Archive for June, 2016

Failure of Dual Antimicrobial Therapy in Treatment of Gonorrhea

N Engl J Med June 2016 V.374 P.2504-2506


To the Editor:

Resistance to all antimicrobial agents has developed in some Neisseria gonorrhoeae strains. Dual antimicrobial therapy (ceftriaxone plus azithromycin) is a recommended first-line empirical treatment in many countries.1-3 We describe treatment failure with dual therapy in a patient with gonorrhea….


June 29, 2016 at 3:36 pm

Management of Adult Syphilis

Clinical Infectious Diseases Dec.2011 V.53 N.12 Suppl.3  S110-S128

Khalil G. Ghanem1 and Kimberly A. Workowski2,3

1Johns Hopkins University School of Medicine, Baltimore, Maryland

2National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention

3Emory University, Atlanta, Georgia

There are several important unanswered key questions in the management of adult syphilis. A systematic literature review was conducted and tables of evidence were constructed to answer these important questions. A single dose of 2.4 million units of benzathine penicillin G remains the drug of choice for managing early syphilis. Enhanced antibiotic therapy has not been shown to improve treatment outcomes, regardless of human immunodeficiency virus (HIV) status. Although additional data on the efficacy of azithromycin in treating early syphilis have emerged, reported increases in the prevalence of a mutation associated with azithromycin resistance precludes a recommendation for its routine use. Cerebrospinal fluid (CSF) examination should be performed in all persons with serologic evidence of syphilis infection and neurologic symptoms. In those persons with early syphilis who do not achieve a ≥4-fold serologic decline in their rapid plasma reagin (RPR) titers 6–12 months after adequate therapy and those with late latent infection who do not achieve a similar decline within 12–24 months, CSF examination should be considered. Among HIV-infected persons, CSF examination among all those with asymptomatic late latent syphilis is not recommended owing to lack of evidence that demonstrates clinical benefit. HIV-infected persons with syphilis of any stages whose RPR titers are ≥1:32 and/or whose CD4 cell counts are <350 cells/mm3 may be at increased risk for asymptomatic neurosyphilis. If CSF pleocytosis is evident at initial CSF examination, these examinations should be repeated every 6 months until the cell count is normal. Several important questions regarding the management of syphilis remain unanswered and should be a priority for future research.


June 29, 2016 at 9:05 am

Sexually Transmitted Diseases in Men Who Have Sex With Men

Clinical Infectious Diseases Dec.2011 V.53 N.12 Suppl.3  S79-S83

Kenneth H. Mayer1,2

1Harvard Medical School, Beth Israel Deaconess Medical Center

2Fenway Institute, Fenway Health, Boston, Massachusetts

Men who have sex with men (MSM) have increased rates of human immunodeficiency virus (HIV) infection and sexually transmitted diseases (STDs) compared with demographically matched controls. The reasons for the disproportionate infection burden are complex, including biological, behavioral, and sociocultural factors. HIV and syphilis may often be coprevalent among MSM. The use of nucleic acid amplification testing has enhanced the ability to detect frequently asymptomatic gonococcal and chlamydial infections of the rectum and other sites. Lymphogranuloma proctitis outbreaks among MSM were noted in the developed world several years ago but have not been common recently. MSM are at increased risk for viral hepatitis and anal human papillomavirus disease. Preventive interventions include vaccination for the former and anal cytologic screening for the latter. Because of the diverse ways in which MSM may be exposed to STDs, it is essential for clinicians to obtain a thorough sexual history in a culturally competent manner.


June 29, 2016 at 9:03 am

Sexually Transmitted Infections Among Women Who Have Sex With Women

Clinical Infectious Diseases Dec.2011 V.53 N.12 Suppl.3  S84-S91

Linda M. Gorgos1 and Jeanne M. Marrazzo2

1Infectious Disease Bureau, Public Health Division, New Mexico Department of Health, Santa Fe

2Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle

Women who have sex with women (WSW) are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring bacterial, viral, and protozoal sexually transmitted infections (STIs) from current and prior partners, both male and female. Bacterial vaginosis is common among women in general and even more so among women with female partners. WSW should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same-sex behavior by women should not deter providers from considering and performing screening for STIs, including chlamydia, in their clients according to current guidelines. Effective delivery of sexual health services to WSW requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between care providers and their female clients.


