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Gamble KC, Rose DTT, Mondy K, Thyagarajan R, Jaso T, Coats L, Reveles KR. 911. Impact of Intensified Clindamycin Stewardship Initiatives in Three Phases: A Quasi-Experimental Study. Open Forum Infect Dis 2022. [PMCID: PMC9752965 DOI: 10.1093/ofid/ofac492.756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Clindamycin utilization has provoked gram-positive and anaerobic bacterial resistance and is associated with Clostridioides difficile infections (CDI). The purpose of this study was to evaluate if implementing local clindamycin-focused stewardship initiatives impacts clindamycin utilization and outcome metrics. Methods This multicenter, retrospective quasi-experimental study was conducted in adult hospitalized patients who received clindamycin from 2018 to 2020. Outcomes were compared in three phases between an intervention and control group (Figure 1). The primary outcome was inappropriate utilization: a resistant pathogen, concurrent antibiotic(s) with pathogen activity, a non-necrotizing infection, an alternative agent was preferred, or alternative reasons per expert discretion. Secondary outcomes included clindamycin duration of therapy per 1000 patient hospital days (DOT/1000 PD), 30-day CDI, 30-day readmission, and in-hospital mortality. Outcomes were compared between groups using the chi-square, Fisher’s exact, or Kruskal-Wallis tests as appropriate.
Study Design ID: infectious diseases, I: intervention group, C: control group Results The study included 481 patients (Table 1). Inappropriate clindamycin use in the intervention group was highest in Phase 1 (94%), then decreased in Phase 2 (72%) and Phase 3 (74%) (p< 0.01). Comparing Phase 1, Phase 2, and Phase 3 between the intervention and control groups, respectively, the primary outcome occurred in 94% vs 93% (p=0.80), 72% vs 88% (p=0.02), and 74% vs 89% (p=0.03). The DOT/1000 PD was 10 in Phase 1, 9.2 in Phase 2, and 6.2 in Phase 3. Initiatives were not associated with significant reductions in 30-day CDI (1% in Phase 1, 0% in Phase 2, 0% in Phase 3, p=0.64), 30-day readmission (18% in Phase 1, 31% in Phase 2, 22% in Phase 3, p=0.13), or in-hospital mortality (0% in Phase 1, 2% in Phase 2, 0% in Phase 3, p=0.33).
Outcomes I: intervention group, C: control group, DOT/1000 PD: days of therapy per 1000 patient days, CDI: Clostridioides difficile infection Conclusion Clindamycin-focused stewardship initiatives reduced inappropriate prescribing patterns by approximately 20% but still remained high in Phase 3. Clindamycin was primarily ordered in the emergency department (ED). Additional initiatives may include formal criteria for use and removing clindamycin from automated dispensing cabinets in the ED. Our initiatives may serve as a model for other institutions to reduce clindamycin utilization and its associated complications. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
| | - Dusten T T Rose
- Dell Seton Medical Center at the University of Texas, Austin, Texas
| | - Kristin Mondy
- Dell Seton Medical Center at the University of Texas, Dell Medical School at the University of Texas Austin, Austin, Texas
| | - Rama Thyagarajan
- Dell Seton Medical Center at the University of Texas, Dell Medical School at the University of Texas Austin, Austin, Texas
| | - Theresa Jaso
- Ascension Seton Medical Center Austin, Austin, Texas
| | - Leslie Coats
- University of Texas at Austin College of Pharmacy, Austin, Texas
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Bagwell K, Vasudevan J, Mondy K. Recurrent Strongyloides stercoralis infection in an HIV+ patient. IDCases 2021; 26:e01325. [PMID: 34786343 PMCID: PMC8577494 DOI: 10.1016/j.idcr.2021.e01325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
Although infection with Strongyloides stercoralis is often subclinical, some infections persist for decades due to the parasite’s autoinfective lifecycle. Hyperinfection syndrome, however, characterized by a massive increase in parasite burden as a result of host immunosuppression causes a myriad of clinical symptoms and is associated with high mortality. Use of corticosteroids and infection with HTLV-1 virus are the biggest traditional risk factors for hyperinfection syndrome, though its development can occur with virtually any degree of immunosuppression. Recurrent hyperinfection syndrome, though rare, has also been demonstrated in persons with ongoing immunosuppression, prompting many experts to recommend continued prophylactic treatment in at risk populations. We present the case of a recurrent S. stercoralis hyperinfection occurring four years after previous treatment with anti-helminthic therapy in a patient with AIDS with intermittent adherence to antiretroviral therapy (ART), highlighting diagnostic and treatment issues in the management of recurrent S. stercoralis infection.
