Features of Cytomegalovirus DNAemia Blips in Allogeneic Hematopoietic Stem Cell Transplant Recipients: Implications for Optimization of Preemptive Antiviral Therapy Strategies.

Cytomegalovirus (CMV) DNAemia occurs frequently in allogeneic hematopoietic stem cell transplant recipients (allo-HSCT). There is limited information about the incidence, features, and clinical impact of CMV DNAemia blips (episodes defined by an isolated positive PCR result) in this setting. In this retrospective study, 225 consecutive adult patients undergoing any modality of allo-HSCT at our center between May 2012 and July 2019 were included. Plasma CMV DNA load was monitored using a highly sensitive real-time PCR assay. In all, 187 of 225 patients had CMV DNAemia through day 365 after allo-HSCT (total number of episodes, n = 379). Eighty-three of the 187 patients had 1 or more blips (n = 104). Blips occurred as a first episode of CMV DNAemia as opposed to prolonged CMV DNAemia (≥2 consecutive positive PCR results) in 47 patients; in 20 of these patients, blips represented the only documented episode throughout the study period, and in 27 patients, blips preceded a prolonged CMV DNAemia episode. In the remaining 36 patients, blips developed as recurrences. Blips presenting as initial episodes occurred more frequently (P < .001) in patients receiving an allograft from a CMV-seropositive donor. The cumulative incidence of recurrent CMV DNAemia following initial blips, self-resolving prolonged CMV DNAemia episodes, or CMV DNAemia episodes treated preemptively with antivirals was not significantly different (P = .34). Receiver operating characteristic curve analysis indicated that a CMV DNA load cutoff of 48 IU/mL yielded the highest combined sensitivity (66%) and specificity (70.2%) for predicting a prolonged CMV DNAemia episode. The practical implications of our data in the optimization of preemptive antiviral therapy strategies are discussed.

Assessing the risk of cytomegalovirus DNAaemia in allogeneic stem cell transplant recipients by monitoring oxidative-stress markers in plasma.

The level of antioxidants, such as thiol-containing tripeptide glutathione (GSH), in cytomegalovirus (CMV)-infected cells is notably increased. We previously showed that GSH levels in plasma, as measured by untargeted 1H nuclear magnetic resonance, are higher in allogeneic stem cell transplant (allo-SCT) recipients who subsequently develop CMV viraemia. We hypothesized that the net level of oxidative-stress markers present in plasma may be reduced in patients who develop CMV DNAaemia compared to those who do not. We serially monitored the levels of malondialdehyde (MDA) and carbonylated proteins (CPs) early after allo-SCT and assessed whether they could predict the occurrence of CMV DNAaemia. MDA levels were measured in 43 patients (28 had CMV DNAaemia) and CPs were quantified in 53 patients (38 patients developed CMV DNAaemia). The area under the curve (AUC) value for MDA, but not for CPs, was significantly lower in patients who subsequently developed CMV DNAaemia compared to those who remained DNAaemia-free (P=0.043). A trend toward lower MDA AUC values was observed in episodes of CMV DNAaemia with faster CMV replicative kinetics and in those who reached higher peak CMV DNA levels. Moreover, receiver operating characteristic curve analyses indicated that the MDA biomarker had the predictive ability to discriminate between patients with or without subsequent CMV DNAaemia (AUC=0.69, 95 % confidence interval 0.51-0.85, P=0.05). In summary, serial quantitation of MDA may be useful for individualizing antiviral prophylaxis therapies (targeted prophylaxis) in the upcoming era of new antiviral drugs with improved safety profiles.

Influence of inadequate antimicrobial therapy on prognosis in elderly patients with severe urinary tract infections.

BACKGROUND: Inadequate empirical antimicrobial therapy (IEAT) in intensive care unit (ICU) is associated with adverse outcomes. However, the influence of IEAT on prognosis for elderly patients with urinary tract infection (UTI) in non-ICU settings is unknown. METHODS: A retrospective cross-sectional study of elderly patients admitted to a non-ICU ward in a university hospital with a primary diagnosis of UTI over a 3-year period was done. Data relating to age, sex, background comorbidities, severity of infection, bacteremia, microorganisms isolated in urine, treatment given, length of stay and prognosis were obtained using chart review. Cases were segregated according to the adequacy of empirical antimicrobial therapy. In-hospital mortality rate was the main outcome variable evaluated. RESULTS: A total of 270 patients with a mean age of 83.7years were studied. Sixty-eight percent were health-care associated infections. Seventy-nine (29.3%) cases received IEAT. IEAT was associated with previous hospitalization, urinary catheter and previous antibiotic. A Gram stain of urine with a gram-positive cocci was predictive of IEAT by multivariate analysis (OR, 6.29; 95% CI, 1.05-37.49). In-hospital mortality rate was 8.9%. IEAT (OR, 3.47; 95% CI, 1.42-8.48) was an independent risk factor for mortality along with APACHE II ≥15 (OR, 3.14; 95% CI, 1.24-7.90), dementia (OR, 3.10; 95% CI, 1.19-8.07) and neoplasia (OR, 3.49; 95% CI, 1.13-10.77). IEAT was not associated with length of stay in hospital. CONCLUSION: IEAT is associated with mortality in elderly patients with UTI admitted to a non-ICU ward, suggesting that improving empirical antimicrobial therapy could have a favorable impact on prognosis.

