Efficacy and Safety of RBX2660 in PUNCH CD3, a Phase III, Randomized, Double-Blind, Placebo-Controlled Trial with a Bayesian Primary Analysis for the Prevention of Recurrent Clostridioides difficile Infection

BACKGROUND

Recurrent Clostridioides difficile infection, associated with dysbiosis of gut microbiota, has substantial disease burden in the USA. RBX2660 is a live biotherapeutic product consisting of a broad consortium of microbes prepared from human stool that is under investigation for the reduction of recurrent C. difficile infection.

METHODS

A randomized, double-blind, placebo-controlled, phase III study, with a Bayesian primary analysis integrating data from a previous phase IIb study, was conducted. Adults who had one or more C. difficile infection recurrences with a positive stool assay for C. difficile and who were previously treated with standard-of-care antibiotics were randomly assigned 2:1 to receive a subsequent blinded, single-dose enema of RBX2660 or placebo. The primary endpoint was treatment success, defined as the absence of C. difficile infection diarrhea within 8 weeks of study treatment.

RESULTS

Of the 320 patients screened, 289 were randomly assigned and 267 received blinded treatment (n = 180, RBX2660; n = 87, placebo). Original model estimates of treatment success were 70.4% versus 58.1% with RBX2660 and placebo, respectively. However, after aligning the data to improve the exchangeability and interpretability of the Bayesian analysis, the model-estimated treatment success rate was 70.6% with RBX2660 versus 57.5% with placebo, with an estimated treatment effect of 13.1% and a posterior probability of superiority of 0.991. More than 90% of the participants who achieved treatment success at 8 weeks had sustained response through 6 months in both the RBX2660 and the placebo groups. Overall, RBX2660 was well tolerated, with manageable adverse events. The incidence of treatment-emergent adverse events was higher in RBX2660 recipients compared with placebo and was mostly driven by a higher incidence of mild gastrointestinal events.

CONCLUSIONS

RBX2660 is a safe and effective treatment to reduce recurrent C. difficile infection following standard-of-care antibiotics with a sustained response through 6 months.

CLINICAL TRIAL REGISTRATION

NCT03244644; 9 August, 2017.

The Association of Metabolic-Associated Fatty Liver Disease with Clinical Outcomes of COVID-19: A Systematic Review and Meta-Analysis

Introduction

Metabolic-associated fatty liver disease (MAFLD) is a hepatic manifestation of metabolic syndrome (MS). MAFLD patients have a higher prevalence of COVID-19. MAFLD also is associated with worse clinical outcomes of COVID-19, such as disease severity, intensive care unit (ICU) admission rate, and higher mortality rates. However, this evidence has not been well characterized in the literature. This meta-analysis aimed to determine the clinical outcomes of COVID-19 among MAFLD patients compared to the non-MAFLD group.

Methods

A comprehensive search was conducted in the Cumulative Index of Nursing and Allied Health (CINAHL), PubMed/Medline, and Embase for studies reporting MAFLD prevalence among COVID-19 patients and comparing clinical outcomes such as severity, ICU admission, and mortality among patients with and without MAFLD. The pooled prevalence of MAFLD among COVID-19 patients and the pooled odds ratios (OR) with 95% confidence intervals (CI) for clinical outcomes of COVID-19 were calculated.

Results

Sixteen observational studies met inclusion criteria involving a total of 11,484 overall study participants, including 1,746 MAFLD patients. The prevalence of COVID-19 among MAFLD patients was 0.29 (95% CI: 0.19–0.40). MAFLD was associated with the COVID-19 disease severity OR 3.07 (95% CI: 2.30–4.09). Similarly, MAFLD was associated with an increased risk of ICU admission compared to the non-MAFLD group OR 1.46 (95% CI: 1.12–1.91). Lastly, the association between MAFLD and COVID-19 mortality was not statistically significant OR 1.45 (95% CI: 0.74–2.84).

Conclusions

In this study, a high percentage of COVID-19 patients had MAFLD. Moreover, MAFLD patients had an increased risk of COVID-19 disease severity and ICU admission rate.