June 29, 2016 at 9:01 am

Análisis de costes y de coste/eficacia de las pautas recomendadas por GESIDA/Plan Nacional sobre el Sida en 2015 para el tratamiento antirretroviral inicial en adultos infectados por el VIH

Enf Inf & Microb Clin Junio 2016 V.34 N.6 P.361-71

Juan Berenguer, Antonio Rivero, Antonio Javier Blasco, José Ramón Arribas, Vicente Boix, Bonaventura Clotet, Pere Domingo, Juan González-García, Hernando Knobel, Pablo Lázaro, Juan Carlos López, Josep M. Llibre, Fernando Lozano, José M. Miró, Daniel Podzamczer, Montserrat Tuset, Josep M. Gatell

a Unidad de Enfermedades Infecciosas/VIH, Hospital General Universitario Gregorio Marañón, Madrid, Spain

b Sección de Enfermedades Infecciosas, Hospital Universitario Reina Sofía/IMIBIC, Cordoba, Spain

c Independent Researcher, Madrid, Spain

d Servicio de Medicina Interna, Unidad de VIH, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain

e Unidad de Enfermedades Infecciosas, Hospital General de Alicante, Alicante, Spain

f Fundació Lluita contra la Sida, Unitat VIH, Hospital Universitari Germans Trias i Pujol, Badalona, Spain

g Universitat Autònoma de Barcelona, Barcelona, Spain

h Irsicaixa, UVic, Barcelona, Spain

i Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain

j Servicio de Enfermedades Infecciosas, Hospital del Mar, Barcelona, Spain

k Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, Spain

l Servicio de Enfermedades Infecciosas, Hospital Clínic-IDIBAPS, Universidad de Barcelona, Barcelona, Spain

m Unidad VIH, Servicio de Enfermedades Infecciosas, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain

n Servicio de Farmacia, Hospital Clínic, Barcelona, Spain


El panel de expertos de GESIDA/Plan Nacional del Sida ha recomendado pautas preferentes (PP), pautas alternativas (PA) y otras pautas (OP) para el tratamiento antirretroviral como terapia de inicio en pacientes infectados por VIH para 2015. El objetivo de este estudio es evaluar los costes y la eficiencia de iniciar tratamiento con estas pautas.


Evaluación económica de costes y eficiencia (coste/eficacia) mediante construcción de árboles de decisión. Se definió eficacia como la probabilidad de tener carga viral <50 copias/mL en la semana 48 en análisis por intención de tratar. Se definió coste de iniciar tratamiento con una pauta como los costes del tratamiento antirretroviral y de todas sus consecuencias (efectos adversos, cambios de pauta y estudio de resistencias) que se producen en las siguientes 48 semanas. Se utilizó la perspectiva del Sistema Nacional de Salud, considerando solo costes directos diferenciales: tratamiento antirretroviral (a precio oficial), manejo de efectos adversos, estudios de resistencias y determinación de HLA B*5701. El ámbito es España, con costes de 2015. Se realizó análisis de sensibilidad determinista construyendo 3 escenarios para cada pauta: basal, más favorable y más desfavorable.


En el escenario basal, los costes de iniciar tratamiento oscilaron entre 4.663 euros para 3TC + LPV/r (OP) y 10.902 euros para TDF/FTC + RAL (PP). La eficacia osciló entre 0,66 para ABC/3TC + ATV/r (PA) y ABC/3TC + LPV/r (OP), y 0,89 para TDF/FTC + DTG (PP) y TDF/FTC/EVG/COBI (PA). La eficiencia, en términos de coste/eficacia, osciló entre 5.280 y 12.836 euros por respondedor a las 48 semanas, para 3TC + LPV/r (OP) y RAL + DRV/r (OP), respectivamente.


La pauta más eficiente fue 3TC + LPV/r (OP). Entre las PP o PA, la pauta más eficiente fue TDF/FTC/RPV (PA). De las PP, la más eficiente fue ABC/3TC + DTG.


June 28, 2016 at 8:25 am

Predicción del coste antiretroviral elevado según la complejidad clínica. Validación de un índice clínico

Enf Inf & Microb Clin Marzo 2016 V.34 N.3 P.149-58

Cesar Velasco, Inaki Pérez, Daniel Podzamczer, Josep Maria Llibre, Pere Domingo, Juan González-García, Inma Puig, Pilar Ayala, Mayte Martín, Antoni Trilla, Pablo Lázaro, Josep Maria Gatell

a Preventive Medicine and Epidemiology Unit, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain

b Infectious Disease and HIV Service, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain

c HIV Unit, Infectious Disease Service, Hospital Universitari de Bellvitge, L’Hospitalet, Barcelona, Spain

d HIV Unit and “Lluita contra la SIDA” Foundation, University Hospital Germans Trias i Pujol, Badalona, Spain

e Infectious Disease and HIV Service, Hospital Sant Pau, Spain

f Infectious Disease and HIV Service, Hospital La Paz, Spain

g Administration and Economics, Internal Medicine and Dermatology Institute, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain

h Hospital Pharmacy Service, Hospital Clínic de Barcelona, Spain

i Técnicas Avanzadas de Investigación en Servicios de Salud, Madrid, Spain


La financiación de la terapia antirretroviral (ART) se determina generalmente por los costos incurridos en el año anterior, el número de pacientes en tratamiento y las recomendaciones basadas en la evidencia, pero no por las características clínicas de la población.


