Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management

BACKGROUND

Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR).

AIM

To identify pVOM risk factors and evaluate management strategies.

METHODS

From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors.

FINDINGS

Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067).

CONCLUSION

Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.

Economic burden of recurrent Clostridioides difficile infection in adults admitted to Spanish hospitals. A multicentre retrospective observational study

OBJECTIVE

Clostridioides difficile infection (CDI) is associated with increased hospital stays and mortality and a high likelihood of rehospitalization, leading to increased health resource use and costs. The objective was to estimate the economic burden of recurrent CDI (rCDI).

METHODS

Observational, retrospective study carried out in six hospitals. Adults aged ≥18 years with ≥1 confirmed diagnosis (primary or secondary) of rCDI between January 2010 and May 2018 were included. rCDI-related resource use included days of hospital stay (emergency room, ward, isolation and ICU), tests and treatments. For patients with primary diagnosis of rCDI, the complete hospital stay was attributed to rCDI. When diagnosis of rCDI was secondary, hospital stay attributed to rCDI was estimated using 1:1 propensity score matching as the difference in hospital stay compared to controls. Controls were hospitalizations without CDI recorded in the Spanish National Hospital Discharge Database. The cost was calculated by multiplying the natural resource units by the unit cost. Costs (euros) were updated to 2019.

RESULTS

We included 282 rCDI episodes (188 as primary diagnosis): 66.31% of patients were aged ≥65 years and 57.80% were female. The mean hospital stay (SD) was 17.18 (23.27) days: 86.17% of rCDI episodes were isolated for a mean (SD) of 10.30 (9.97) days. The total mean cost (95%-CI) per episode was €10,877 (9,499-12,777), of which the hospital stay accounted for 92.56.

CONCLUSIONS

There is high cost and resource use associated with rCDI, highlighting the importance of preventing rCDI to the Spanish National Health System.

Suppressive antibiotic therapy in prosthetic joint infections: a multicentre cohort study

OBJECTIVES

The aim was to describe the effectiveness of suppressive antibiotic treatment (SAT) in routine clinical practice when used in situations in which removal of a prosthetic implant is considered essential for the eradication of an infection, and it cannot be performed.

METHODS

This was a descriptive retrospective and multicentre cohort study of prosthetic joint infection (PJI) cases managed with SAT. SAT was considered to have failed if a fistula appeared or persisted, if debridement was necessary, if the prosthesis was removed due to persistence of the infection or if uncontrolled symptoms were present.

RESULTS

In total, 302 patients were analysed. Two hundred and three of these patients (67.2%) received monotherapy. The most commonly used drugs were tetracyclines (39.7% of patients) (120/302) and cotrimoxazole (35.4% of patients) (107/302). SAT was considered successful in 58.6% (177/302) of the patients (median time administered, 36.5 months; IQR 20.75-59.25). Infection was controlled in 50% of patients at 5 years according to Kaplan-Meier analysis. Resistance development was documented in 15 of 65 (23.1%) of the microbiologically documented cases. SAT failure was associated with age <70 years (sub-hazard ratio (SHR) 1.61, 95% CI 1.1-2.33), aetiology other than Gram-positive cocci (SHR 1.56, 95% CI 1.09-2.27) and location of the prosthesis in the upper limb (SHR 2.4, 95% CI 1.5-3.84). SAT suspension was necessary due to adverse effects in 17 of 302 patients (5.6%).

CONCLUSIONS

SAT offers acceptable results for patients with PJI when surgical treatment is not performed or when it fails to eradicate the infection.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

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.

Increased risk of non-AIDS-related events in HIV subjects with persistent low CD4 counts despite cART in the CoRIS cohort

The aim was to analyze clinical complications in HIV-infected subjects who persistently maintain low CD4 levels despite virological response to cART in the Spanish CoRIS cohort. The main inclusion criteria were CD4 counts <200cells/mm(3) at cART-initiation and at least 2years under cART achieving a viral load <500copies/mL. Those patients with CD4 counts <250cells/mm(3) 2years after cART were classified as the Low-CD4 group, and clinical events were collected from this time-point. Poisson regression models were used to calculate incidence rate ratios of death, AIDS-defining events, serious non-AIDS-defining events (NAE) and of each specific NAE category (non-AIDS-defining malignancies (non-ADM), cardiovascular, kidney- and liver-related events). Of 9667 patients in the cohort, a total of 1128 met the criteria and 287 (25.4%) were classified in the Low-CD4 group. A higher risk of death (aIRR: 4.71; 95% CI: 1.88-11.82; p-value=0.001) and of non-ADM were observed in this group (aIRR: 2.23; 95% CI: 1.07-4.63; p=0.03). Our results stress the need to control accelerated aging in this population to counter their increased risk of non-AIDS-defining diseases, particularly cancer, and are consistent with the concept that clinical complications are potentially affected by genetics and lifestyle.