In-Person Education During the Early COVID-19 Pandemic at Wichita Collegiate School

Introduction. The COVID-19 pandemic forced most schools in Kansas in 2020-2021 to adopt remote or hybrid learning. Wichita Collegiate School proceeded with an in-person teaching model. The purpose of this study was to determine if in-person learning can be done safely during the COVID-19 pandemic prior to vaccine use. Methods. Wichita Collegiate is a private school located in Sedgwick County, Kansas. The study population included 671 students (grades 1-12) and 130 staff.  The procedures implemented during the school year (8/19/20- 5/21/21) included: mandatory face coverings, six feet physical distancing, and daily temperature checks. A registered nurse performed contact tracing and executed quarantine requirements per the Center for Disease Control and Prevention (CDC) guidelines.  Results. Over the study period, 487 students and staff were tested for COVID-19, and 18.5% (n=90) were positive. Overall, students and staff rate of COVID 19 infection was lower than the expected rate when compared to the surrounding community of Sedgwick County. Thorough contract tracing of positive cases revealed that 2.2% (n=2) individuals were likely exposed to COVID-19 at school.  Conclusions. This study suggests that transmission of COVID-19 was infrequent in a school setting with in-person attendance, even before widespread vaccine availability. By following public health guidelines and utilizing contact tracing, this study suggests that it is possible to limit the spread of COVID-19 during in-person learning. This has immediate implications for how schools safely returned to in-person learning in the post vaccine era.     

Improving Stewardship of Clostridioides difficile Testing with EMR and Provider Phone Calls

Introduction

Modern laboratory techniques cannot differentiate between Clostridium difficile colonization and infection; therefore, testing must be indicated clinically. To reduce hospital-onset of C. difficile infections (HO-CDI), Ascension Via Christi Hospitals (AVCH) in Wichita intervened in three stages by introducing: 1) a C. diflcile testing algorithm; 2) an electronic medical record (EMR)-based decision support system to enforce said algorithm; and 3) phone calls from the infection prevention department to providers to discontinue tests not collected within 24 hours of the order. The goal of this study was to determine if these interventions improved the HO-CDI rate.

Methods

At AVCH, the three study periods were compared: baseline with algorithm training only, the EMR intervention, and the EMR intervention with additional phone calls (EMR with phone calls). Data were abstracted from the hospital EMR.

Results

A total of 311 charts were reviewed. Adherence to the algorithm increased from 34% at baseline to 52% after the EMR intervention (p = 0.010). During the EMR with phone calls period, more tests were discontinued (87%; n = 39) compared to baseline (54%; n = 15) and EMR (54%; n = 15; p = 0.003). The HO-CDI rate ranged from 8.5 cases per 10,000 patient-days at baseline, to 7.9 during EMR, to 4.0 during EMR with phone calls (p = 0.007).

Conclusions

The EMR and EMR with phone call interventions were associated with a significant decrease in the HO-CDI rate and an increase in provider adherence to the algorithm.

The Effect of a Clinical Pathway on Reducing the Rate of Healthcare-Onset Clostridioides difficile

Introduction

Stool assays used to diagnose Clostridioides difficile infection (CDI) do not differentiate acute CDI from asymptomatic carriers, which contributes to a falsely elevated rate of healthcare-facility onset (HO) CDI when CD stool assays are inappropriately ordered. The aim of this study was to investigate the rate of HO-CDI before and after implementing a mandatory clinical pathway prior to ordering stool tests when suspecting CDI.

Methods

A single-center retrospective observational study was conducted that spanned 12 months. All patients who developed diarrhea 48 hours after being admitted and whose primary physician requested a CD stool assay were included in the study. The intervention consisted of a mandatory sequence of questions that allowed providers to order a CD stool assay only if clinically indicated.

Results

Differences in HO-CDI rates pre- and post-intervention were analyzed. The HO-CDI rate during the pre-intervention and post-intervention periods were 24.1 and 0.0, respectively (p = 0.023).

Conclusion

A marked reduction of the rate of HO-CDI occurred after implementing a mandatory clinical pathway. Setting up a mandatory pre-testing questionnaire could decrease the misclassification of asymptomatic carriers as HO-CDI and the unnecessary prescription of antibiotics in situations where it is not indicated.

The CHROME Study, a Real-world Experience of Single- and Multiple-Dose Oritavancin for Treatment of Gram-Positive Infections

Background

Oritavancin (ORI) is a long-acting lipoglycopeptide indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSIs) caused or suspected to be caused by susceptible Gram-positive (GP) pathogens.

Methods

Data collected from a retrospective observational program (2014–2017), Clinical and Historic Registry and Orbactiv Medical Evaluation (CHROME), describe the utilization, outcomes, and adverse events (AEs) associated with ORI in 440 patients treated at 26 US sites for ABSSSI and other GP infections.

