ABSTRACT
INTRODUCTION: Outcomes of human immunodeficiency virus (HIV) infected patients admitted to intensive care units (ICU) have improved with antiretroviral therapy (ART). However, whether the outcomes have improved in low- and middle-income countries, paralleling those of high-income countries is unknown. The objective of this study was to describe a cohort of HIV-infected patients admitted to ICU in a middle-income country and identify the risk factors associated with mortality. METHODOLOGY: A cohort study of HIV-infected patients admitted to five ICUs in Medellín, Colombia, between 2009 and 2014 was done. The association of demographic, clinical and laboratory variables with mortality was analyzed using a Poisson regression model with random effects. RESULTS: During this time period, 472 admissions of 453 HIV-infected patients were included. Indications for ICU admission were: respiratory failure (57%), sepsis/septic shock (30%) and central nervous system (CNS) compromise (27%). Opportunistic infections (OI) explained 80% of ICU admissions. Mortality rate was 49%. Factors associated with mortality included hematological malignancies, CNS compromise, respiratory failure, and APACHE II score ≥ 20. CONCLUSIONS: Despite advances in HIV care in the ART era, half of HIV-infected patients admitted to the ICU died. This elevated mortality was associated to underlying disease severity (respiratory failure and APACHE II score ≥ 20), and host conditions (hematological malignancies, admission for CNS compromise). Despite the high prevalence of OIs in this cohort, mortality was not directly associated to OIs.
Subject(s)
Acquired Immunodeficiency Syndrome , HIV Infections , Hematologic Neoplasms , Respiratory Insufficiency , Shock, Septic , Humans , Colombia/epidemiology , Cohort Studies , Hospital Mortality , HIV Infections/complications , HIV Infections/drug therapy , HIV Infections/epidemiology , Critical Care , Risk Factors , Intensive Care UnitsABSTRACT
PURPOSE: Given that vitamin D (25(OH)D) contributes to immune defense, we sought to determine if deficiency of 25(OH)D was significantly associated with methicillin-resistant Staphylococcus aureus (MRSA) infection. METHODS: All patients with 25(OH)D determinations at the Atlanta VAMC from 2007 to 2010 were included in the analyses. These patients were cross-referenced with a prospectively collected MRSA infection database at the AVAMC (2006-2010). Patients with one or more MRSA infections during the study period were considered MRSA-infected patients. Multivariate logistic regression was used to determine the association between 25(OH)D status [deficient (<20 ng/mL) vs. non-deficient (≥20 ng/mL)] and MRSA infection. RESULTS: A total of 6405 patients with 25(OH)D determinations were included in the analyses, of which 401 (6.3 %) were MRSA-infected patients. Mean (SD) vitamin D levels, in ng/mL, were 21.1 (12.4) and 24.0 (12.6) for MRSA-infected patients and non-MRSA infected patients, respectively (p < 0.0001). The multivariate logistic regression model confirmed associations between MRSA infection and sex, race, BMI, HIV status, and 25(OH)D [odds ratio for 25(OH)D: 1.94; 95 % confidence interval: 1.51-2.49]. CONCLUSION: MRSA-infected patients had significantly lower serum vitamin D levels than non-MRSA infected patients, even when controlling for potential confounding variables.
Subject(s)
Methicillin-Resistant Staphylococcus aureus/isolation & purification , Staphylococcal Infections/epidemiology , Staphylococcal Infections/microbiology , Vitamin D Deficiency/complications , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Prospective StudiesABSTRACT
OBJECTIVES: We aimed to describe and compare the prevalence of vitamin D deficiency between HIV-negative and HIV-infected veterans in the southern United States, and to determine risk factors for vitamin D deficiency for HIV infected patients. METHODS: Cross-sectional, retrospective study including all patients followed at the Atlanta VA Medical Center with the first 25-hydroxyvitamin D [25(OH)D] level determined between January 2007 and August 2010. Multivariate logistic regression analysis was used to determine risk factors associated with vitamin D deficiency (< 20 ng/ml). RESULTS: There was higher prevalence of 25(OH)D deficiency among HIV-positive compared to HIV-negative patients (53.2 vs. 38.5%, p <0.001). Independent risk factors for vitamin D deficiency in HIV + patients included black race (OR 3.24, 95% CI 2.28-4.60), winter season (OR 1.39, 95% CI 1.05-1.84) and higher GFR (OR 1.01, CI 1.00-1.01); increasing age (OR 0.98, 95% CI 0.95-0.98), and tenofovir use (OR 0.72, 95% CI 0.54-0.96) were associated with less vitamin D deficiency. CONCLUSIONS: Vitamin D deficiency is a prevalent problem that varies inversely with age and affects HIV-infected patients more than other veterans in care. In addition to age, tenofovir and kidney disease seem to confer a protective effect from vitamin D deficiency in HIV-positive patients.
