Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial.

PLoS Med. 2017 Jul 25;14(7):e1002357.

Koenig SP1,2, Dorvil N1, Dévieux JG3, Hedt-Gauthier BL4, Riviere C1, Faustin M1, Lavoile K1, Perodin C1, Apollon A1, Duverger L1, McNairy ML5,6, Hennessey KA1, Souroutzidis A7, Cremieux PY7, Severe P1, Pape JW1,5.

Author information

1 Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti.

2 Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America.

3 AIDS Prevention Program, Florida International University, Miami, Florida, United States of America.

4 Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America.

5 Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America.

6 Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America.

7 Analysis Group, Boston, Massachusetts, United States of America.

Abstract

BACKGROUND:

Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression.

METHODS AND FINDINGS:

We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain.

CONCLUSIONS:

Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease.

TRIAL REGISTRATION:

This study is registered with ClinicalTrials.gov number NCT01900080.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526526/pdf/pmed.1002357.pdf

Advertisements

September 7, 2017 at 8:15 am

Infección por Candida spp. sobre prótesis articulares

Rev Esp Quimioter 2011:24(1):37-41

GARCÍA-OLTRA, S. GARCÍA-RAMIRO, J. C MARTÍNEZ, R. TIBAU, G. BORI, J. BOSCH, J. MENSA, A. SORIANO

Introducción

Las infecciones periprotésicas por Candida spp.constituyen una entidad poco frecuente. El objetivo de este trabajo fue revisar la experiencia en dos centros hospitalarios.

Material y métodos

Se realizó una revisión retrospectiva de los casos de infección protésica de etiología fúngica atendidos en dos hospitales de Barcelona entre febrero de 2002 y octubre de 2010. Se incluyeron todos aquellos pacientes con criterios clínicos de infección y aislamiento de Candida spp. Se recogieron las principales variables demográficas, microbiológicas, terapéuticas y evolutivas.

Resultados

Se identificaron 10 casos, 8 mujeres y 2 varones, cuya edad media fue de 77,7 (rango 66-92) años. Nueve pacientes habían tenido una infección bacteriana previa, por la que recibieron tratamiento antibiótico durante más de 15 días y precisaron desbridamiento en más de una ocasión. La especie más frecuente fue Candida albicans con 6 casos. Todos los pacientes recibieron fluconazol y tratamiento quirúrgico consistente en desbridamiento sin retirada de la prótesis en 3 casos y recambio en 2 tiempos con un espaciador en los 7 restantes. El tratamiento fracasó en los 10 casos y fue necesario practicar un desbridamiento adicional en 1 caso, artroplastia de resección en 8 y tratamiento “supresivo”con fluconazol en uno. Tras un seguimiento medio de 31 meses (rango 2-67) dos pacientes estaban libres de enfermedad.

Conclusión

La infección protésica por Candida spp. se observa en pacientes que han recibido tratamiento antibiótico previo prolongado y han sido intervenidos en más de una ocasión. El tratamiento con fluconazol y desbridamiento o recambio en 2 tiempos con un espaciador se asoció a una elevada tasa de fracaso.

PDF

http://seq.es/seq/0214-3429/24/1/garciaoltra.pdf

September 3, 2017 at 7:05 pm

Papel de daptomicina en el tratamiento empírico y dirigido de infecciones por cocos grampositivos del paciente crítico

Revista Española de Quimioterapia Marzo 2011 V.24 N.1 P.14-24

GARNACHO-MONTERO, R. AMAYA-VILLAR, M. L. GÓMEZ-GRANDE, V. JEREZ, L. LORENTE-RAMOS, A. LOZA, A. MARTÍNEZ, J. C. POZO, R. SIERRA, J. POMARES, M. V. DE LA TORRE, C. ORTIZ

Las infecciones graves causadas por bacterias grampositivas son un problema grave y que se asocia a una elevada mortalidad. Entre ellas, hay que resaltar las causadas por Staphylococcus aureus resistente a meticilina siendo la bacteriemia primaria o asociada a catéter o a endocarditis las principales presentaciones.

Vancomicina ha sido tradicionalmente el tratamiento de elección para estas infecciones pero su actividad no es satisfactoria especialmente en caso de SARM con concentración mínima inhibitoria (CMI) >1mg/L.

Daptomicina es un antibiótico lipopéptido cuyo espectro de acción son las bacterias grampositivas incluyendo SARM y Enterococcus spp resistente a glucopéptido.