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Affiliation(s)
- Kelli Bagwell
- University of Texas at Austin Dell Medical School, Department of Internal Medicine, 1500 Red River St, Austin, TX 78701, USA
| | - Jaya Vasudevan
- University of Texas at Austin Dell Medical School, Department of Internal Medicine, 1500 Red River St, Austin, TX 78701, USA
| | - Kristin Mondy
- University of Texas at Austin Dell Medical School, Department of Infectious Diseases, 1500 Red River St, Austin, TX 78701, USA
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Abstract
We report a case of acute, vectorborne Chagas disease, acquired locally in central Texas, USA, manifesting as Romaña’s sign, which was initially mistaken for orbital cellulitis. After the infection failed to respond to antibiotics, DNA-based next generation sequencing on plasma yielded high levels of Trypanasoma cruzi; results were confirmed by PCR.
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Liu W, Rose D, Jaso T, Helmink B, Mondy K. Clinical Outcomes of Hospital-Acquired and Healthcare-Associated Pneumonia with and without Empiric Vancomycin in a Non-critically Ill Population. Open Forum Infect Dis 2017. [DOI: 10.1093/ofid/ofx163.1522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Douglass E, Mondy K, Huth RG. Salmonella Epidural Abscess in a Patient With Rheumatoid Arthritis Treated With Tocilizumab. Infectious Diseases in Clinical Practice 2016. [DOI: 10.1097/ipc.0000000000000320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Escota GV, Mondy K, Bush T, Conley L, Brooks JT, Önen N, Patel P, Kojic EM, Henry K, Hammer J, Wood K, Lichtenstein KA, Overton ET. High Prevalence of Low Bone Mineral Density and Substantial Bone Loss over 4 Years Among HIV-Infected Persons in the Era of Modern Antiretroviral Therapy. AIDS Res Hum Retroviruses 2016; 32:59-67. [PMID: 26366785 DOI: 10.1089/aid.2015.0158] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
HIV-infected persons are living longer on combination antiretroviral therapy (cART) but experiencing more comorbidities including low bone mineral density (BMD). Using data from the Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN Study), we determined the prevalence of low BMD (T-score below one standard deviation of the reference mean) and compared it with matched controls from the National Health and Nutrition Examination Survey (NHANES). We also assessed 4-year longitudinal BMD changes among participants virologically suppressed on cART. Of 653 participants included in this analysis (77% male, 29% black, median age 41 years, median CD4(+) cell count 464 cells/mm(3), 89% with HIV RNA <400 copies/ml), 51% and 10% had baseline osteopenia and osteoporosis, respectively. Low BMD at the femoral neck was significantly more prevalent than for the NHANES controls (47% versus 29%, p<0.001). Lower body mass index, nonwhite race, longer tenofovir exposure, older age, being unemployed or retired, and lower apolipoprotein E were independently associated with baseline osteoporosis. Among 170 participants virologically suppressed on cART and with longitudinal BMD data, 31% experienced substantial bone loss (≥5% BMD decline from baseline) over 4 years. Female sex, current smoking, and longer stavudine use were more common among participants who had substantial bone loss, although these variables failed to reach statistical significance. Low BMD was highly prevalent among HIV-infected persons. One-third of participants experienced substantial bone loss despite cART, suggesting the need for monitoring and potential clinical interventions.