Subject(s)
HIV Infections/blood , Vitamin D Deficiency/blood , Adult , Aged , Aged, 80 and over , Comorbidity , Cross-Sectional Studies , Female , HIV Infections/epidemiology , Homosexuality, Male , Humans , Male , Middle Aged , Multivariate Analysis , Obesity , Retrospective Studies , Risk Factors , Veterans , Vitamin D Deficiency/epidemiology , Young AdultABSTRACT
Approximately 8 million people have Trypanosoma cruzi infection, and nearly 30% will manifest Chagas cardiomyopathy (CC). Identification of reliable early indicators of CC risk would enable prioritization of treatment to those with the highest probability of future disease. Serum markers and electrocardiogram (EKG) changes were measured in 68 T. cruzi-infected individuals in various stages of cardiac disease and 17 individuals without T. cruzi infection or cardiac disease. T. cruzi-infected individuals were assigned to stage A (normal EKG/chest x-ray [CXR]), B (abnormal EKG/normal CXR), or C (abnormal EKG/cardiac structural changes). Ten serum markers were measured using enzyme-linked immunosorbent assay (ELISA)/Luminex, and QRS scores were calculated. Higher concentrations of transforming growth factor-ß1 (TGFß1), and TGFß2 were associated with stage B compared with stage A. Matrix Metalloproteinase 2 (MMP2), Tissue Inhibitors of MMP 1, QRS score, and Brain Natriuretic Protein rose progressively with increasing CC severity. Elevated levels of several markers of cardiac damage and inflammation are seen in early CC and warrant additional evaluation in longitudinal studies.
Subject(s)
Biomarkers/blood , Chagas Cardiomyopathy/blood , Chagas Cardiomyopathy/diagnostic imaging , Chagas Cardiomyopathy/physiopathology , Electrocardiography , Enzyme-Linked Immunosorbent Assay , Humans , RadiographyABSTRACT
We evaluated the annual and weighted incidence of methicillin-resistant Staphylococcus aureus infections by specific risk factors in a prospective cohort of HIV patients. We found 228 infections in 167 patients from 2002 to 2009. Higher rates were seen in men who have sex with men and intravenous drug users, patients with lower CD4 cell counts, patients not on antiretrovirals and younger patients. The annual incidence peaked in 2007 and has decreased since.
Subject(s)
HIV Infections/epidemiology , Methicillin-Resistant Staphylococcus aureus , Staphylococcal Infections/epidemiology , Adult , Aged , Aged, 80 and over , CD4 Lymphocyte Count , Female , HIV Infections/immunology , HIV Infections/microbiology , Humans , Incidence , Male , Middle Aged , Prospective Studies , Staphylococcal Infections/immunologyABSTRACT
BACKGROUND: Patients with Chagas disease have migrated to cities, where obesity, hypertension and other cardiac risk factors are common. METHODOLOGY/PRINCIPAL FINDINGS: The study included adult patients evaluated by the cardiology service in a public hospital in Santa Cruz, Bolivia. Data included risk factors for T. cruzi infection, medical history, physical examination, electrocardiogram, echocardiogram, and contact 9 months after initial data collection to ascertain mortality. Serology and PCR for Trypanosoma cruzi were performed. Of 394 participants, 251 (64%) had confirmed T. cruzi infection by serology. Among seropositive participants, 109 (43%) had positive results by conventional PCR; of these, 89 (82%) also had positive results by real time PCR. There was a high prevalence of hypertension (64%) and overweight (body mass index [BMI] >25; 67%), with no difference by T. cruzi infection status. Nearly 60% of symptomatic congestive heart failure was attributed to Chagas cardiomyopathy; mortality was also higher for seropositive than seronegative patients (p = 0.05). In multivariable models, longer residence in an endemic province, residence in a rural area and poor housing conditions were associated with T. cruzi infection. Male sex, increasing age and poor housing were independent predictors of Chagas cardiomyopathy severity. Males and participants with BMI =25 had significantly higher likelihood of positive PCR results compared to females or overweight participants. CONCLUSIONS: Chagas cardiomyopathy remains an important cause of congestive heart failure in this hospital population, and should be evaluated in the context of the epidemiological transition that has increased risk of obesity, hypertension and chronic cardiovascular disease.