Tuberculosis in a cohort of HIV-positive patients: epidemiology, clinical practice and treatment outcomes

OBJECTIVE

To describe tuberculosis (TB) incidence, risk factors, clinical presentation, disease management and outcomes in human immunodeficiency virus (HIV) infected patients from the CoRIS cohort, Spain, 2004-2010.

DESIGN

Open multicentre cohort of antiretroviral treatment (ART) naïve patients at entry. Incidence and risk factors were evaluated using multivariate Poisson regression.

RESULTS

Among 6811 patients, 271 were eligible for the study and 198 for the estimation of the incidence rate; TB incidence ranged from 12.1 to 14.1/1000 person-years. TB was associated with low education level (rate ratio [RR] 2.65, 95%CI 1.73-4.07), being sub-Saharan African (RR 3.14, 95%CI 1.81-5.45), heterosexual (RR 2.01, 95%CI 1.22-3.29) or an injecting drug user (RR 2.11, 95%CI 1.20-3.69), not undergoing ART (RR 3.33, 95%CI 2.22-4.76), CD4 <200 cells/mm(3) (RR 5.20, 95%CI 3.25-8.33) and log-viral load of 4-5 (RR 5.44, 95%CI 3.28-9.02) or >5 (RR 13.10, 95%CI 8.27-20.76). Overall, 87% were new cases and 13% were previously treated cases; 175 (65%) were bacteriologically confirmed. Drug susceptibility testing was performed in 146 (83%) patients: resistance to first-line drugs was 11.1% in new and 36.4% in previously treated cases. Standard anti-tuberculosis treatment with four or three drugs was prescribed in respectively 55% and 36% of cases. Treatment default was 11%, and was higher among previously treated cases; 80% received ART during anti-tuberculosis treatment, 80% of new and 50% of previously treated cases were cured or completed treatment, and 18 (6.6%) died.

CONCLUSION

TB incidence in HIV-infected patients remains high. Interventions should include early HIV diagnosis and access to ART, enhanced bacteriological confirmation, wider use of four-drug regimens and reduction in treatment default.

Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study

We aim to evaluate the epidemiology and outcome of gram-negative prosthetic joint infection (GN-PJI) treated with debridement, antibiotics and implant retention (DAIR), identify factors predictive of failure, and determine the impact of ciprofloxacin use on prognosis. We performed a retrospective, multicentre, observational study of GN-PJI diagnosed from 2003 through to 2010 in 16 Spanish hospitals. We define failure as persistence or reappearance of the inflammatory joint signs during follow-up, leading to unplanned surgery or repeat debridement>30 days from the index surgery related death, or suppressive antimicrobial therapy. Parameters predicting failure were analysed with a Cox regression model. A total of 242 patients (33% men; median age 76 years, interquartile range (IQR) 68-81) with 242 episodes of GN-PJI were studied. The implants included 150 (62%) hip, 85 (35%) knee, five (2%) shoulder and two (1%) elbow prostheses. There were 189 (78%) acute infections. Causative microorganisms were Enterobacteriaceae in 78%, Pseudomonas spp. in 20%, and other gram-negative bacilli in 2%. Overall, 19% of isolates were ciprofloxacin resistant. DAIR was used in 174 (72%) cases, with an overall success rate of 68%, which increased to 79% after a median of 25 months' follow-up in ciprofloxacin-susceptible GN-PJIs treated with ciprofloxacin. Ciprofloxacin treatment exhibited an independent protective effect (adjusted hazard ratio (aHR) 0.23; 95% CI, 0.13-0.40; p<0.001), whereas chronic renal impairment predicted failure (aHR, 2.56; 95% CI, 1.14-5.77; p 0.0232). Our results confirm a 79% success rate in ciprofloxacin-susceptible GN-PJI treated with debridement, ciprofloxacin and implant retention. New therapeutic strategies are needed for ciprofloxacin-resistant PJI.