Establecer un índice que relacione el coste de ART y los pacientes de elevada complejidad clínica con el fin de entender las diferencias de coste entre los hospitales de la región que podrían explicarse por la diferente complejidad clínica de sus poblaciones.


Análisis retrospectivo de los pacientes que reciben TAR en un hospital terciario entre 2009 y 2011. Los factores potencialmente asociados con un mayor coste de TAR se evaluaron mediante análisis bivariado y multivariado. Se desarrollaron dos modelos de predicción de “coste elevado”. Se calculó el coste estimado normalizado (ajustado por el índice de complejidad) y se comparó con el coste real normalizado.


En el hospital índice, 631 (16.8%) de los 3.758 pacientes que recibieron TAR asumió “coste elevado”, definido como el 25% más alto del gasto en TAR. Las variables basales que fueron asociadas a alto coste en el modelo Clínic-B en el análisis multivariado fueron: vía de transmisión del VIH, criterios de sida, nacionalidad española, año de inicio del TAR, nadir de CD4+ y número de ingresos hospitalarios. El índice de complejidad Clínic-B varió de 0 a 13 puntos, y el valor medio (5.97) fue menor que el valor medio global de los cuatro hospitales (6.16).


La complejidad clínica de los pacientes VIH influye en el coste de la TAR. Las puntuaciones Clínic-B y Clínic-BF predijeron los pacientes con alto costo de TAR y podrían utilizarse para comparar y asignar costes corregidos según la complejidad clínica de los pacientes.


June 28, 2016 at 8:24 am

El coste del tratamiento de la infección por el virus de la inmunodeficiencia humana: ¿puede optimizarse de modo razonable?

Enf Inf & Microb Clin Marzo 2016 V.34 N.3 P.147-8


Santiago Moreno

Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, España

A pesar del elevado coste de los fármacos, el tratamiento antirretroviral se ha establecido como una de las estrategias más coste-efectivas de la medicina moderna. El tratamiento ha logrado modificar la historia natural de la infección por el virus de la inmunodeficiencia adquirida (VIH), con un aumento notable de la supervivencia y de la calidad de vida de las personas afectadas1. Todas las estimaciones actuales coinciden en que, con tratamiento antirretroviral adecuado y en ausencia de otros factores asociados (uso de drogas, enfermedades concomitantes graves), la supervivencia de las personas infectadas por VIH es similar a la de la población no infectada2. No cabe duda, por tanto, que proporcionar tratamiento a las personas que lo precisan no supone solo una medida excelente para el cuidado de la salud individual, e incluso para la salud colectiva, sino que es rentable desde el punto de vista económico….


June 28, 2016 at 8:23 am

The 2015 Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections in HIV-Infected Koreans: Guidelines for Opportunistic Infections.

Infect Chemother. 2016 Mar;48(1):54-60.

Korean Society for AIDS.


The Committee for Clinical Guidelines for the Treatment and Prevention of Opportunistic Infections of the Korean Society for AIDS was founded in 2011. The first edition of the Korean guidelines was published in 2012. The guideline recommendations contain important information for physicians working with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in the clinical field. It has become necessary to revise the guidelines due to new data in this field. These guidelines aim to provide up-to-date, comprehensive information regarding the treatment and prevention of opportunistic infections in HIV-infected Koreans. These guidelines deal with several common opportunistic infections, including pneumocystis pneumonia, tuberculosis, cryptococcal meningitis, etc. A brief summary of the revised guidelines is provided below. Recommendations are rated using the same system used in the previous guidelines.


June 28, 2016 at 8:22 am

Treatment of Dermatological Conditions Associated with HIV/AIDS: The Scarcity of Guidance on a Global Scale.

AIDS Res Treat. 2016;2016:3272483.

Paul S1, Evans R2, Maurer T3, Muhe LM4, Freeman EE5.

Author information

1Harvard Medical School, Boston, MA, USA.

2HIV Department, World Health Organization, Geneva, Switzerland.