Subject(s)
Chagas Cardiomyopathy/epidemiology , Chagas Cardiomyopathy/pathology , Trypanosoma cruzi/isolation & purification , Adolescent , Adult , Aged , Aged, 80 and over , Antibodies, Protozoan/blood , Bolivia/epidemiology , Chagas Cardiomyopathy/complications , Chagas Cardiomyopathy/mortality , Chronic Disease , DNA, Protozoan/blood , Enzyme-Linked Immunosorbent Assay , Female , Heart Failure/epidemiology , Heart Failure/etiology , Humans , Male , Middle Aged , Polymerase Chain Reaction , Prevalence , Risk Factors , Trypanosoma cruzi/genetics , Trypanosoma cruzi/immunology , Young AdultABSTRACT
We evaluated isolates of Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii that were reported to the National Healthcare Safety Network from January 2006 through December 2008 to determine the proportion that represented multidrug-resistant phenotypes. The pooled mean percentage of resistance varied by the definition used; however, multidrug resistance was relatively common and widespread.
Subject(s)
Cross Infection , Drug Resistance, Multiple, Bacterial , Gram-Negative Bacteria/drug effects , Gram-Negative Bacterial Infections , Acinetobacter baumannii/drug effects , Anti-Bacterial Agents/pharmacology , Cross Infection/epidemiology , Cross Infection/microbiology , Gram-Negative Bacteria/classification , Gram-Negative Bacterial Infections/epidemiology , Gram-Negative Bacterial Infections/microbiology , Humans , Klebsiella pneumoniae/drug effects , Microbial Sensitivity Tests , Population Surveillance/methods , Pseudomonas aeruginosa/drug effectsABSTRACT
Concordant with the emergence of methicillin-resistant Staphylococcus aureus (MRSA) in the community setting, colonization and infections with this pathogen have become a prevalent problem among the human immunodeficiency virus (HIV)-positive population. A variety of different host- and, possibly, pathogen-related factors may play a role in explaining the increased prevalence and incidence observed. In this article, we review pathophysiology, epidemiology, clinical manifestations, and treatment of MRSA in the HIV-infected population.
ABSTRACT
Meticillin-resistant Staphylococcus aureus (MRSA), usually known as a nosocomial pathogen, has emerged as the predominant cause of skin and soft-tissue infections in many communities. Concurrent with the emergence of community-acquired MRSA (CA-MRSA), there have been increasing numbers of reports of community-acquired necrotising pneumonia in young patients and others without the classic health-care-associated risk factors. Community-onset necrotising pneumonia due to CA-MRSA is now recognised as an emerging clinical entity with distinctive clinical features and substantial morbidity and mortality. A viral prodrome (eg, influenza or influenza-like illness) followed by acute onset of shortness of breath, sepsis, and haemoptysis is the most frequent clinical presentation. The best treatment of this partly toxin-mediated disease has not been clearly defined. Whereas cases of CA-MRSA pneumonia have now been reported from almost every continent, the overall burden of disease of this emerging syndrome remains incompletely described. We report two related cases of community-onset pneumonia due to the MRSA USA300 genotype and review the literature regarding the emergence of CA-MRSA pneumonia.
Subject(s)
Communicable Diseases, Emerging/microbiology , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Pneumonia, Staphylococcal/microbiology , Adult , Anti-Bacterial Agents/therapeutic use , Bacterial Proteins/genetics , Bacterial Toxins/genetics , Clindamycin/therapeutic use , Communicable Diseases, Emerging/drug therapy , Communicable Diseases, Emerging/physiopathology , Community-Acquired Infections/drug therapy , Community-Acquired Infections/microbiology , Community-Acquired Infections/physiopathology , Drug Resistance, Multiple, Bacterial/genetics , Exotoxins/genetics , Female , Genotype , Humans , Intubation, Intratracheal , Leukocidins/genetics , Male , Methicillin-Resistant Staphylococcus aureus/genetics , Middle Aged , Penicillin-Binding Proteins , Pneumonia, Staphylococcal/drug therapy , Pneumonia, Staphylococcal/physiopathology , United States , Virulence FactorsABSTRACT
In HIV-infected patients, central nervous system (CNS) aspergillosis is rare. Historically, the outcome of such infections has been almost invariably fatal. We report a case involving an AIDS patient with an Aspergillus fumigatus brain abscess who survived for longer than 10 months after surgical drainage and therapy with voriconazole.