Use of cohort data to estimate national prevalence of transmitted drug resistance to antiretroviral drugs in Spain (2007-2012)

Prevalence of transmitted drug resistance (pTDR) to antiretroviral drugs in Spain (2007-2012) was estimated using the CoRIS cohort, adjusting its territorial distribution and transmission route to the reference population from the Spanish Information System on New human immunodeficiency virus diagnoses. A total of 2702 patients from ten autonomous communities and with naive FASTA sequence within 6 months of human immunodeficiency virus diagnosis were selected. Weighted pTDR, estimated using the inverse probability of selection in the sample by autonomous communities and transmission group, was 8.12% (95% CI 6.44-9.80), not significantly different from unweighted pTDR. We illustrate how proportional weighting can maximize representativeness of cohort-based data, and its value to monitor pTDR at country level.

Incidence and risk factors for tuberculosis in HIV-positive subjects by HAART status

OBJECTIVE

To estimate incidence rates and risk factors for tuberculosis (TB) in human immunodeficiency virus seroprevalent subjects.

METHODS

Multicentre, hospital-based cohort study of patients presenting to 10 Spanish hospitals from 1 January 1997 to 31 December 2003. Poisson regression was used and highly active antiretroviral treatment (HAART) was modelled as a time-dependent covariate.

RESULTS

A total of 4268 patients were followed for a median of 3.8 years; 221 TB cases were diagnosed over 16 464 person-years (py). TB rates were higher in HAART-naïve subjects (1.56 per 100 py, 95%CI 1.36-1.79) than those on HAART (0.5/100 py, 95%CI 0.31-0.80). Among HAART-naïves, TB risk factors were: being male, being an injecting drug user (IDU) (RR 2.01, 95%CI 1.28-3.16), having low CD4 counts (P < 0.001) and high viral loads (P < 0.001). HAART was protective (RR 0.26, 95%CI 0.16-0.40) and reductions in TB rates were observed in the last calendar period (RR 0.74, 95%CI 0.55-1.00). For patients on HAART, no differences were observed by category of transmission. Low CD4 counts at entry were associated with higher TB rates (P < 0.001).

CONCLUSIONS

HAART was associated with lower TB rates, and TB risk factors differed according to whether or not patients had received HAART. To further reduce TB rates, additional strategies are needed, such as timely access and adherence to HAART, especially in IDUs.

Prevalence of M. tuberculosis infection and tuberculosis disease among HIV-infected people in Spain

OBJECTIVE

To study the prevalence of Mycobacterium tuberculosis infection (MTBI) and past/current tuberculosis (TB) among human immunodeficiency virus (HIV) infected persons in Spain.

DESIGN

Longitudinal study conducted between 2000 and 2003 at 10 HIV hospital-based clinics. Data were drawn from clinical records. Associations were measured using odds ratios (ORs) and their 95% confidence intervals (95%CI).

RESULTS

Of the 1242 persons who met the eligibility criteria, most were male (75%), aged <40 years (75%) and unemployed (40%). HIV infection occurred through intravenous drug use (53%), heterosexual sex (29%) and sex between men (16%). In the initial evaluation, 315 subjects had evidence of MTBI: 84 (6.8%) had a history of TB, 23 (1.8%) current TB and 208 (16.8%) latent tuberculosis infection (LTBI). MTBI was associated with male sex, age 30-49 years, contact with a TB case, homelessness, poor education, and negatively with CD4 <100 cells/mm(3). Among subjects with MTBI, past/current TB was associated with retirement/disability (OR 6, 95%CI 1.6-22.5), CD4 <200 cells/mm(3) (OR 9.7, 95%CI 3.8-24.6), viral load >55,000 copies (OR 5.3, 95%CI 1.4-20.0), and negatively, with skilled work (OR 0.4, 95%CI 0.1-1.0) or administrative/managerial/professional work (OR 0.05, 95%CI 0.01-0.4).

CONCLUSION

Social context has an impact on the effectiveness of HIV and TB control programmes even in industrialised countries with free access to health care.

Health-Related Quality of Life in HIV Patients Switching to Twice-Daily Indinavir/Ritonavir Regimen or Continuing with Three-Times-Daily Indinavir-Based Therapy

Objective

To evaluate health-related quality of life (HRQoL) changes in patients treated with indinavir three-times daily after switching to a twice-daily indinavir/ritonavir regimen or continuing with the same regimen.

