RESUMEN
BACKGROUND: Systematic treatment with intravenous acyclovir is usually given when varicella zoster virus (VZV) DNA is isolated in cerebrospinal fluid (CSF), indicating central nervous system (CNS) involvement. Our study aimed to describe therapeutic management and acute kidney injury (AKI) occurrence during acyclovir treatment of VZV infection with CNS involvement. METHODS: Multicentre, retrospective study including all patients from 2010 to 2022 with VZV DNA in CSF. Patient management and outcomes were compared according to clinical presentation and indications for intravenous acyclovir: i) definite (encephalitis, myelitis or stroke, peripheral nervous system (PNS) with ≥ 2 roots, herpes zoster ≥ 3 dermatomes, immunosuppression), ii) questionable (1 or 2 dermatomes) or iii) no indication (other situations). RESULTS: 154 patients were included (median age 66 (interquartile range 43-77), 87 (56%) males); 60 (39%) had encephalitis, myelitis or stroke, 35 (23%) had PNS involvement, 37 (24%) had isolated meningitis, 14 (9%) had isolated cutaneous presentation, and 8 (5%) had other presentations. Overall, 128 (83%) received intravenous acyclovir for more than 72 h. AKI occurred in 57 (37%) patients. Finally, 42 (27%) and 25 (16%) patients had respectively no or a questionable indication for intravenous acyclovir, while 29 (69%) and 23 (92%) of them received it for more than 72 h, with AKI in 13 (35%) and 13 (52%) patients, respectively. In-hospital mortality was 12% (n = 18), and no deaths were reported in isolated meningitis. CONCLUSIONS: Intravenous acyclovir is widely prescribed when VZV DNA is isolated in CSF, regardless of the clinical presentation, with a high rate of AKI. Further studies are needed to better define the value of intravenous acyclovir in isolated VZV meningitis.
RESUMEN
BACKGROUND: First-line antiretroviral therapy (1st ART) is an important step in a patient's management and often considered a long-term therapy at treatment initiation. METHODS: To describe the duration of 1st ART and the factors associated with treatment modification in a recent real-life setting, antiretroviral-naive patients who began their 1st ART in six French hospitals in 2009-2012 were included in a cohort. Clinical, immunological, virological and therapeutic data, as well as the reasons for therapeutic changes, if any, were retrospectively collected. RESULTS: A total of 206 patients started 1st ART, mainly a protease inhibitor-based triple therapy (73%), with a tenofovir-including backbone (87%). Of these, 89 (43%) had their 1st ART modified after a median of 16.5 months (IQR 8.0-32.8). Having a CD4+ T-cell count <200 cells/mm3, being pregnant, or 1st ART including zidovudine + lamivudine or lopinavir/r were significantly associated with a higher risk for treatment modification in multivariate analysis. In 47 patients (53%), 1st ART was modified for safety reasons, with no significant association with a given antiretroviral drug or class. No significant difference in virological, immunological and clinical outcomes was observed between the patients who had their 1st ART modified and those who did not. CONCLUSIONS: The proportion of modifications of the 1st ART during the first 2 years remains high. These modifications are frequently because of safety issues and the willingness to simplify treatment, and less often driven by virological failure, thus emphasizing that 1st ART is not - or is no longer - a lifelong treatment.