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Affiliation(s)
- Gerome V. Escota
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Kristin Mondy
- Central Texas Veterans Healthcare System, Austin, Texas
| | - Tim Bush
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lois Conley
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John T. Brooks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nur Önen
- Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Pragna Patel
- Center of Global Health, Non-Communicable Diseases Unit, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erna Milunka Kojic
- Division of Infectious Diseases, Brown University, Miriam Hospital, Providence, Rhode Island
| | - Keith Henry
- HIV Program, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota
| | - John Hammer
- Denver Infectious Disease Consultants, Denver, Colorado
| | - K.C. Wood
- Cerner Corporation, Vienna, Virginia
| | | | - Edgar T. Overton
- Division of Infectious Diseases, University of Alabama School of Medicine, Birmingham, Alabama
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Huth RG, Douglass E, Mondy K, Vasireddy S, Wallace RJ. Treatment of Mycobacterium abscessus subsp. massiliense tricuspid valve endocarditis. Emerg Infect Dis 2015; 21:535-7. [PMID: 25695799 PMCID: PMC4344259 DOI: 10.3201/eid2103.140577] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Sutepvarnon A, Apisarnthanarak A, Camins B, Mondy K, Fraser VJ. Inappropriate Use of Antifungal Medications in a Tertiary Care Center in Thailand: A Prospective Study. Infect Control Hosp Epidemiol 2015; 29:370-3. [DOI: 10.1086/587633] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The incidence and factors associated with inappropriate use of antifungal medications were studied in a Thai tertiary care center. The incidence of inappropriate antifungal use was 74% (in 42 of 57 patients). Isolation of Candida species from urine (P = .004) was a risk factor, whereas receipt of an infectious diseases consultation (P = .004) was protective.
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Cade WT, Overton ET, Mondy K, Fuentes LDL, Davila-Roman VG, Waggoner AD, Reeds DN, Lassa-Claxton S, Krauss MJ, Peterson LR, Yarasheski KE. Relationships among HIV infection, metabolic risk factors, and left ventricular structure and function. AIDS Res Hum Retroviruses 2013; 29:1151-60. [PMID: 23574474 DOI: 10.1089/aid.2012.0254] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Our objective was to determine if the presence of metabolic complications (MC) conveyed an additional risk for left ventricular (LV) dysfunction in people with HIV. HIV⁺ and HIV⁻ men and women were categorized into four groups: (1) HIV⁺ with MC (43±7 years, n=64), (2) HIV⁺ without MC (42±7 years, n=59), (3) HIV⁻ with MC (44±8 years, n=37), or (4) HIV⁻ controls without MC (42±8 years, n=41). All participants underwent two-dimensional (2-D), Doppler, and tissue Doppler echocardiography. Overall, the prevalence of systolic dysfunction (15 vs. 4%, p=0.02) and LV hypertrophy (9 vs. 1%, p=0.03) was greater in HIV⁺ than in HIV⁻ participants. Participants with MC had a greater prevalence of LV hypertrophy (10% vs. 1%). Early mitral annular velocity during diastole was significantly (p<0.005) lower in groups with MC (HIV⁺/MC⁺: 11.6±2.3, HIV⁻/MC⁺: 12.0±2.3 vs. HIV⁺/MC⁻: 12.4±2.3, HIV⁻/MC⁻: 13.1±2.4 cm/s) and tended to be lower in groups with HIV (p=0.10). However, there was no interaction effect of HIV and MC for any systolic or diastolic variable. Regardless of HIV status, participants with MC had reduced LV diastolic function. Although both the presence of MC and HIV infection were associated with lower diastolic function, there was no additive negative effect of HIV on diastolic function beyond the effect of MC. Also, HIV was independently associated with lower systolic function. Clinical monitoring of LV function in individuals with metabolic risk factors, regardless of HIV status, is warranted.