Results

Clinical success in evaluable patients receiving at least 1 dose of oritavancin was 88.1% (386/438). In a subgroup of patients who received ORI for skin and soft tissue infections (n = 401) and bacteremia (n = 7), clinical success was achieved in 89.0% and 100%, respectively. A cohort of 32 patients received 2–10 ORI doses separated by no more than 14 days for complicated GP infections. Clinical success was observed in 30 of 32 patients (93.8%), including 10 of 11 (90.9%) patients with bone and joint infections and 7 of 8 (87.5%) patients with osteomyelitis. In the safety evaluable population, the overall rate of AEs was 6.6%.

Conclusions

We describe results from a real-world program that includes the largest multicenter, retrospective, observational study in patients who received at least 1 dose of ORI for the treatment of GP infections. This study confirms that ORI is an effective, well-tolerated antibiotic used in single and multiple doses for the treatment of ABSSSIs and complicated GP infections.

443. The CHROME Study, a Real-World Experiential Registry of the Use of Oritavancin for Treatment of Gram-Positive Infections

Background

Oritavancin (ORI) is a long-acting lipoglycopeptide antibiotic indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused or suspected to be caused by susceptible Gram-positive (GP) pathogens.

Methods

Data collected from a retrospective observational registry program (2014–2017), Clinical and Historic Registry and Orbactiv Medical Evaluation (CHROME), describe the utilization, outcomes, and adverse events (AEs) associated with ORI in 440 patients treated at 26 US sites.

Results

Mean (SD) age was 58 (16) years; 37% of patients were = 65 years old (range, 18–98). Mean (SD) BMI was 32.8 (9.0) (range, 14–65). At least 1 co-morbidity was observed in 85% of patients. Patients were treated for cellulitis (61%), wound infection (15%) or abscess (15%); 32 patients received ORI to treat other infections, such as bone and joint. Ten patients received single-dose ORI for completion of osteomyelitis therapy. Of recovered GP isolates, MRSA was the most common (46%). Infusion of ORI was mostly in infusion center settings (72%). Clinical success was 88% in the single-dose group (387 patients) and 86% in the multi-dose group (51 patients). A cohort of 32 patients received 2 to 10 ORI doses separated by no more than 14 days for complicated GP infections. Clinical success was observed in 30 of 32 patients (94%), including 10 of 11 (91%) patients with bone and joint infections and 7 of 8 (88%) patients with osteomyelitis. AEs were observed for 29 of 440 (6.6%) of patients; there was a single serious AE. Six (1.4%) patients discontinued ORI infusions due to an AE.

Conclusion

The CHROME program confirms that ORI is an effective and well-tolerated long-acting lipoglycopeptide antibiotic for the treatment of a range of Gram-positive infections.

Disclosures

All authors: No reported disclosures.

Endemic fungal infections in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention and management of blastomycosis, histoplasmosis, and coccidioidomycosis in the pre- and post-transplant period. Though each of these endemic fungal infections has unique epidemiology and clinical manifestations, they all share a predilection for primary pulmonary infection and may cause disseminated infection, particularly in immunocompromised hosts. Culture remains the gold standard for definitive diagnosis, but more rapid diagnosis may be achieved with direct visualization of organisms from clinical specimens and antigen-based enzyme immunoassay assays. Serology is of limited utility in transplant recipients. The mainstay of treatment for severe infections remains liposomal amphotericin followed by a step-down azole therapy. Cases of mild to moderate severity with no CNS involvement may be treated with azole therapy alone. The newer generation azoles provide additional treatment options, but supported currently with limited clinical efficacy data. Azole therapy in transplant recipients presents a unique challenge owing to the drug-drug interactions with immunosuppressant agents. Therapeutic drug monitoring of azole levels is an essential component of effective and safe therapy. Infection prevention centers around minimizing epidemiological exposures, early clinical recognition, and azole prophylaxis in selected individuals.

Contribution of the BioFire® FilmArray® Meningitis/Encephalitis Panel: Assessing Antimicrobial Duration and Length of Stay

INTRODUCTION

Traditional evaluation of meningitis includes cerebrospinal fluid (CSF) culture and gram stain to pinpoint specific causal organisms. The BioFire^® FilmArray^® Meningitis/Encephalitis (ME) Panel has been implemented as a more timely evaluation method. This study sought to assess if the BioFire^® ME Panel was associated with a decreased length of stay or decreased antimicrobial duration when used in the diagnosis of meningitis or encephalitis.

