A Rare Case of Peritoneal Dialysis-Associated Peritonitis Caused by Neisseria sicca.

Peritonitis is a critical complication in peritoneal dialysis, often leading to peritoneal dialysis (PD) treatment failure. We present a rare case of Neisseria sicca (NS)-related peritonitis in a 47-year-old male with multiple comorbidities. Despite NS's infrequent association with infections, prompt diagnosis and antibiotic therapy based on International Society for Peritoneal Dialysis (ISPD) guidelines led to a favorable outcome. This case emphasizes identifying uncommon pathogens in immunocompromised individuals and highlights the importance of prompt treatment to prevent morbidity.

Should Histoplasmosis be Screened for Before Initiation of Tumour Necrosis Factor Alpha Inhibitors?

Histoplasmosis is a soil-based dimorphic fungus endemic to the Midwest and Southeastern United States and is responsible for infection through inhalation of conidia. Infection is usually asymptomatic, as the fungal growth is contained by formation of granulomas. However, dissemination can occur in immunocompromised hosts due to the lack of optimal activity of interferon gamma, tumour necrosis factor alpha (TNF-alpha) and interleukin-17. There is a significant overlap between the symptomatology of histoplasmosis and granulomatosis with polyangiitis (GPA). We report a case of a 48-year-old female who presented with high-grade fever, worsening generalised weakness and tachycardia. She had a previous history of bilateral cavitary lung lesions for which she was evaluated at an outside facility. As her entire infectious investigation was negative and found to be positive for antineutrophil cytoplasmic antibody (ANCA), a diagnosis of GPA was made, and she was initiated on rituximab infusions 7 weeks prior to her presentation to our facility. Repeat infectious investigations at our facility were positive for (1-3)-ß-D-glucan test and urine histoplasma antigen. Prompt discontinuation of rituximab and initiation of systemic antifungal therapy led to clinical improvement. Based on this experience, we highlight the association of histoplasma with ANCA positivity along with the importance of closely monitoring these patients for possible clinical worsening after the initiation of TNF-alpha inhibitors, despite the negative infectious work-up. Also routine screening or pre-emptive therapy for histoplasmosis before the initiation of TNF-inhibitors is not recommended. LEARNING POINTS: Histoplasmosis is associated with ANCA positivity.Despite the negative investigations for histoplasmosis and criteria for GPA being met, patients should be closely monitored for possible clinical worsening after the initiation of immunosuppressive therapy, especially TNF-alpha inhibitors.Current guidelines are not recommending routine screening or pre-emptive therapy for histoplasmosis before initiation of TNF-alpha inhibitors.

Immune Reconstitution Inflammatory Syndrome in Aids Patient After Successful Induction of Virological Suppression with Cabotegravir/Rilpivirine.

Long-acting (LA) cabotegravir/rilpivirine (CAB/RPV) is a complete regimen for the management of human immunodeficiency virus type 1 (HIV-1) infection to replace their oral antiretroviral therapy (ART) when they have been virologically suppressed. We present a case of successful achievement of undetectable HIV RNA viral load levels in an acquired immunodeficiency syndrome (AIDS) patient with long-standing virologic failure within two months of CAB/RPV LA initiation. This was later complicated by immune reconstitution inflammatory syndrome (IRIS) due to Mycobacterium avium-intracellulare (MAI) infection and hepatitis B virus (HBV) reactivation. LEARNING POINTS: This case highlights the efficacy of monthly CAB/RPV LA in rapidly reducing the HIV viral load level in a poorly controlled patient who lacked significant resistance to the two drugs.This is the first case of IRIS reported in the literature while using CAB/RPV LA. IRIS in the setting of occult MAI is well recognised. It would have occurred with good adherence to any regimen which rapidly suppressed the viral load and is unlikely to be due to CAB/RPV. CAB/RPV has no activity against HBV, which may have contributed to its reactivation.The patient had serologic evidence of resolution of prior HBV. However, some patients have covalently closed circular DNA (cccDNA) that may remain long term in hepatocyte nuclei.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria.

Importance: Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. Objective: To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. Design, Setting, and Participants: This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Exposure: Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Main Outcomes and Measures: Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Results: Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). Conclusions and Relevance: This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

Cryptococcus neoformans var. grubii septic arthritis in an immunocompromised patient on haemodialysis with history of splenectomy and sarcoidosis.

