

RESULTS

The mean age was 62 +/- 14 years, and 14 (70%) patients had no known predisposing cardiac condition. The principal antimicrobials used were penicillin G (N = 10) and amoxycillin (N = 8). Surgery was required in four (20%) patients. Neurologic complications occurred in eight (40%) patients, after initiation of therapy in six (75%) (mean time: 14 days). An unfavorable outcome was observed in four of 20 patients and tended to be more frequent in patients who had had neurologic complications (P = 0.10). Colonic tumors were present in 11 of 16 (69%) patients.

CONCLUSIONS

Advanced age, occurrence of IE on presumably normal valves, high rate of neurologic complications, associated gastrointestinal diseases and low mortality rate during initial follow-up are characteristic features of S. bovis IE observed in this study.

Lack of reactivation of cytomegalovirus retinitis in an AIDS patient, during and after stopping long-term cidofovir treatment: case report

The case of an AIDS patient with cytomegalovirus (CMV) retinitis who was treated with cidofovir for 17 consecutive months, without any adverse effect, is presented. In the context of antiretroviral therapy, cidofovir therapeutic regimen was 5 mg/kg of body weight for 2 weeks and 5 mg/kg thereafter every other week. Probenecid, hydration and monitoring for proteinuria were also used to prevent nephrotoxicity. The patient stopped maintenance therapy for CMV retinitis after the permanent rise of CD4+ cells above 100 c/mm3. For more than 10 months after drug withdrawal the patient remains free of retinitis.