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Affiliation(s)
- William Todd Cade
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Edgar Turner Overton
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Kristin Mondy
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri
| | - Lisa de las Fuentes
- Cardiovascular Imaging and Clinical Research Core Laboratory, Washington University School of Medicine, St. Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Victor G. Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Washington University School of Medicine, St. Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Alan D. Waggoner
- Cardiovascular Imaging and Clinical Research Core Laboratory, Washington University School of Medicine, St. Louis, Missouri
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Dominic N. Reeds
- Division of Geriatrics and Nutritional Science, Washington University School of Medicine, St. Louis, Missouri
| | - Sherry Lassa-Claxton
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa J. Krauss
- Division of Biostatistics, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Linda R. Peterson
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
| | - Kevin E. Yarasheski
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
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Overton ET, Patel P, Mondy K, Bush T, Conley L, Rhame F, Kojic EM, Hammer J, Henry K, Brooks, for the SUN Study Investiga JT. Cystatin C and baseline renal function among HIV-infected persons in the SUN Study. AIDS Res Hum Retroviruses 2012; 28:148-55. [PMID: 21480819 DOI: 10.1089/aid.2011.0018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In the combination antiretroviral therapy (cART) era, renal dysfunction remains common. The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) (ClinicalTrials.gov number, NCT00146419) is a prospective observational cohort study of HIV-infected adults. At baseline, comprehensive data were collected, including cystatin C and measures of renal function. Univariate and multivariate regression analyses were performed to identify factors associated with baseline renal dysfunction [estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m(2) calculated using the simplified Modification of Diet in Renal Disease equation] and elevated cystatin C (>1.0 mg/liter) in a cross-sectional analysis. Among 670 subjects with complete data (mean age 41 years, mean CD4 cell count 530 cells/mm(3), 79% prescribed cART), the mean eGFR was 96.8 ml/min/1.73 m(2). Forty percent of subjects had renal dysfunction; 3.3% had chronic kidney disease (eGFR < 60 ml/min/1.73 m(2)). Elevated cystatin C was present in 18% of subjects. In multivariate analysis, renal dysfunction was associated with older age, non-Hispanic white race/ethnicity, higher body mass index (BMI), hypertension, higher cystatin C levels, and current prescription of ritonavir. Factors associated with elevated cystatin C included hepatitis C coinfection, hypertension, current smoking, older age, current tenofovir use, detectable plasma HIV RNA, and elevated microalbuminuria. The prevalence of chronic kidney disease (CKD) was low in this contemporary HIV cohort. However, mild to moderate renal dysfunction was common despite the widespread use of cART.