A male adult in his mid-40s with end-stage renal disease (ESRD) on haemodialysis, with history of splenectomy and sarcoidosis, developed septic arthritis of the knee. Excision and drainage was performed and empiric antibiotics were initiated. Cultures were initially negative without clinical improvement. Eventually, the aerobic synovial fluid culture grew Cryptococcus neoformans (formerly Cryptococcus neoformans var. grubii). The patient was treated with liposomal amphotericin B and then switched to fluconazole until the infection resolved. This case highlights the less well-recognised association between cryptococcal arthritis and immunodeficiency states like ESRD, splenectomy and sarcoidosis.

A Statewide Collaborative Quality Initiative to Improve Antibiotic Duration and Outcomes in Patients Hospitalized With Uncomplicated Community-Acquired Pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). METHODS: This prospective collaborative quality initiative included patients hospitalized with uncomplicated CAP who qualified for a 5-day antibiotic duration. Between 23 February 2017 and 5 February 2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance incentives. Changes in outcomes, including appropriate receipt of 5 ± 1-day antibiotic treatment and 30-day postdischarge composite adverse events (ie, deaths, readmissions, urgent visits, and antibiotic-associated adverse events), were assessed over time (per 3-month quarter), using logistic regression and controlling for hospital clustering. RESULTS: A total of 41 hospitals and 6553 patients were included. The percentage of patients treated with an appropriate 5 ±â€…1-day duration increased from 22.1% (predicted probability, 20.9% [95% confidence interval: 17.2%-25.0%]) to 45.9% (predicted probability, 43.9% [36.8%-51.2%]; adjusted odds ratio [aOR] per quarter, 1.10 [1.07-1.14]). Thirty-day composite adverse events occurred in 18.5% of patients (1166 of 6319) and decreased over time (aOR per quarter, 0.98 [95% confidence interval: .96-.99]) owing to a decrease in antibiotic-associated adverse events (aOR per quarter, 0.91 [.87-.95]). CONCLUSIONS: Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional collaborative quality initiatives with data collection and benchmarking, sharing of best practices, and pay-for-performance incentives may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.

Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department.

BACKGROUND: Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. METHODS: We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018-February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. RESULTS: Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08-1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). CONCLUSIONS: Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

A Deeper Dive Into Antibiotic Stewardship Needs: A Multihospital Survey.

In a 2016 survey of 46 Michigan hospitals, we identified four key needs for antibiotic stewardship: clinically-relevant antibiotic data, monitoring compliance, syndrome-specific interventions, and discharge stewardship. A stewardship initiative now addresses these needs within the Michigan Hospital Medicine Safety Consortium.

Risk Factors and Outcomes Associated With Treatment of Asymptomatic Bacteriuria in Hospitalized Patients.

IMPORTANCE: Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined. OBJECTIVE: To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis. EXPOSURES: One or more antibiotic dose for treatment of ASB. MAIN OUTCOMES AND MEASURES: Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post-acute care settings, Clostridioides difficile infection (formerly known as Clostridium difficile) at 30 days, and duration of hospitalization after urine testing. RESULTS: Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/µL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting. CONCLUSIONS AND RELEVANCE: Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study.

Background: Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration. Objective: To examine predictors and outcomes associated with excess duration of antibiotic treatment. Design: Retrospective cohort study. Setting: 43 hospitals in the Michigan Hospital Medicine Safety Consortium. Patients: 6481 general care medical patients with pneumonia. Measurements: The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment. Results: Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Limitation: Retrospective design; not all patients could be contacted to report 30-day outcomes. Conclusion: Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes. Primary Funding Source: Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.

Pulmonary actinomycosis and tracheal squamous cell carcinoma: A rare simultaneous presentation of both in a single patient.

A 57-year-old male with schizophrenia and a 37 pack-year smoking history presented with cough productive of purulent sputum associated with hemoptysis and worsening shortness of breath. Computed tomography (CT) scan revealed multiple masses in the right upper and lower lobes with a small distal tracheal mass and significant mediastinal lymphadenopathy. CT guided biopsy of the largest lung mass in the right lower lobe confirmed a diagnosis of pulmonary actinomycosis. The patient received appropriate antibiotic therapy for four weeks, but his condition did not improve. A repeat CT scan showed worsening of the right lung consolidation with increasing occlusion of the trachea. Bronchoscopy was performed which revealed a friable necrotic mass occupying 70% of the tracheal lumen. Histopathology showed squamous cell carcinoma of the trachea likely of primary origin. Unfortunately, the patient was not a candidate for any surgical intervention or oncologic treatment, and he died few days later. This patient had a rare simultaneous presentation of both pulmonary actinomycosis and tracheal squamous cell carcinoma. To the best of our knowledge, this is the first reported case of simultaneous diagnosis of both conditions in the same patient. This case illustrates the importance of looking for an alternative diagnosis in patients with actinomycosis who do not respond well to appropriate therapy.

