Relationship of polypharmacy to HIV RNA suppression in people aged ≥ 50 years living with HIV.

OBJECTIVES: People living with HIV (PLWH) aged ≥ 50 years face unique challenges regarding their medication therapies, especially antiretroviral therapy (ART). Use of ARTs, along with medications for comorbidities, may lead to adverse events, drug-drug interactions (DDIs) and poor adherence. The objective of this study was to identify the number of medications above which PLWH aged ≥ 50 years are less likely to be virally suppressed and to describe other associated patient-specific risk factors. METHODS: This was a cross-sectional study of PLWH aged ≥ 50 years, prescribed ART, and seen at least once in the Northwestern Infectious Disease Center between 1 June 2013 and 31 May 2015. Variables concerning medication use and comorbidities were collected. The primary outcome was the presence of an undetectable plasma HIV RNA level (viral load). RESULTS: Among the 621 included patients, there was a higher percentage taking ≤ 15 medications with an undetectable plasma HIV RNA (n = 453; 80.6%) vs. patients taking > 15 medications (n = 40; 67.8%; P = 0.03). Taking > 15 medications [odds ratio (OR) 0.49; 95% confidence interval (CI) 0.26-0.96], pulmonary disease (OR 0.54; 95% CI 0.3-0.97) and CD4 T-lymphocyte count < 200 cells/µL (OR 0.39; 95% CI 0.22-0.68) decreased the odds of having an undetectable plasma HIV RNA. CONCLUSIONS: PLWH taking > 15 medications were less likely to have an undetectable HIV RNA. Further studies are needed to evaluate the impact of overall medication economic burden on clinical outcomes among PLWH ≥ 50 years of age.

Thirteen-year evolution of azole resistance in yeast isolates and prevalence of resistant strains carried by cancer patients at a large medical center.

Drug resistance is emerging in many important microbial pathogens, including Candida albicans. We performed fungal susceptibility tests with archived isolates obtained from 1984 through 1993 and fresh clinical isolates obtained from 1994 through 1997 by testing their susceptibilities to fluconazole, ketoconazole, and miconazole and compared the results to the rate of fluconazole use. All isolates recovered prior to 1993 were susceptible to fluconazole. Within 3 years of widespread azole use, we detected resistance to all agents in this class. In order to assess the current prevalence of resistant isolates in our hematologic malignancy and transplant patients, we obtained rectal swabs from hospitalized, non-AIDS, immunocompromised patients between June 1995 and January 1996. The swabs were inoculated onto sheep's blood agar plates containing 10 microg of vancomycin and 20 microg of gentamicin/ml of agar. One hundred one yeasts were recovered from 97 patients and were tested for their susceptibilities to amphotericin B, fluconazole, flucytosine, ketoconazole, and miconazole. The susceptibility pattern was then compared to those for all clinical isolates obtained throughout the medical center. The antifungal drug histories for each patient were also assessed. The yeasts from this surveillance study were at least as susceptible as the overall hospital strains. There did not appear to be a direct linkage between prior receipt of antifungal agent therapy and carriage of a new, drug-resistant isolate. Increased resistance to newer antifungal agents has occurred at our medical center, but it is not focal to any high-risk patient population that we studied. Monitoring of susceptibility to antifungal agents appears to be necessary for optimizing clinical therapeutic decision making.

Molecular typing for investigating an outbreak of Candida krusei.

Invasive infections due to Candida krusei are often observed in immunocompromised patients who have received prior therapy with fluconazole, although infection has also occurred in patients in the absence of this antifungal agent. From August 25 through September 19, 1995, we identified four patients with C. krusei fungemia on our hematology/oncology unit. Molecular typing of all the isolates was performed by restriction endonuclease analysis of genomic DNA using HinfI. A total of 7 patients found to be colonized or infected with C. krusei were matched with 14 controls. There was no difference between the cases and controls with respect to underlying disease, duration of hospitalization, or neutropenia. The numbers of days of hyperalimentation, corticosteroids, and antibiotics were similar between both groups. The mean number of antibiotics was greater in the cases versus controls (5.0 versus 2.5; p = .003). There was no difference with respect to total dose or duration of fluconazole administration. Molecular typing of the isolates revealed that four had identical DNA banding patterns, plus another two that differed by one band and were considered related. Three historical strains were unrelated. In conclusion, this report demonstrates that molecular typing can be used to define clonality and, thereby, support increased infection control practices to eliminate such outbreaks when evidence of clonal spread is present.