Subject(s)
Acquired Immunodeficiency Syndrome/complications , Aspergillus fumigatus/isolation & purification , Neuroaspergillosis/diagnosis , Adult , Antifungal Agents/therapeutic use , Brain/pathology , Head/diagnostic imaging , Humans , Male , Neuroaspergillosis/drug therapy , Neuroaspergillosis/surgery , Pyrimidines/therapeutic use , Radiography , Survival , Time Factors , Treatment Outcome , Triazoles/therapeutic use , VoriconazoleABSTRACT
OBJECTIVE: To describe the frequency of selected antimicrobial resistance patterns among pathogens causing device-associated and procedure-associated healthcare-associated infections (HAIs) reported by hospitals in the National Healthcare Safety Network (NHSN). METHODS: Data are included on HAIs (ie, central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections) reported to the Patient Safety Component of the NHSN between January 2006 and October 2007. The results of antimicrobial susceptibility testing of up to 3 pathogenic isolates per HAI by a hospital were evaluated to define antimicrobial-resistance in the pathogenic isolates. The pooled mean proportions of pathogenic isolates interpreted as resistant to selected antimicrobial agents were calculated by type of HAI and overall. The incidence rates of specific device-associated infections were calculated for selected antimicrobial-resistant pathogens according to type of patient care area; the variability in the reported rates is described. RESULTS: Overall, 463 hospitals reported 1 or more HAIs: 412 (89%) were general acute care hospitals, and 309 (67%) had 200-1,000 beds. There were 28,502 HAIs reported among 25,384 patients. The 10 most common pathogens (accounting for 84% of any HAIs) were coagulase-negative staphylococci (15%), Staphylococcus aureus (15%), Enterococcus species (12%), Candida species (11%), Escherichia coli (10%), Pseudomonas aeruginosa (8%), Klebsiella pneumoniae (6%), Enterobacter species (5%), Acinetobacter baumannii (3%), and Klebsiella oxytoca (2%). The pooled mean proportion of pathogenic isolates resistant to antimicrobial agents varied significantly across types of HAI for some pathogen-antimicrobial combinations. As many as 16% of all HAIs were associated with the following multidrug-resistant pathogens: methicillin-resistant S. aureus (8% of HAIs), vancomycin-resistant Enterococcus faecium (4%), carbapenem-resistant P. aeruginosa (2%), extended-spectrum cephalosporin-resistant K. pneumoniae (1%), extended-spectrum cephalosporin-resistant E. coli (0.5%), and carbapenem-resistant A. baumannii, K. pneumoniae, K. oxytoca, and E. coli (0.5%). Nationwide, the majority of units reported no HAIs due to these antimicrobial-resistant pathogens.
Subject(s)
Bacterial Infections/epidemiology , Centers for Disease Control and Prevention, U.S. , Cross Infection/epidemiology , Cross Infection/microbiology , Electronic Data Processing/methods , Anti-Infective Agents/pharmacology , Bacteria/drug effects , Bacterial Infections/microbiology , Catheter-Related Infections/epidemiology , Catheter-Related Infections/microbiology , Drug Resistance, Bacterial , Drug Resistance, Multiple, Bacterial , Fungi/drug effects , Fungi/physiology , Hospitals/statistics & numerical data , Humans , Mycoses/epidemiology , Mycoses/microbiology , Pneumonia, Ventilator-Associated/epidemiology , Pneumonia, Ventilator-Associated/microbiology , United States/epidemiologySubject(s)
Anti-Bacterial Agents/pharmacology , Daptomycin/pharmacology , Drug Resistance, Bacterial , Endocarditis, Bacterial/microbiology , Enterococcus faecalis/drug effects , Anti-Bacterial Agents/therapeutic use , Daptomycin/therapeutic use , Enterococcus faecalis/isolation & purification , Fatal Outcome , Humans , Male , Microbial Sensitivity Tests , Middle Aged , Treatment OutcomeABSTRACT
BACKGROUND: Surveillance cultures performed at hospital admission have been recommended to identify patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) but require substantial resources. We determined the prevalence of and risk factors for MRSA colonization at the time of hospital admission among patients cared for at a public urban hospital. METHODS: Anterior nares cultures were obtained within 48 h after admission during a 1-month period. A case-control study and molecular typing studies were performed. RESULTS: A total of 53 (7.3%) of 726 patients had a nares culture positive for MRSA, and 119 (16.4%) had a nares culture that was positive for methicillin-susceptible S. aureus. In multivariate analysis, risk factors for MRSA colonization included antibiotic use within 3 months before admission (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.2-5.0), hospitalization during the past 12 months (OR, 4.0; 95% CI, 2.0-8.2), diagnosis of skin or soft-tissue infection at admission (OR, 3.4; 95% CI, 1.5-7.9), and HIV infection. A total of 47 (89%) of 53 case patients colonized with MRSA had at least 1 of these independent risk factors, in contrast to 343 (51%) of 673 control patients (OR, 7.5; 95% CI, 3.2 -17.9). Molecular typing demonstrated that 16 (30%) of 53 MRSA nares isolates (2.2% of the 726 isolates) belonged to the USA300 community-associated MRSA (CA-MRSA) genotype. CONCLUSION: The prevalence of MRSA colonization at the time of patient admission was high (>7%). Limiting surveillance cultures to patients with >or=1 of the identified risk factors may allow for targeted screening. The emergence of CA-MRSA colonization represents a new, unrecognized reservoir of MRSA within hospitals, potentially increasing the risk for horizontal transmission.