Assessment of human cytomegalovirus specific T cell immunity in human immunodeficiency virus infected patients in different disease stages following HAART and in long-term non-progressors.

T cell immunity to human cytomegalovirus (HCMV) was assessed in HAART-treated HIV-1 infected patients (9 asymptomatic, CDC group A; and 22 symptomatic, CDC group B), and in eight HIV-1 long term non-progressors. Patients were either prospectively or cross-sectionally examined for CD4(+) T cell counts, HIV RNA load, HCMV leukoDNAemia, HCMV DNA in urine, lymphoproliferative response (LPR) to HCMV and phytohemagglutinin (PHA), and cytokine secretion (IFN-gamma and IL-4) by HCMV-stimulated peripheral blood mononuclear cell (PBMC) cultures. No patient either progressed to clinical AIDS or developed HCMV active infection during the study period. Twenty-nine patients responded to HAART, though 12 patients failed to recover the LPR to HCMV over the study period (three from CDC group A and nine from CDC group B). In contrast to healthy control individuals, most patients displaying positive LPRs LPRs to HCMV had unstable responses. Sustained LPRs to HCMV were significantly associated with high pre-HAART nadir CD4(+) T cell counts. Long-term suppression of HIV viremia correlated with recovery of LPR to HCMV. Sequential PBMC cultures from most patients secreted IFN-gamma (but not IL-4) at normal levels upon HCMV stimulation, irrespective of the pre-HAART nadir CD4(+) T cell counts and CDC group to which patients belonged. Failure to reconstitute IFN-gamma response was associated with very low pre-HAART nadir CD4(+) T cell counts. Control of HCMV infection in the cohort was associated with either recovery or maintenance of IFN-gamma response rather than with reconstitution of LPR to HCMV. A LPR to HCMV was absent in three out of eight long term non-progressors; contrarily, all patients showed preserved IFN-gamma responses.

Human cytomegalovirus (HCMV)-specific CD4+ T lymphocyte response in AIDS patients with no past or current HCMV disease following HAART.

BACKGROUND: The incidence of Human Cytomegalovirus (HCMV) end-organ disease has dramatically decreased since the implementation of highly active antiretroviral therapies (HAARTs), but the precise immune mechanism whereby HCMV is controlled remains to be elucidated. OBJECTIVES: To investigate the effect of (HAART) on CD4+ T-cell immunity to HCMV in AIDS patients with no past or current HCMV disease. STUDY DESIGN: Seventeen patients were prospectively examined for CD4+ (CD45RO+ and CD45 RA+) T-cell counts (flow cytometry), HIV RNA load (Amplicor HIV test), HCMV leukoDNAemia and HCMV DNA in urine (nested PCR), lymphoproliferative response (LPR) to HCMV, phytohemagglutinin (PHA) and purified protein derived from Mycobacterium tuberculosis (PPD) by measurement of 5-bromo-2'-deoxyuridine incorporation to DNA (ELISA) and cytokine secretion (IFN-gamma, IL-4 and IL-10) by HCMV-stimulated peripheral blood mononuclear cell (PBMC) cultures (ELISA). RESULTS: Fifteen patients responded favorably to HAART (virologically, immunologically, or both). Of these, six patients presented LPR to HCMV at least once during follow-up, whereas most displayed detectable LPRs to PHA. IFN-gamma was detected at least once in supernatants of HCMV-stimulated PBMC cultures from 14 of the 17 patients. All but one patient tested negative for HCMV leukoDNAemia and HCMV DNA in urine, and none developed HCMV disease during the observation period. CONCLUSIONS: Control of HCMV replication and the absence of HCMV disease are not consistently associated with recovery and/or maintenance of LPR to HCMV in AIDS patients under HAART and with no prior HCMV disease. Whether detection of IFN-gamma by PBMCs upon HCMV antigenic stimulation may serve as a surrogate marker for protection against HCMV disease requires further investigation.

Application of a 5-bromo-2'-deoxyuridine ELISA for measuring the lymphoproliferative response to human cytomegalovirus in HIV-1-infected patients.

Assessment of the lymphoproliferative response to human cytomegalovirus (HCMV) may help to identify human immunodeficiency virus (HIV)-1-infected patients at high risk of developing HCMV end-organ disease. The tritiated thymidine ([3H]-TdR)-incorporation assay is the gold standard for measuring lymphoproliferative responses, though it is unsuitable as a routine laboratory procedure. An alternative non-radioactive technique, a 5-bromo-2'-deoxyuridine (BrdU) enzyme-linked immunosorbent assay, was applied for measuring T-cell proliferation in response to HCMV. Stimulation of either 1 x 10(5) or 5 x 10(4) peripheral blood mononuclear cells (PBMCs)/well with 10 PFU/well (before inactivation) of inactivated HCMV (AD169 strain) virions during 5 days, followed by an 18 h period of pulsing with BrdU (10 microM) proved to be the optimal laboratory conditions. The assay is simple, economical and feasible for monitoring the lymphoproliferative response to HCMV in HIV-1-infected patients.