3Department of Dermatology, University of California San Francisco School of Medicine, San Francisco, CA, USA.

4Department of Maternal, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.

5Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 6R, 55 Fruit Street, Boston, MA 02114, USA.


Background. Skin diseases associated with Human Immunodeficiency Virus (HIV) infection are associated with significant morbidity and mortality. In resource-limited settings, nondermatologists and lay health care providers on the front line of HIV care provide much of the treatment for these conditions.

Objective. To evaluate guidelines for treatment of HIV-related skin conditions and assess their accessibility, comprehensiveness, and quality of evidence employed. Methods. A review was undertaken of all national and society guidelines which included treatment information on the ten highest burden HIV-related skin conditions. The search strategy included gray and peer-reviewed literature.

Results. Of 430 potential guidelines, 86 met inclusion criteria, and only 2 were written specifically to address HIV-related skin diseases as a whole. Treatment information for HIV-related skin conditions was embedded within guidelines written for other purposes, primarily HIV/AIDs treatment guidelines (49%). Development of guidelines relied either partially or completely on expert opinion (62%). Only 16% of guidelines used gradation of evidence quality and these were primarily from high-income countries (p = 0.001).

Limitations. Due to the nature of gray literature, not all guidelines may have been identified. Conclusion. This review highlights the need for evidence-based summary guidelines that address treatment for HIV-related skin conditions in an accessible format.


June 28, 2016 at 8:21 am

Time to HAART Initiation after Diagnosis and Treatment of Opportunistic Infections in Patients with AIDS in Latin America.

PLoS One. 2016 Jun 7;11(6):e0153921.

Crabtree-Ramírez B1, Caro-Vega Y1, Shepherd BE2, Grinsztejn B3, Wolff M4, Cortes CP4, Padgett D5, Carriquiry G6, Fink V7, Jayathilake K8, Person AK8, McGowan C8, Sierra-Madero J1; Caribbean, Central and South America Network for HIV Epidemiology (CCASAnet), of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Program.

Author information

1Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico.

2Vanderbilt University, Department of Biostatistics, Nashville, TN, United States of America.

3Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil.

4Universidad de Chile- Fundación Arriarán, Santiago, Chile.

5Instituto Hondureño de Seguro Social and Hospital Escuela Universitario, Tegucigalpa, Honduras.

6Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru.

7Fundación Huésped, Investigaciones Clínicas, Buenos Aires, Argentina.

8Vanderbilt University, Department of Medicine, Nashville, TN, United States of America.



Since 2009, earlier initiation of highly active antiretroviral therapy (HAART) after an opportunistic infection (OI) has been recommended based on lower risks of death and AIDS-related progression found in clinical trials. Delay in HAART initiation after OIs may be an important barrier for successful outcomes in patients with advanced disease. Timing of HAART initiation after an OI in “real life” settings in Latin America has not been evaluated.


Patients in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) ≥18 years of age at enrolment, from 2001-2012 who had an OI before HAART initiation were included. Patients were divided in an early HAART (EH) group (those initiating within 4 weeks of an OI) and a delayed HAART (DH) group (those initiating more than 4 weeks after an OI). All patients with an AIDS-defining OI were included. In patients with more than one OI the first event reported was considered. Calendar trends in the proportion of patients in the EH group (before and after 2009) were estimated by site and for the whole cohort. Factors associated with EH were estimated using multivariable logistic regression models.


A total of 1457 patients had an OI before HAART initiation and were included in the analysis: 213 from Argentina, 686 from Brazil, 283 from Chile, 119 from Honduras and 156 from Mexico. Most prevalent OI were Tuberculosis (31%), followed by Pneumocystis pneumonia (24%), Invasive Candidiasis (16%) and Toxoplasmosis (9%). Median time from OI to HAART initiation decreased significantly from 5.7 (interquartile range [IQR] 2.8-12.1) weeks before 2009 to 4.3 (IQR 2.0-7.1) after 2009 (p<0.01). Factors associated with starting HAART within 4 weeks of OI diagnosis were lower CD4 count at enrolment (p-<0.001), having a non-tuberculosis OI (p<0.001), study site (p<0.001), and more recent years of OI diagnosis (p<0.001).


The time from diagnosis of an OI to HAART initiation has decreased in Latin America coinciding with the publication of evidence of its benefit. We found important heterogeneity between sites which may reflect differences in clinical practices, local guidelines, and access to HAART. The impact of the timing of HAART initiation after OI on patient survival in this “real life” context needs further evaluation.


June 28, 2016 at 8:19 am

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