Destacar también que frente a S.aureus sensible a meticilina, daptomicina es rápidamente bactericida y más activo que vancomicina y al menos tan activo como las penicilinas isoxazólicas.

En el presente artículo se discute el papel de este antibiótico en el tratamiento empírico y dirigido de las infecciones por bacterias grampositivas que afectan a los pacientes críticos.

PDF

http://seq.es/seq/0214-3429/24/1/garnacho.pdf

September 3, 2017 at 7:01 pm

Comparison Between Carbapenems and β-Lactam/β-Lactamase Inhibitors in the Treatment for Bloodstream Infections Caused by Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae: A Systematic Review and Meta-Analysis

Open Forum Infectious Diseases April 2017 V.4 N.2

Maged Muhammed; Myrto Eleni Flokas; Marios Detsis; Michail Alevizakos; Eleftherios Mylonakis

Background.

Carbapenems are widely used for the management of bloodstream infections (BSIs) caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE). However, the wide use of carbapenems has been associated with carbapenem-resistant Enterobacteriaceae development.

Methods.

We searched the PubMed and Scopus databases (last search date was on June 1, 2016) looking for studies that reported mortality in adult patients with ESBL-PE BSIs that were treated with carbapenems or β-lactam/β-lactamase inhibitors (BL/BLIs).

Results.

Fourteen studies reported mortality data in adult patients with ESBL-PE BSI that were treated with carbapenems or BL/BLIs. Among them, 13 studies reported extractable data on empiric therapy, with no statistically significant difference in mortality of patients with ESBL-PE BSI that were treated empirically with carbapenems (22.1%; 121 of 547), compared with those that received empiric BL/BLIs (20.5%; 109 of 531; relative risk [RR], 1.05; 95% confidence interval [CI], 0.83–1.37; I2 = 20.7%; P = .241). In addition, 7 studies reported data on definitive therapy. In total, 767 patients (79.3%) received carbapenems and 199 patients (20.6%) received BL/BLIs as definitive therapy, and there was again no statistically significant difference (RR, 0.62; 95% CI, 0.25–1.52; I2 = 84.6%; P < .001). Regarding specific pathogens, the use of empiric BL/BLIs in patients with BSI due to ESBL-Escherichia coli was not associated with a statistically significant difference in mortality (RR, 1.014; 95% CI, 0.491–2.095; I2 = 62.5%; P = .046), compared with the use of empiric carbapenems.

Conclusions.

These data do not support the wide use of carbapenems as empiric therapy, and BL/BLIs might be effective agents for initial/empiric therapy for patients with BSI caused by likely ESBL-PE, and especially ESBL-E coli.

PDF

https://watermark.silverchair.com/api/watermark?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAc8wggHLBgkqhkiG9w0BBwagggG8MIIBuAIBADCCAbEGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM5BUXSGMYAIN3BE1LAgEQgIIBgqYDSmwh2K3TlymgVZZt0vquuMz0auSmoQ71OT_r9GA6JxA5dMpUtlTojUXLhC28lojPv7HxfS47oBD9v2qsjEy2p-YKFemlWrwcVp4a0v99qMl6D4nzA-0WlQGOA8o89kr97soTVbSLC–nilk62R1koE5p7oZ9D_ISiuLzN2kAUCBvoxQyTMdE_byt2eEzK1r1HXrv7Fe8FmERbpAk_at7HXqOJhvZcC5xz2cOGfJV1-oNl4n2d74O2hQfdokHRlPu8EbPx_L2t8kwDaES7f7bBzT52cQi-jvuBr7a9OQwBEpUWzMOyB03zwoqpls1eIYxsh_m67d9gyQherNT3E0cEKNAEb5K49VZLMhAxTv33722rS1o_jeIUi_Chv1ndbM0itD725XwvoUADC7ner73YqpCb7l8MXlJYcLhmm_ikYkppJWs6jVyyN4cx8ueRN3pW2UqcVW4AX6WKz_na2W0xPt6IQB55hUMflu_B10duTKe2j30Ae3vV__Uqef9GfVl

September 3, 2017 at 6:57 pm

Antibiotic Prescribing for Adults Hospitalized in the Etiology of Pneumonia in the Community Study

Open Forum Infectious Diseases April 2017 V.4 N.2

Sara Tomczyk; Seema Jain; Anna M Bramley; Wesley H Self; Evan J Anderson …

Background

Community-acquired pneumonia (CAP) 2007 guidelines from the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) recommend a respiratory fluoroquinolone or beta-lactam plus macrolide as first-line antibiotics for adults hospitalized with CAP. Few studies have assessed guideline-concordant antibiotic use for patients hospitalized with CAP after the 2007 IDSA/ATS guidelines. We examine antibiotics prescribed and associated factors in adults hospitalized with CAP.