METHODS

A case, historical-control, chart review was performed on patients admitted to a regional medical center with CSF pleocytosis during Cohort 1 (the year prior to BioFire^® ME Panel implementation) and Cohort 2 (the year after BioFire^® ME Panel implementation). Length of hospital stay, duration of antimicrobials, and BioFire^® ME Panel result were gathered and analyzed.

RESULTS

Average length of stay for both cohorts was about four hospital days. Approximately three-fourths of all patients received antibiotic/antiviral treatment with an average of three days duration. No significant differences were observed between groups. The mean (median) duration of antimicrobials in the year prior to and after the BioFire^® ME Panel implementation was 3.6 (3) and 3.1 (2) days, respectively (p = 0.835). The mean (median) length of stay in the year prior to and after the BioFire^® ME Panel implementation was 5.8 (4) and 5.4 (4) days, respectively (p = 0.941). Among the patients admitted after the implementation of the BioFire^® ME Panel, 4.3 % (n = 2) had a positive bacterial result, 38.3% (n = 18) had a positive viral result, and 57.4% (n = 27) had a negative result. Of the 27 negative results, 77.8% (n = 21) were treated with antimicrobial medication.

CONCLUSIONS

This study suggested there is no difference between length of stay or antimicrobial duration in presumed meningitis cases assessed with traditional methods as compared to the BioFire^® ME Panel.

Contribution of the BioFire® FilmArray® Meningitis/Encephalitis Panel:

Introduction. Traditional evaluation of meningitis includes cerebrospinalfluid (CSF) culture and gram stain to pinpoint specific causalorganisms. The BioFire® FilmArray® Meningitis/Encephalitis (ME)Panel has been implemented as a more timely evaluation method.This study sought to assess if the BioFire® ME Panel was associatedwith a decreased length of stay or decreased antimicrobial durationwhen used in the diagnosis of meningitis or encephalitis.Methods.xA case, historical-control, chart review was performed onpatients admitted to a regional medical center with CSF pleocytosisduring Cohort 1 (the year prior to BioFire® ME Panel implementation)and Cohort 2 (the year after BioFire® ME Panel implementation).Length of hospital stay, duration of antimicrobials, and BioFire® MEPanel result were gathered and analyzed.Results. Average length of stay for both cohorts was about fourhospital days. Approximately three-fourths of all patients receivedantibiotic/antiviral treatment with an average of three days duration.No significant differences were observed between groups. The mean(median) duration of antimicrobials in the year prior to and afterthe BioFire® ME Panel implementation was 3.6 (3) and 3.1 (2) days,respectively (p = 0.835). The mean (median) length of stay in the yearprior to and after the BioFire® ME Panel implementation was 5.8 (4)and 5.4 (4) days, respectively (p = 0.941). Among the patients admittedafter the implementation of the BioFire® ME Panel, 4.3 % (n =2) had a positive bacterial result, 38.3% (n = 18) had a positive viralresult, and 57.4% (n = 27) had a negative result. Of the 27 negativeresults, 77.8% (n = 21) were treated with antimicrobial medication.Conclusions. This study suggested there is no difference betweenlength of stay or antimicrobial duration in presumed meningitis casesassessed with traditional methods as compared to the BioFire® MEPanel. Kans J Med 2019;12(1):1-3.

Central nervous system histoplasmosis: Multicenter retrospective study on clinical features, diagnostic approach and outcome of treatment

Central nervous system (CNS) involvement occurs in 5 to 10% of individuals with disseminated histoplasmosis. Most experience has been derived from small single center case series, or case report literature reviews. Therefore, a larger study of central nervous system (CNS) histoplasmosis is needed in order to guide the approach to diagnosis, and treatment.A convenience sample of 77 patients with histoplasmosis infection of the CNS was evaluated. Data was collected that focused on recognition of infection, diagnostic techniques, and outcomes of treatment.Twenty nine percent of patients were not immunosuppressed. Histoplasma antigen, or anti-Histoplasma antibodies were detected in the cerebrospinal fluid (CSF) in 75% of patients. One year survival was 75% among patients treated initially with amphotericin B, and was highest with liposomal, or deoxycholate formulations. Mortality was higher in immunocompromised patients, and patients 54 years of age, or older. Six percent of patients relapsed, all of whom had the acquired immunodeficiency syndrome (AIDS), and were poorly adherent with treatment.While CNS histoplasmosis occurred most often in immunocompromised individuals, a significant proportion of patients were previously, healthy. The diagnosis can be established by antigen, and antibody testing of the CSF, and serum, and antigen testing of the urine in most patients. Treatment with liposomal amphotericin B (AMB-L) for at least 1 month; followed by itraconazole for at least 1 year, results in survival among the majority of individuals. Patients should be followed for relapse for at least 1 year, after stopping therapy.