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Affiliation(s)
| | - Pragna Patel
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kristin Mondy
- University of Texas Medical Branch, Austin Programs, Austin, Texas
| | - Tim Bush
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lois Conley
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Frank Rhame
- Abbott Northwestern Hospital, Minneapolis, Minnesota
- University of Minnesota, Minneapolis, Minnesota
| | | | - John Hammer
- Denver Infectious Disease Consultants, Denver, Colorado
| | - Keith Henry
- University of Minnesota, Minneapolis, Minnesota
- HIV Program, Hennepin County Medical Center, Minneapolis, Minnesota
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Onen NF, Overton ET, Seyfried W, Stumm ER, Snell M, Mondy K, Tebas P. Aging and HIV infection: a comparison between older HIV-infected persons and the general population. HIV Clin Trials 2010; 11:100-9. [PMID: 20542846 DOI: 10.1310/hct1102-100] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND As HIV-infected persons age, the relative contribution of HIV infection, combination antiretroviral therapy (cART), and the normal aging process to the frequent comorbidities is unknown. METHODS We prospectively evaluated comorbidities, cardiovascular risk, cognitive function, and anthropomorphic and laboratory parameters of HIV-infected persons aged 50 years and over in two US urban clinics. Results were compared to controls from the National Health and Nutrition Examination Survey (NHANES) matched 1:1 by age, race, gender, smoking status, and body mass index (BMI). RESULTS We enrolled 122 HIV-infected persons; median age 55 years, 83% male, 57% Caucasian, 39% current smokers, mean BMI 26 kg/m2, and 92% on cART. Compared to controls, HIV-infected persons had a higher prevalence of hypertension (54% vs 38%), hypertriglyceridemia (51% vs 33%), low bone mineral density (BMD) (39% vs 0%), and lipodystrophy and greater receipt of antihypertensive and lipid-lowering medications (all Ps < .05). Groups were similar in prevalence of coronary heart disease, diabetes mellitus, chronic viral hepatitis, non-AIDS-defining malignancies and Framingham Risk and cognitive function scores. CONCLUSIONS Older HIV-infected persons have a higher prevalence of hypertension, hypertriglyceridemia, low BMD, and lipodystrophy than matched controls, suggesting that HIV and treatment-related factors exceed "normal" aging in the development of those problems.
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Affiliation(s)
- Nur F Onen
- Washington University, School of Medicine, St. Louis, Missouri 63110, USA.
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Önen NF, Overton ET, Presti R, Blair C, Powderly WG, Mondy K. Sub-optimal CD4 recovery on long-term suppressive highly active antiretroviral therapy is associated with favourable outcome. HIV Med 2009; 10:439-46. [DOI: 10.1111/j.1468-1293.2009.00711.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nurutdinova D, Onen NF, Hayes E, Mondy K, Overton ET. Adverse effects of tenofovir use in HIV-infected pregnant women and their infants. Ann Pharmacother 2008; 42:1581-5. [PMID: 18957630 DOI: 10.1345/aph.1l083] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Data regarding use of tenofovir disoproxil fumarate in HIV-infected pregnant women are limited. OBJECTIVE To identify adverse effects of tenofovir use during pregnancy in HIV-infected women and their infants. METHODS In a retrospective case series, the charts of 127 pregnant HIV-infected women who received highly active antiretroviral therapy (HAART) between 2001 and 2005 were reviewed. Those who received tenofovir during pregnancy were selected for this study. Each woman's chart was reviewed for clinical data and adverse events during the pregnancy; each infant's chart was reviewed for growth parameters from birth to 12 months. RESULTS Fifteen HIV-infected women with limited treatment options were prescribed HAART containing tenofovir during 16 pregnancies. In utero tenofovir exposure was a median of 127 days (range 6-259). Tenofovir was well tolerated by all women throughout pregnancy. There were 15 successful deliveries occurring at a median (range) of 36 weeks (30-40), with a median birth weight of 3255 g (1135-3610). Complications, including 1 spontaneous abortion, occurred in 9 pregnancies and were not attributed to tenofovir. Eleven (73%) women had abnormal laboratory results, including 6 who experienced grade 1 hemoglobin abnormalities; 4 of these women had preexisting anemia. Calculated glomerular filtration rate (calculated by Modification of Diet in Renal Disease equation) remained above 90 mL/min/1.73 m(2) in all women, except one who had a transient decline. Fourteen infants demonstrated normal growth and development for weight and height at birth, as well as during the 12-month follow-up period; no congenital malformations were documented. Mother-to-child transmission of HIV was not observed in this cohort. CONCLUSIONS Tenofovir was found to be a well-tolerated component of HAART in this small cohort. Longer-term assessment of tenofovir effects on childhood growth and larger prospective studies of tenofovir use in pregnant women are warranted.
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Affiliation(s)
- Diana Nurutdinova
- St. Louis Veterans Affairs Medical Center, 915 North Grand Blvd., St. Louis, MO 63106, USA.