Methods

From January 2010 to June 2012, adults hospitalized with clinical and radiographic CAP were enrolled in a prospective Etiology of Pneumonia in the Community study across 5 US hospitals. Patients were interviewed using a standardized questionnaire, and medical charts were reviewed. Antibiotics prescribed were classified according to defined nonrecommended CAP antibiotics. We assessed factors associated with nonrecommended CAP antibiotics using logistic regression.

Results

Among enrollees, 1843 of 1874 (98%) ward and 440 of 446 (99%) ICU patients received ≥1 antibiotic ≤24 hours after admission. Ward patients were prescribed a respiratory fluoroquinolone alone (n = 613; 33%), or beta-lactam plus macrolide (n = 365; 19%), beta-lactam alone (n = 240; 13%), among other antibiotics, including vancomycin (n = 235; 13%) or piperacillin/tazobactam (n = 157; 8%) ≤24 hours after admission. Ward patients with known risk for healthcare-associated pneumonia (HCAP), recent outpatient antibiotic use, and in-hospital antibiotic use <6 hours after admission were significantly more likely to receive nonrecommended CAP antibiotics.

Conclusions

Although more than half of ward patients received antibiotics concordant with IDSA/ATS guidelines, a number received nonrecommended CAP antibiotics, including vancomycin and piperacillin/tazobactam; risk factors for HCAP, recent outpatient antibiotic, and rapid inpatient antibiotic use contributed to this. This hypothesis-generating descriptive epidemiology analysis could help inform antibiotic stewardship efforts, reinforces the need to harmonize guidelines for CAP and HCAP, and highlights the need for improved diagnostics to better equip clinicians.

PDF

https://watermark.silverchair.com/api/watermark?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAdgwggHUBgkqhkiG9w0BBwagggHFMIIBwQIBADCCAboGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMDYIVnpr-z1CRBqorAgEQgIIBixnHl6eqWdaZ9CZ7wTRmvTjD6a6x5vX03U52NtyGN_eRbk6K5A8JoDC_8YOl-F3DFUVvCdrM2tlefJZwRSteEGpcn1_xcbjNlNlTwC-Gl9H0OONkgFG-AvcYnRwOngyTGQkbjNhFzNMyHdvAXJRwVJ2FcQK1VS5OqQSyiArwXU-bN5lCnu-WE2HFdSp0GYFFsFRXBmZNLK6gK_R10k7lTlUTcyq8QEkQ_4QvqQjodxS1CzcLZAdPYjinVqHA9o0CcsBiPFJK9WrzYIc83ks_CVwRLgdV21jV9xscgn1xyRT0hiRzSqufjqWfBp4v0oMJE48W-NdnUKEfYpiTSsGoOY9pzT72__mDUX-Gr_pziS5IkErNt8OPcHyM9s465HQbpWz_8xejx31KwWXddlmHxGTtJ8b8GbRzRK0HvN-xEREcpgYDuKw5B1FLsXUrp-tEvuwdyeA5TSzfK9QwSCX1TTpTaj63XNSq_igGOaZUu-_z_joU6TopoTcBv4Yo-kqAlZC9DkTT4lRuHhEz

September 3, 2017 at 6:54 pm

Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials

Open Forum Infectious Diseases April 2017 V.4 N.2

Elizabeth L. Alexander; Jeffery Loutit; Mario Tumbarello; Richard Wunderink; Tim Felton …

Background.

The increasing incidence of multidrug-resistant Gram negatives, such as carbapenem-resistant Enterobacteriaceae (CRE), has resulted in a critical need for new antimicrobials. Most studies of new antimicrobials have been performed in patients with nondrug-resistant pathogens. We performed a retrospective analysis of patients with CRE infections to inform the design of phase 3 clinical trials.

Methods.

This was a retrospective study at 22 centers in 4 countries. Baseline data, treatment, and outcomes were collected in patients with complicated urinary tract infection (cUTI)/acute pyelonephritis (AP), hospital-acquired bacterial pneumonia (HABP), ventilator-associated bacterial pneumonia (VABP), and bacteremia due to CRE.

Results.