Histoplasma capsulatum endocarditis: multicenter case series with review of current diagnostic techniques and treatment

Infective endocarditis is an uncommon manifestation of infection with Histoplasma capsulatum. The diagnosis is frequently missed, and outcomes historically have been poor. We present 14 cases of Histoplasma endocarditis seen in the last decade at medical centers throughout the United States. All patients were men, and 10 of the 14 had an infected prosthetic aortic valve. One patient had an infected left atrial myxoma. Symptoms were present a median of 7 weeks before the diagnosis was established. Blood cultures yielded H. capsulatum in only 6 (43%) patients. Histoplasma antigen was present in urine and/or serum in all but 3 of the patients and provided the first clue to the diagnosis of histoplasmosis for several patients. Antibody testing was positive for H. capsulatum in 6 of 8 patients in whom the test was performed. Eleven patients underwent surgery for valve replacement or myxoma removal. Large, friable vegetations were noted at surgery in most patients, confirming the preoperative transesophageal echocardiography findings. Histopathologic examination of valve tissue and the myxoma revealed granulomatous inflammation and large numbers of organisms in most specimens. Four of the excised valves and the atrial myxoma showed a mixture of both yeast and hyphal forms on histopathology. A lipid formulation of amphotericin B, administered for a median of 29 days, was the initial therapy in 11 of the 14 patients. This was followed by oral itraconazole therapy, in all but 2 patients. The length of itraconazole suppressive therapy ranged from 11 months to lifelong administration. Three patients (21%) died within 3 months of the date of diagnosis. All 3 deaths were in patients who had received either no or minimal (1 day and 1 week) amphotericin B.

Cryptococcal meningitis post autologous stem cell transplantation

Disseminated Cryptococcus disease occurs in patients with defective T-cell immunity. Cryptococcal meningitis following autologous stem cell transplant (SCT) has been described previously in only 1 patient, 4 months post SCT and while off antifungal prophylaxis. We present a unique case of Cryptococcus meningitis pre-engraftment after autologous SCT, while the patient was receiving fluconazole prophylaxis. A 41-year-old man with non-Hodgkin's lymphoma underwent autologous SCT. Post-transplant prophylaxis consisted of fluconazole 400 mg daily, levofloxacin 500 mg daily, and acyclovir 800 mg twice daily. On day 9 post transplant, he developed fever and headache. Peripheral white blood cell count (WBC) was 700/μL. Magnetic resonance imaging of the brain showed lesions consistent with meningoencephalitis. Cerebrospinal fluid (CSF) analysis revealed a WBC of 39 with 77% lymphocytes, protein 63, glucose 38, CSF pressure 20.5 cmH2 O, and a positive cryptococcal antigen. CSF culture confirmed Cryptococcus neoformans. The patient was treated with liposomal amphotericin B 5 mg/kg intravenously daily, and flucytosine 37.5 mg/kg orally every 6 h. He was switched to fluconazole 400 mg daily after 3 weeks of amphotericin therapy, with sterilization of the CSF with negative CSFCryptococcus antigen and negative CSF culture. Review of the literature revealed 9 cases of cryptococcal disease in recipients of SCT. Median time of onset was 64 days post transplant. Only 3 meningitis cases were described; 2 of them after allogeneic SCT. Fungal prophylaxis with fluconazole post autologous SCT is recommended at least through engraftment, and for up to 100 days in high-risk patients. A high index of suspicion is needed to diagnose and treat opportunistic infections, especially in the face of immunosuppression and despite adequate prophylaxis. Infection is usually fatal without treatment, thus prompt diagnosis and therapy might be life saving.

Histoplasmosis after solid organ transplant

BACKGROUND

To improve our understanding of risk factors, management, diagnosis, and outcomes associated with histoplasmosis after solid organ transplant (SOT), we report a large series of histoplasmosis occurring after SOT.

METHODS

All cases of histoplasmosis in SOT recipients diagnosed between 1 January 2003 and 31 December 2010 at 24 institutions were identified. Demographic, clinical, and laboratory data were collected.