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Önen NF, Nurutdinova D, Sungkanuparph S, Gase D, Mondy K, Overton ET. Effect of Postpartum HIV Treatment Discontinuation on Long-Term Maternal Outcome. ACTA ACUST UNITED AC 2008; 7:245-51. [DOI: 10.1177/1545109708325466] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Long-term maternal outcomes after postpartum antiretroviral therapy (ART) discontinuation are unknown. Methods. Retrospective review of pregnancies in HIV-infected women on treatment between 1997 and 2005. Women were grouped by postpartum ART use and followed until new opportunistic infection (OI), death or last clinic visit. Results. Of 172 pregnancies, postpartum ART discontinuation occurred in 123 (71.5%) women and was associated with greater parity, no partner during pregnancy, and no indication for OI prophylaxis or preconception ART in multivariate analysis (P < .05). Median follow-up was 32.5 months after delivery. There were 12 OIs and 2 deaths; 10 OIs and both deaths occurred in women who had discontinued ART. Conclusion. Postpartum ART discontinuation is common, especially among those with less advanced HIV disease, but may leave women at increased risk of long term adverse outcomes. This study highlights the need for larger longitudinal studies to determine appropriate recommendations for postpartum ART administration.
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Affiliation(s)
- Nur F. Önen
- Washington University School of Medicine, St. Louis, Missouri,
| | | | | | - Debra Gase
- Washington University School of Medicine, St. Louis, Missouri
| | - Kristin Mondy
- Washington University School of Medicine, St. Louis, Missouri
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Abstract
The use of highly active antiretroviral therapy (HAART) has resulted in sustained reductions in mortality from HIV infection. In recent years, HAART has also been associated with metabolic complications that may increase patients' cardiovascular disease risk. Recent studies have begun to support a more complex interaction between HAART, HIV infection itself, and other traditional social and immunologic factors that may predispose patients to premature cardiovascular disease. Substantial progress has been made in the development of newer antiretroviral therapies that have a better metabolic profile with respect to dyslipidemia, hyperglycemia, and lipodystrophy. Optimal selection of metabolically neutral antiretroviral therapies, together with aggressive management of other modifiable coronary risk factors, may improve cardiovascular disease risk in the long term.
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Affiliation(s)
- Kristin Mondy
- Washington University School of Medicine, Saint Louis, Missouri 63110, USA.
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Mondy K, Overton ET, Grubb J, Tong S, Seyfried W, Powderly W, Yarasheski K. Metabolic syndrome in HIV-infected patients from an urban, midwestern US outpatient population. Clin Infect Dis 2007; 44:726-34. [PMID: 17278068 PMCID: PMC3170426 DOI: 10.1086/511679] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 10/12/2006] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The association between the use of highly active antiretroviral therapy (HAART) and an increased risk of metabolic syndrome and cardiovascular disease remains unclear. METHODS We conducted a prospective, cross-sectional study of the risk factors associated with metabolic syndrome and cardiovascular disease among patients from an urban outpatient human immunodeficiency virus (HIV) clinic. Evaluation included laboratory data that were obtained after an overnight fast and a health survey that assessed traditional risk factors associated with cardiovascular disease, HIV-related factors, and comorbidities. Data collected were compared with data files from a cohort from the National Health and Nutrition Examination Survey (NHANES; 2001-2002) of persons who were seronegative for HIV infection who were matched for age, sex, race, and tobacco use. RESULTS Four hundred seventy-one HIV-infected subjects provided complete data. The overall prevalence of metabolic syndrome was similar between the group HIV-infected patients and the group of persons who were seronegative for HIV infection (25.5% vs. 26.5%, respectively), although the HIV-infected patients had a significantly smaller waist circumference, lower body mass index, lower high-density lipoprotein cholesterol levels, higher triglyceride levels, and lower glucose levels, compared with the subjects from the NHANES cohort. Framingham 10-year risk scores were also similar between the 2 groups. HIV-infected patients with metabolic syndrome were more likely to be diabetic, older, and white and have a high CD4 cell count and body mass index, compared with patients without metabolic syndrome (P<.05 for all). The type or duration of antiretroviral therapy was not an independent risk factor for metabolic syndrome. CONCLUSIONS The prevalence of metabolic syndrome is high among HIV-infected persons, but not higher than the prevalence among HIV-uninfected persons. Traditional risk factors play a more significant role in the development of metabolic syndrome than do HIV treatment-associated factors.