Two hundred fifty-six cases of CRE infection were identified: 75 cUTI/AP, 21 HABP, 20 VABP, and 140 bacteremia. The patient population had significant comorbidities: 32.8% had chronic renal insufficiency, and 26.2% were immunocompromised. Illness severity at presentation was high: 29.3% presented with septic shock. Treatment regimens varied widely; however, a majority of patients received combination therapy. Outcomes were universally poor (28-day mortality was 28.1%) across all sites of infection, particularly in dialysis patients and those with sepsis.

Conclusions.

The CRE infections occured in patients with substantial comorbidities and were associated with high mortality and low rates of clinical cure with available antibiotics. Patients with these comorbidities are often excluded from enrollment in clinical trials for registration of new drugs. These results led to changes in the inclusion/exclusion criteria of a phase 3 trial to better represent the patient population with CRE infections and enable enrollment. Observational studies may become increasingly important to guide clinical trial design, inform on the existing standard of care, and provide an external control for subsequent trials.

PDF

https://watermark.silverchair.com/api/watermark?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAdkwggHVBgkqhkiG9w0BBwagggHGMIIBwgIBADCCAbsGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMZn7w0r8kx37PhNraAgEQgIIBjLKt0DouuWV11sRc8O-B6xxvAIOOUu170cfToimWAarK3pS8vgvRxMV2TmD9D5uxdT4RMRGUCy1jGrb7r7xt1tk71qTQlb-FDjXMkJR7SLpBdM24mW0SwQm1hUTgypdBxUZ9yNwoPvwE76KstP4DSUN6NKj0ioTM22Um7TOftKff3_cOlDS1O9Ex2sX89wsxgZFWOJieIgRj-Hts05GPoJG2DopwY2yBh6SsGZWREU4Fb9yAn3uSvHcWpeO_ORV8tsCuIrC1zprKAnL-KIrEmK6QR-1GNhnkvecyUt-PPDChwRylfyLGBpt797EaSyK8BbijeZwUQmGB28bd9Rms12-pZc2-eoheKmI_TpcTXr4A5cBh9LT3h0Bw1wOhsK9zhFLj7i1k90L3rpUEMcaDbIiqV8PfmaIFD6jGp2tVjiHIlHElyxymezBMy04QssCemVf29hUNX02GEbMnV2kQEmfdSzEq_0hp4v7t5mBroxc7TR3M7GRaWXp4pN4i1STLXYYg5QQGBPS5IFboGw

September 3, 2017 at 6:51 pm

Comparative Sensitivity of Transthoracic and Transesophageal Echocardiography in Diagnosis of Infective Endocarditis Among Veterans With Staphylococcus aureus Bacteremia

Open Forum Infectious Diseases April 2017 V.4 N.2

Poorani Sekar; James R. Johnson; Joseph R. Thurn; Dimitri M. Drekonja; Vicki A. Morrison …

Background.

Echocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial.

Methods.

We identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making.

Results.

Of 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of 17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%).

Conclusions.

Patients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.

PDF

https://watermark.silverchair.com/api/watermark?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAdMwggHPBgkqhkiG9w0BBwagggHAMIIBvAIBADCCAbUGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMeFcAOsBub-Q7icrBAgEQgIIBhvFldBYwYOWKFTDnKiWkUjQyp_Gxbkh70UcMoyuF46dvh-nnVQTQy7ygLKkkpK6vTCU2tUMBizKzMT4XGA48UGtEM9DzFFasOBvRLsExTYiR39zBNKjAj1AwvwU84VDhgmJXtFxML40CHUM6ew40Ag8-FJQX5kS0NJEfis9te1G5VVL_DySxQeoW_79YrJfcIkbBEAQR5NdFmlINDBgaWIegD8wSyD1ejwbon7K_SiTsO7EDlEzq7nEJutnEGPqCJtFWeEmaFSC0_7mMEmkq7xKy9IQdPkRiLPNdPcWBoN-LkkwTK6SOMNyP3X8CKwkyNkPCZgcd-VVAN05Ydq3AGmsMQqNa8z0Fg9OXnJqaD9SjYKb5_cAX3bfVAx7I23aN7FMgAACaoK7AavAC9KdSPnitBIyIKcu2pNB7iyOTB2r8U5_BfSrTi_SHfYXApP72cbSWJVdWd1bnqmiCSHVVx5o9IrEvzPuVlORi0RRQQ7Wv7_dYRUY0LjbZsFiiJ5StZo4C1oq8YQ

September 3, 2017 at 6:46 pm

Older Posts


Categories

  • Feeds RSS

  • Feeds