Unrecognized staphylococcal vertebral osteomyelitis leading to fatal outcome in a previously healthy patient.

New onset low back pain which is recalcitrant to usual treatment should be evaluated aggressively even in the absence of fever or neurologic deficits. Corticosteroids given for back pain will accelerate occult spinal infection and may mask symptomatology leading to more severe disease.

Salmonella Typhimurium para-aortic root abscess managed non-surgically.

Introduction: Para-aortic root abscess is a destructive vascular condition that can result in significant morbidity and mortality. We describe a rare case of para-aortic root abscess due to Salmonella Typhimurium that was successfully managed medically. Presentation of case: A 72-year-old diabetic man with a prosthetic aortic graft presented with fever and expressive aphasia with left sided weakness. Magnetic resonance imaging (MRI) of the brain showed multiple embolic cerebral vascular accidents. Computed tomography angiography (CTA) of the chest showed a 5.7 × 2.7 cm (cm) para-aortic root abscess. Blood cultures grew Salmonella Typhimurium. The patient was started on ceftriaxone initially, and then ciprofloxacin was added on day 5. Given an unacceptably high risk of mortality expected with surgery, the patient was managed medically.After five months of both ceftriaxone and ciprofloxacin, ceftriaxone was stopped. Twelve months later, the patient is doing well on ciprofloxacin alone with a plan for lifelong suppression. Discussion: Cases of para-aortic root abscess due to Salmonella Typhimurium have not been reported in the literature. There are no guidelines to dictate the antibiotic choice or management of para-aortic root abscess due to Salmonella Typhimurium. Conclusion: This report adds to the body of literature regarding the treatment of this infection including successful non-surgical management.

Development and implementation of a pharmacist-managed outpatient parenteral antimicrobial therapy program.

PURPOSE: The development and implementation of a pharmacist-managed outpatient parenteral antimicrobial therapy (OPAT) program in a county teaching hospital are described. SUMMARY: A pharmacist-managed OPAT program was developed and implemented at a county teaching hospital to provide consistent evaluation, approval, and monitoring of patients requiring OPAT for the treatment of infection. The developmental and implementation stages of the OPAT program included (1) a needs assessment, (2) the identification of resources necessary for program operation, (3) delineation of general OPAT program operations and activities of individual OPAT clinicians, (4) the development of patient selection criteria, including a plan of care algorithm, and (5) acquisition of administrative support to approve the program. In this program, the OPAT pharmacist plays an integral role in the management and oversight of OPAT patients, working under a collaborative agreement with infectious diseases physicians. The OPAT pharmacist assists with appropriate patient and regimen selection, confirmation of orders on discharge, assuring that laboratory tests for safety surveillance are performed and evaluated, performing routine monitoring for adverse events and line complications, and assuring the removal of the vascular access device upon the completion of OPAT. CONCLUSION: The OPAT program provides structured monitoring, patient follow-up, and led to improvements in patient outcome with minimization of treatment and line-related adverse events.

Dolutegravir: a next-generation integrase inhibitor for treatment of HIV infection.

Dolutegravir (DTG), a next-generation integrase strand transfer inhibitor (INSTI), was recently approved for use in the treatment of human immunodeficiency virus infection. In treatment-naive trial participants, DTG given at 50 mg once daily without pharmacologic boosting combined with a standard nucleoside backbone was shown to be noninferior or superior to first-line regimens containing efavirenz, darunavir/ritonavir, or raltegravir regardless of pretreatment viral load. This drug also exhibited efficacy in antiretroviral therapy-experienced participants and has proven to retain activity when dosed twice daily in some participants harboring resistance to the other INSTIs, raltegravir and elvitegravir. DTG has few drug interactions and is taken without regard to meals. It causes benign elevations in serum creatinine based on its inhibition of tubular creatinine secretion without affecting the glomerular filtration rate. Overall, DTG is well tolerated, with headache and insomnia being the most frequently reported adverse events.