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Affiliation(s)
- Kristin Mondy
- Washington University School of Medicine, St. Louis, MO 63108, USA.
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Grubb JR, Singhatiraj E, Mondy K, Powderly WG, Overton ET. Patterns of primary antiretroviral drug resistance in antiretroviral-naive HIV-1-infected individuals in a midwest university clinic. AIDS 2006; 20:2115-6. [PMID: 17053358 DOI: 10.1097/01.aids.0000247579.08449.b6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A total of 192 HIV-1-infected antiretroviral-naive individuals had genotyping performed in our midwest university clinic between 2003 and 2005. The overall prevalence of resistance with either a reverse transcriptase or major protease mutation was 18%. There did not seem to be a significant difference in primary resistance patterns between different modes of HIV transmission (heterosexual versus men who have sex with men), gender or between white and African-American individuals.
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Affiliation(s)
- Jessica R Grubb
- Washington University School of Medicine, St Louis, Missouri, USA
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Mondy K, Powderly WG, Claxton SA, Yarasheski KH, Royal M, Stoneman JS, Hoffmann ME, Tebas P. Alendronate, Vitamin D, and Calcium for the Treatment of Osteopenia/Osteoporosis Associated With HIV Infection. J Acquir Immune Defic Syndr 2005; 38:426-31. [PMID: 15764959 DOI: 10.1097/01.qai.0000145352.04440.1e] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Osteopenia and osteoporosis are frequent complications of HIV infection and/or its treatment. Alendronate is the only bisphosphonate approved for the treatment of osteoporosis in men and women. We conducted a 48-week prospective, randomized, open-label study to evaluate the effects of alendronate, vitamin D, and calcium supplementation on bone mineral density (BMD) in patients with HIV infection. METHODS Thirty-one HIV-infected subjects with lumbar spine BMD t-scores less than -1.0 on antiretroviral therapy for a minimum of 6 months were randomized to receive (n = 15) or not to receive (n = 16) 70 mg of alendronate weekly for 48 weeks. All subjects received calcium (1000 mg daily as calcium carbonate) and vitamin D supplementation (400 IU daily). The study was powered to detect 3% changes in BMD in the lumbar spine within arms at 48 weeks. RESULTS Thirty-one patients were enrolled; most were male, with an average length of HIV infection of 8 years. Eighty-four percent had an HIV RNA load below 400 copies/mL, with a current median CD4+ T-cell count of 561 cells/mm3 (median nadir CD4 cell count of 167 cells/mm). At baseline, the median t-score in the lumbar spine was -1.52 and the median t-score in the hip was -1.02. Alendronate in combination with vitamin D and calcium increased lumbar spine BMD by 5.2% (95% confidence interval [CI]: 1.3-6.4) at 48 weeks compared with an increase of 1.3% (95% CI: -2.4 to 4.0) in subjects receiving vitamin D and calcium alone. One subject discontinued treatment in each arm. There were no serious adverse events. CONCLUSIONS Alendronate, vitamin D, and calcium are safe and potentially useful in the treatment of osteopenia/osteoporosis associated with HIV infection.
