Persistent and relapsing babesiosis in immunocompromised patients.

BACKGROUND: Human babesiosis is a tickborne malaria-like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine. Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain. METHODS: We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy. This retrospective case-control study was performed in southern New England, New York, and Wisconsin. RESULTS: All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects. Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died. Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear. CONCLUSIONS: Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for >or=6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.

Antiretroviral treatment regimen outcomes among HIV-infected prisoners.

BACKGROUND: Despite the high prevalence of HIV in correctional settings, the duration of therapy and response to various highly active antiretroviral therapy (HAART) regimens in this setting is unknown. METHOD: Using a retrospective cohort study (1997-2002) of HIV-infected prisoners in Connecticut that linked demographic, pharmacy, and laboratory data, we compared HIV-1 RNA (VL) and CD4 lymphocyte responses to four treatment strategies at baseline and at the end of incarceration. RESULTS: Using an analysis of 1,044 incarceration periods or 1,099 subjects for whom 6 months of continuous data were available, HAART regimens that included a triple NRTI, two NRTIs + either a PI or NNRTI, or a three-class (NRTI+NNRTI+PI) strategy demonstrated no difference in virological and immunological outcomes. The proportion of subjects who were initiated with NRTI, NNRTI, PI, or three-class regimens were 14%, 32%, 46%, and 8%, respectively. For all study groups, the mean change from baseline in CD4 and VL was +74 cells/muL and -0.93 log(10) copies/mL (p < .0001), respectively. Overall, 59% of subjects had an HIV-1 RNA level below the level of detection (<400 copies/mL) by the end of their incarceration. Using Kaplan-Meier curves to examine the time to change in the initial HAART strategy over the incarceration period, the three-class strategy was significantly more likely to be changed earlier than all others (p < .05). CONCLUSION: Although the three-class strategy was less durable, initiating HAART with any strategy resulted in similar and impressive virological and immunological outcomes by the end of incarceration, further supporting prison as an important site for the initiation and provision of effective antiretroviral therapy.

Chronic osteomyelitis: results obtained by an integrated team approach to management.

BACKGROUND: The pathology of chronic osteomyelitis suggests that thorough debridement of bone and soft tissue, with closure of dead space, supported by appropriate antibiotics would be the optimal therapeutic strategy. METHODS: In 1993, we formed a multidisciplinary Bone Infection Team (orthopaedic surgeon, infectious diseases specialist, plastic surgeon, and nurse practitioner) to apply those principles to the treatment of chronic osteomyelitis. We present the outcomes of such therapy in 82 patients treated by the Team in the first seven years. All patients underwent surgical debridement with other procedures including bone distraction, muscle flap implantation and bone grafts as necessary to foster restoration of bone and soft-tissue integrity. Antibiotic choice was based on sensitivity data, with a short course of intravenous antibiotics and a prolonged course of oral antibiotics being the usual therapy. RESULTS: During the first seven years, we treated 82 patients for chronic osteomyelitis. Most patients required multiple surgical procedures (mean = 2.2), with 10 patients requiring five or more operations. Staphylococcus aureus was the single most common pathogen, although the majority (57%) of the infections were polymicrobial. Intravenous antibiotics were administered for a median of 16 days; 16 patients received intravenous antibiotics only during the immediate perioperative period. Oral antibiotics were administered for a median of 59 days. The infection was cured in all but one patient in our clinic; the remaining patient had definitive surgical repair at another clinic and is now infection free. In 77/82 patients, the limb afflicted with chronic osteomyelitis was salvaged. Because of extensive damage to bones and surrounding soft tissues, amputation was necessary in five patients. Five patients required internal fixation 12 or more months after the infection was controlled for nonunion; all such procedures were successful. No patient whose infection remained inactive for six or more months after surgical debridement has reactivated the infection during a median follow-up of 56 months (range: 23-89 months). CONCLUSIONS: Management of chronic osteomyelitis requires thorough debridement of infected bone and soft tissues coupled with rigid stabilization with external fixators, elimination of dead space, often requiring soft-tissue flap coverage, and staged bone reconstruction. When such a surgical approach is accompanied by appropriate antibiotics based on the sensitivity of the microbes isolated from the infected site, the infected focus is eliminated and bone length and integrity are restored.

Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community.

Responses to highly active antiretroviral therapy (HAART) in correctional settings and their sustained benefit in prisoners after release are currently not known. To examine the human immunodeficiency virus type 1 (HIV-1) RNA level (VL) and CD4 lymphocyte response to HAART during incarceration and upon reentry to the correctional system, we conducted a retrospective cohort study of longitudinally linked demographic, pharmacy, and laboratory data from the Connecticut prison system. During incarceration, the mean CD4 lymphocyte count increased by 74 lymphocytes/ mu L, and the mean VL decreased by 0.93 log10 copies/mL (P<.0001). Fifty-nine percent of the subjects achieved a VL of <400 copies/mL at the end of each incarceration period. For the 27% of subjects who were reincarcerated, the mean CD4 lymphocyte count decreased by 80 lymphocytes/ mu L, and the mean VL increased by 1.14 log10 (P<.0001). Although HAART use resulted in impressive VL and CD4 lymphocyte outcomes during the period of incarceration, recidivism to prison was high and was associated with a poor outcome. More effective community-release programs are needed for incarcerated patients with HIV disease.