Mandatory infectious diseases approval of outpatient parenteral antimicrobial therapy (OPAT): clinical and economic outcomes of averted cases.

OBJECTIVES: The use of outpatient parenteral antimicrobial therapy (OPAT) has been increasing worldwide due to its evident clinical utility; however, there is also concern about overuse and increased risk to patients in terms of antibiotic toxicity and intravenous line-associated complications. At our university-affiliated county teaching hospital with mandatory Infectious Diseases (ID) approval for all OPAT courses, we looked at clinical outcomes and cost savings of patients denied OPAT. METHODS: Electronic medical records of patients denied OPAT were retrospectively reviewed. Demographic, medical, infection-specific and drug-specific data were collected for each patient, including the regimen ultimately recommended by ID in lieu of OPAT. Patients were determined to have clinical cure, probable cure or treatment failure based on resolution or recurrence of infection for up to 1 year after OPAT denial. The amount of money saved in direct OPAT costs in these patients was calculated. RESULTS: Fifty-six patients were denied OPAT during the study period and were discharged with either oral or no additional antibiotics. Clinical cure was documented in 42 patients (75%), probable cure in 7 patients (12.5%) and treatment failure in 7 patients (12.5%). Of the seven treatment failures, only one patient (1.8%) was deemed to be a true failure after thorough chart review. Overall, the estimated OPAT-specific cost saving was $215 424 or $3847 per patient. CONCLUSIONS: Mandatory ID approval of all OPAT courses can decrease healthcare costs while maintaining good clinical outcomes.

The role of etravirine in the management of treatment-experienced pediatric patients with HIV.

Pediatric patients infected with human immunodeficiency virus (HIV) are now living longer, healthier lives due to the advent of combined antiretroviral (ARV) therapy, including regimens that often contain non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, first-generation NNRTIs such as nevirapine (NVP) and efavirenz (EFV) have a low genetic barrier to resistance, and both drugs can become ineffective with a single viral point mutation. New agents with activity against resistant viral strains must be available to salvage children and adolescents with virologic failure after NNRTI use. One such drug, etravirine, an oral second-generation NNRTI approved for use in the US in heavily treatment-experienced HIV-1-infected adults in 2008, is accumulating data in this younger population. Etravirine became approved by the US Food and Drug Administration in early 2012 to be used in combination with other ARV medications in HIV-1-infected children aged 6 years to <18 years who are failing their regimens with HIV-1 strains resistant to NNRTIs and other ARVs. This approval was largely based on data from a prospective, open-label, phase II clinical trial in this age group prescribed etravirine at 5.2 mg/kg twice daily (up to the adult dose of 200 mg twice daily) in combination with an investigator-selected optimized background regimen. Currently available 48-week follow-up data show complete viral suppression (<50 copies/mL) in 56% of the patients, with relatively few serious adverse events attributed to the drug. Additional studies and case reports from the field suggest its utility in clinical practice. This review is designed to increase the background understanding of this drug in pediatric HIV providers, to lay out the current pediatric data to support its use, and to define its practical role in the treatment of HIV-infected children now and in the future.

Bariatric surgery outcomes in HIV-infected subjects: a case series.

Obesity is now a common problem among HIV-infected patients receiving antiretroviral therapy (ART). Gastric bypass surgery may be an option for some patients who have failed diet and therapeutic lifestyle changes, changes in ART or other treatment modalities for HIV/ART-related lipohypertrophy and obesity. However, few data are available regarding HIV-related outcomes after such surgery and its impact on ART tolerability. We present here a case series of seven subjects with HIV infection who underwent bariatric surgery. Viral suppression was maintained in five of the six subjects who were receiving ART prior to surgery, including three subjects who experienced surgical complications. The median (range) decrease in body mass index (BMI) postoperatively was 10 kg/m(2) (6-28 kg/m(2)). Improvements were also seen in serum lipid fractions with median (range) changes in total cholesterol of -19 mg/dL (-61 to +3 mg/dL) and triglycerides of -185 mg/dL (-739 to +35 mg/dL). Four of the subjects had a reduction in their metabolic medication prescriptions postoperatively. Three of the subjects experienced postsurgical complications. Based on our experience, bariatric surgery may provide an effective treatment modality for obesity and its related comorbidities in the HIV-infected population while not sacrificing virologic suppression. Larger studies are needed to verify these results, especially in regards to surgical complications.