RESULTS

One hundred fifty-two cases were identified: kidney (51%), liver (16%), kidney/pancreas (14%), heart (9%), lung (5%), pancreas (2%), and other (2%). The median time from transplant to diagnosis was 27 months, but 34% were diagnosed in the first year after transplant. Twenty-eight percent of patients had severe disease (requiring intensive care unit admission); 81% had disseminated disease. Urine Histoplasma antigen detection was the most sensitive diagnostic method, positive in 132 of 142 patients (93%). An amphotericin formulation was administered initially to 73% of patients for a median duration of 2 weeks; step-down therapy with an azole was continued for a median duration of 12 months. Ten percent of patients died due to histoplasmosis with 72% of deaths occurring in the first month after diagnosis; older age and severe disease were risk factors for death from histoplasmosis. Relapse occurred in 6% of patients.

CONCLUSIONS

Although late cases occur, the first year after SOT is the period of highest risk for histoplasmosis. In patients who survive the first month after diagnosis, treatment with an amphotericin formulation followed by an azole for 12 months is usually successful, with only rare relapse.

Assessment of cytomegalovirus-specific cell-mediated immunity for the prediction of cytomegalovirus disease in high-risk solid-organ transplant recipients: a multicenter cohort study

BACKGROUND

Cytomegalovirus (CMV) disease remains an important problem in solid-organ transplant recipients, with the greatest risk among donor CMV-seropositive, recipient-seronegative (D(+)/R(-)) patients. CMV-specific cell-mediated immunity may be able to predict which patients will develop CMV disease.

METHODS

We prospectively included D(+)/R(-) patients who received antiviral prophylaxis. We used the Quantiferon-CMV assay to measure interferon-γ levels following in vitro stimulation with CMV antigens. The test was performed at the end of prophylaxis and 1 and 2 months later. The primary outcome was the incidence of CMV disease at 12 months after transplant. We calculated positive and negative predictive values of the assay for protection from CMV disease.

RESULTS

Overall, 28 of 127 (22%) patients developed CMV disease. Of 124 evaluable patients, 31 (25%) had a positive result, 81 (65.3%) had a negative result, and 12 (9.7%) had an indeterminate result (negative mitogen and CMV antigen) with the Quantiferon-CMV assay. At 12 months, patients with a positive result had a subsequent lower incidence of CMV disease than patients with a negative and an indeterminate result (6.4% vs 22.2% vs 58.3%, respectively; P < .001). Positive and negative predictive values of the assay for protection from CMV disease were 0.90 (95% confidence interval [CI], .74-.98) and 0.27 (95% CI, .18-.37), respectively.

CONCLUSIONS

This assay may be useful to predict if patients are at low, intermediate, or high risk for the development of subsequent CMV disease after prophylaxis.

CLINICAL TRIALS REGISTRATION

NCT00817908.

Graft vs. host disease after liver transplantation: a new approach is needed

Graft-vs.-host disease (GVHD) is a rare, serious complication of orthotopic liver transplantation (OLT). We have treated 5 patients to date with GVHD after OLT. A total of 78 patients worldwide have been reported to have experienced this complication. The means by which GVHD after OLT has been managed is guided by experience with the more common GVHD that occurs after stem cell transplantation. However, despite the use of various treatment modalities, the mortality of GVHD after OLT remains high. This case series and review of the literature demonstrates that successful resolution of GVHD after OLT cannot be expected with the use of those modalities that have been tried to date. It is imperative that new treatments be applied to GVHD after OLT in order to improve the prognosis of patients with this diagnosis.

Gastrointestinal histoplasmosis in the acquired immunodeficiency syndrome: report of 18 cases and literature review

No large case series of gastrointestinal histoplasmosis (GIH) in patients with AIDS has been published. We report 18 cases and review 34 published cases in the medical literature. We did a retrospective chart review from patients seen in our medical practices between 1989 and 2004. Most of our patients were men who had sex with men and who were not receiving highly active antiretroviral therapy. Median CD4 count was 34/muL. The most common presenting symptoms were diarrhea, fever, abdominal pain, and weight loss. The most commonly involved site was the colon or cecum. Biopsies revealed visible Histoplasma capsulatum organisms in 89%. Cultures from any site were positive in 76.9%. Four patients died from GIH. Gastrointestinal histoplasmosis occurs in severely immunocompromised patients with AIDS not receiving highly active antiretroviral therapy. Typical manifestations include diarrhea, fever, abdominal pain, and weight loss. Diagnosis is confirmed by blood or gastrointestinal tissue culture. Improvements in antiretroviral and antifungal therapies appear to have reduced the incidence of GIH and may improve the prognosis of this disease.