Methods

Patients on HAART including indinavir three-times-daily with undetectable viral load were randomly assigned to continue with this therapy or to change to a twice-daily indinavir/ritonavir (800/100 mg) regimen. The Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire was used as the HRQoL measure.

Results

A total of 118 patients participated in the study, of which 59 (50%) were randomly assigned to continue with the three-times-daily regimen. Patients had a mean age of 39 years and 80% of them were male. At baseline, subjects included in the three-times-daily group presented a significantly greater number of symptoms than subjects in the twice-daily group, but no statistically significant differences were observed in MOS-HIV scores between the groups. In the intention-to-treat (ITT) analysis, a reduction in HRQoL scores was observed in both groups, which was greater in the twice-daily group. In the per protocol analysis, reduction of HRQoL was minimal.

Conclusions

A HRQoL deterioration, greater in the twice-daily group, was observed in this study in the ITT analysis, while HRQoL remained stable in both groups in patients who continued with and tolerated the allocated regimen.

Consensus conference on chronic viral hepatitis and HIV infection: updated Spanish recommendations

Chronic hepatitis B and C represent a leading cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients worldwide. New treatment options against both hepatitis B (HBV) and C (HCV) viruses have prompted us to update previous recommendations for the management of coinfected individuals. Fifteen topics (nine related to HCV, five to HBV and one to both viruses) were selected for this purpose. A panel of Spanish experts in the field was invited to review these areas and propose specific recommendations, which were scored according to the Infectious Disease Society of America (IDSA) grading system. These guidelines represent a comprehensive and updated overview on the management of hepatitis B and C in HIV-infected patients.

[Administration of granulocyte colony-stimulating factor in patients infected with human immunodeficiency virus and prolonged neutropenia]

BACKGROUND

Persistent neutropenia is frequent in HIV infected patients with severe immunodeficiency. G-CSF induces proliferation and differentiation of granulocyte precursors. Our objective has been to assess the response to G-CSF therapy on patients with advanced HIV disease and prolonged neutropenia.

METHODS

A retrospective analysis of databases containing demographic information, analytic controls and hospitalizations related to neutropenia for patients attending our Infectious Diseases Unit from December 1, 1992 to January 30, 98. The episodes with absolute neutrophil counts lower than 1,000 x 10(6)/l at least during 7 days which descend below 500 x 10(6)/l at any moment were included.

RESULTS

36 episodes were included. 9 episodes started on treatment with G-CSF. The median duration was 9 (3-76) weeks. Hospitalization with fever related to neutropenia was significantly less frequent in episodes which received G-CSF (22.2%) than episodes without (66.7%).

CONCLUSION

In this study, a significantly lower risk of hospitalization due to fever and neutropenia was associated with administration of G-CSF in patients with absolute neutrophil counts lower than 500 x 10(6)/l.

[Recommendations of GESIDA (Grupo de Estudio de SIDA)/National Plan on AIDS with respect to the anti-retroviral treatment in adult patients infected with the human immunodeficiency virus in the year 2000 (II)]

OBJECTIVE

To update the recommendations for antiretroviral therapy (ART) 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 ART 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 (CAP) 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 randomized and controlled studies, from cohort or case-control studies or from descriptive studies and expert opinions, for that purpose we have reviewed the advanced in HIV pathophysiology and results of efficacy (clinical, virologic and immunologic) and security (toxicity) from clinical trials involving ART lasting at least 12 months, from cohort studies and pharmacokinetic and security data of antoiretrovírico 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 ART.

RESULTS

Nowadays, ART consistent 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 ART must be based upon three elements: presence or absence of symptoms, plasma vírica load and CD4+ cells counts. Thus, in asymptomatic cases with a high CD4+ cells count (> 500/microliter) and low vírica 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 ART. In symptomatic patients we recommend to start it, and in asymptomatic patients, we could recommend or consider ART initiation depending on the risk of progression, established by the vírica load and the CD4+ cells count. In any case, if therapy is started, the objective must be to reach an indetectable vírica load (< 50 copies/ml). The adherence to ART plays a key role for its initial moment and for the duration of the antiviral response. ART can achieve a restoration of cellular immunity inb 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 (lypodistrophy) is a new and limiting factor of ART which requires to look for new therapeutic options. ART 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 ART 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 vírica load) and the possibility of performing resistance studies make therapeutic strategies more dynamic and individualized for each patient and situation. In any case, it is mandatory to ensure a perfect adherence to ART from the patients.

[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.