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Affiliation(s)
- Kristin Mondy
- Washington University School of Medicine, Division of Infectious Diseases, St. Louis, MO, USA
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Abstract
Recently, a high incidence of osteopenia and osteoporosis has been observed in individuals infected with human immunodeficiency virus (HIV). This problem appears to be more frequent in patients receiving potent antiretroviral therapy. Other bone-related complications in HIV-infected individuals, including avascular necrosis of the hip and compression fracture of the lumbar spine, have also been reported. People living with HIV have significant alterations in bone metabolism, regardless of whether they are receiving potent antiretroviral therapy. The underlying mechanisms to account for these observations remain unknown, although studies are underway to examine the relationship between the bone abnormalities and other complications associated with HIV and antiretroviral therapy. HIV-infected patients with osteopenia or osteoporosis should be treated similarly to HIV-seronegative patients with appropriate use of nutritional supplements (calcium and vitamin D) and exercise. Hormone replacement and antiresorptive therapies might be also indicated.
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Affiliation(s)
- Kristin Mondy
- Division of Infectious Diseases, AIDS Clinical Trials Unit, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Mondy K, Yarasheski K, Powderly WG, Whyte M, Claxton S, DeMarco D, Hoffmann M, Tebas P. Longitudinal evolution of bone mineral density and bone markers in human immunodeficiency virus-infected individuals. Clin Infect Dis 2003; 36:482-90. [PMID: 12567307 DOI: 10.1086/367569] [Citation(s) in RCA: 251] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2002] [Accepted: 10/02/2002] [Indexed: 01/04/2023] Open
Abstract
The underlying mechanisms of several bone disorders in human immunodeficiency virus (HIV)-infected persons and any relation to antiretroviral therapy have yet to be defined. A longitudinal study was conducted to estimate the prevalence of osteopenia or osteoporosis in HIV-infected persons; to assess bone mineralization, metabolism, and histomorphometry over time; and to evaluate predisposing factors. A total of 128 patients enrolled the study, and 93 were observed for 72 weeks. "Classic" risk factors (low body mass index, history of weight loss, steroid use, and smoking) for low bone mineral density (BMD) and duration of HIV infection were strongly associated with osteopenia. There was a weak association between low BMD and receipt of treatment with protease inhibitors; this association disappeared after controlling for the above factors. Markers of bone turnover tended to be elevated in the whole cohort but were not associated with low BMD. BMD increased slightly during follow-up. Traditional risk factors and advanced HIV infection play a more significant pathogenic role in the development of osteopenia and osteoporosis associated with HIV infection than do treatment-associated factors.
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Affiliation(s)
- Kristin Mondy
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63108, USA
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Tebas P, Henry K, Mondy K, Deeks S, Valdez H, Cohen C, Powderly WG. Effect of prolonged discontinuation of successful antiretroviral therapy on CD4+ T cell decline in human immunodeficiency virus-infected patients: implications for intermittent therapeutic strategies. J Infect Dis 2002; 186:851-4. [PMID: 12198623 DOI: 10.1086/342603] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2002] [Revised: 05/14/2002] [Indexed: 11/04/2022] Open
Abstract
This study evaluates the change in CD4(+) T cell counts among patients who achieved complete viral suppression and subsequently discontinued highly active antiretroviral therapy (HAART). We included 72 human immunodeficiency virus (HIV)-1-infected patients with plasma HIV RNA loads of <500 copies/mL for at least 3 months who then discontinued therapy for at least 12 weeks. The median CD4(+) T decay while off HAART was 16 cells/mm(3)/month (interquartile range, -6 to -34 cells/month). The mean follow-up after therapy ended was 45 weeks. The slope of the CD4(+) T cell decay was inversely correlated with the increase of CD4(+) T cells while receiving HAART, baseline virus load, CD4(+) T cell count at the time therapy was discontinued, age, and duration HIV RNA levels were undetectable. In a multiple regression analysis model, the increase of CD4(+) T cells while receiving therapy and age were independently associated with the rate of CD4(+) T cell loss.
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Affiliation(s)
- Pablo Tebas
- Washington University School of Medicine, St. Louis, Missouri 63108, USA.
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